From the Research
The safest method for first trocar placement in a patient with prior gastric bypass surgery undergoing laparoscopic cholecystectomy is an open Hasson technique at an alternative site, typically the left upper quadrant or supraumbilical region. This approach involves making a small incision, directly visualizing the layers of the abdominal wall, and placing the trocar under direct vision to avoid injury to underlying structures. For patients with gastric bypass history, the standard umbilical entry point should be avoided due to potential adhesions from previous surgery and altered anatomy, particularly the presence of a gastric remnant or roux limb that may be adherent to the anterior abdominal wall.
The left upper quadrant approach (Palmer's point) located 3 cm below the left costal margin in the midclavicular line is particularly useful as this area is typically free of adhesions even in patients with previous abdominal surgery. Before trocar placement, the stomach should be decompressed with a nasogastric tube, and the site should be percussed to ensure the absence of underlying viscera. This technique minimizes the risk of inadvertent injury to displaced bowel or vascular structures that may result from blind entry techniques like Veress needle insertion in patients with altered anatomy from previous bariatric surgery. According to a study published in 2016 1, the Hasson technique had no reported injuries, whereas the Veress technique and direct placement of an optical trocar had reported injuries, highlighting the safety of the open Hasson technique.
Key points to consider:
- The open Hasson technique allows for direct visualization of the abdominal wall layers and trocar placement, reducing the risk of injury to underlying structures.
- Alternative sites, such as the left upper quadrant or supraumbilical region, should be used in patients with prior gastric bypass surgery to avoid potential adhesions and altered anatomy.
- The use of a nasogastric tube to decompress the stomach and percussion to ensure the absence of underlying viscera are important steps in minimizing the risk of complications.
- The safety of the open Hasson technique is supported by studies, such as the one published in 2016 1, which reported no injuries with this technique.