【Gynecological Laparoscopy】Punch Hole

In surgical operations, laparoscopic technology is more and more widely used, and it is also welcomed by the majority of gynecologists and patients. However, regardless of the doctor's proficiency in laparoscopic technology, the complications of laparoscopic surgery cannot be ignored. Puncture hole bleeding is one of the common complications. It is often found due to intra-abdominal bleeding after surgery, causing panic in patients. If a second operation not only causes economic losses to the patient, but also easily causes medical disputes, it is important to prevent and reduce the incidence.

 
Puncture hole related anatomy
 
1. Commonly used puncture points in gynecology
The first puncture point: the umbilical hole is the preferred observation hole. The puncture point has the weakest tissue structure and few blood vessels. Its anatomical levels are skin, thin subcutaneous tissue, rectus abdominis tendon, posterior sheath, and parietal peritoneum from outside to inside. .
The second and third puncture points: the middle and outer 1/3 of the connection between the umbilical cord and the bilateral anterior superior iliac spine, located between the inferior abdominal wall artery and the deep iliac circumflex artery (the site where bleeding occurs).
The fourth puncture point: the anterior midline is on the left pubic symphysis
 
2. Vulnerable abdominal wall vessels
Puncture method
Lift the skin on both sides, cut the umbilical skin at the puncture site, Grasp the pneumoperitoneum needle with the gesture of holding a pen, and make the puncture at 90° with the wrist against the abdominal wall.
Tips:
There were two times of no things sensation in the puncture process. The first time is to penetrate the anterior sheath of the rectus abdominis muscle, and the second time is to penetrate the peritoneum into the abdominal cavity.
After the needle is inserted into the abdomen, the tail of the needle is connected to a small syringe containing saline. AAfter the second sensation of nothings, the saline will automatically enter the abdominal cavity slowly due to the negative pressure in the abdominal cavity, and the liquid level will drop.
 
Causes of bleeding from puncture holes
1. Improper selection of the puncture hole: blind puncture, causing damage to the subcutaneous, muscle layer and extraperitoneal blood vessels. The puncture hole under the xiphoid process is easy to damage the blood vessels in the round ligament of the liver.
2. Improper puncture direction, vertical abdominal wall entry, Determination of force size, easy to control depth, short path; oblique puncture or migration, long path, unstable position, increase tissue and blood vessel damage.
3. Repeated in and out of the trocar, increase the blood vessel damage of the abdominal wall tissue.
4. The use of trocar: the prismatic trocar is easy to cause tissue damage when rotating, and the round trocar is less bleeding.
5. Blindly dilate or cut the specimen hole with a sharp instrument, which is easy to damage the abdominal wall blood vessels.
6. Incomplete suture: obese patients, too small puncture hole, early recovery from anesthesia, unsatisfactory muscle relaxation, causing abdominal breathing exercises, and difficulty in deep suture.
7. intraoperative omission: it should not be the most frequent occurrence, and must be aware of bleeding.
8. It has been found during the operation that the hemostasis is not complete: incomplete coagulation or suture hemostasis without direct vision. In many cases, the blood vessels are closed under the pressure of the pneumoperitoneum, and the bleeding is omissions after the pneumoperitoneum is removed.
9. Liver cirrhosis, venous hypertension, causes open abdominal collateral circulation, poor blood coagulation, and abdominal wall varicose veins.
 
Prevent bleeding from puncture holes
1. Correctly choose the puncture hole
For example, puncture holes are commonly used. Clinically, there are different puncture points according to different conditions of the patient. No matter how the puncture point is selected, it is necessary to be familiar with the shape of the blood vessel under the puncture point to avoid injury.
2. Microscopic examination of the abdominal wall: avoid the abdominal wall vessels under direct laparoscopic vision. The patient is obese, the abdominal wall is thick, and the abdominal wall vessels cannot be clearly seen under lighting. At this time, the position of the blood vessels should be determined by anatomical landmarks. If the inferior abdominal artery runs from the external iliac artery to the femoral canal (where the round ligament enters the abdominal wall), avoid these parts during puncture.
3. The puncture needle is perpendicular to the abdominal wall and puncture into the pelvic cavity at the shortest distance to prevent the Trocar from entering the abdominal cavity after a certain distance in the abdominal wall. Change the direction to enter the pelvic cavity until the spiral end enters the abdominal cavity.
4. Ensure sufficient intra-abdominal pressure (gynecological surgery often set intra-abdominal pressure 13 -15mmHg); use a blunt puncture
5. Pay attention to the umbilical puncture hole as an observation hole. Most of this hole withdrew at the end, and its condition could not be observed. When the operation is completed, the holes should be observed under laparoscopic monitoring and the trocar should be withdrawn one by one, and the umbilical hole should be carefully observed by entering the lens at the main operating hole. It is not appropriate to rashly.
6. Observe after the gas in the abdominal cavity is released: observe the puncture hole without bleeding under the pressure of the pneumoperitoneum, keep the umbilical lens for monitoring, and observe the bleeding in each hole after a part of the gas is released from the remaining hole.
7. When the incision is sutured after the operation, it is not advisable to resume anesthesia prematurely, so as to facilitate the deep tissue suture firmly and without leaving a dead space.
8. Make adequate preoperative preparations. For patients with severe liver cirrhosis or abnormal coagulation function, the coagulation function should be improved before the operation.
 
Solutions to bleeding from puncture holes
(1) Timely detection and accurate judgment after the operation: Closely observe the patient's condition, the blood pressure continues to drop, the heart rate increases, abdominal pain, severe discomfort of the puncture hole (abdominal wall puncture hematoma) and increased blood drainage. Abdominal drainage tube drains fresh blood>100 ml/h; shock index (heart rate/systolic blood pressure)>1; there was no coagulation after the abdominal puncture device was drawn out, signs of peritonitis; hypovolemic shock can not be corrected after blood transfusion and fluid resuscitation, 4 items are consistent 2 can be diagnosed for intra-abdominal bleeding, and surgical exploration as soon as possible.
(2) Several commonly used methods of hemostasis:
1. Electrocoagulation: carefully find the bleeding site, coagulate the puncture hole exactly, and stop the bleeding on the peritoneal surface.
2. Titanium clips to stop bleeding, if not completely sutured. The No. 18 balloon catheter is inserted into the abdominal cavity, and the abdominal wall is fixed externally after the balloon is filled with water, and the puncture hole is compressed for 24 hours to stop bleeding;
3. Suture: When it is difficult to suture deep tissues, extend the puncture hole if necessary, and suture the peritoneum and muscular layers with a "8".