Laparoscopy is a blind procedure. One
does not know where the tip of the Veress’ needle of the trocar and
cannula is located. One relies on merciful God and enters the
peritoneal cavity. It becomes safer only after the telescope replaces
the trocar and one can see inside the abdomen. Complications are few
if one adheres to strict discipline while performing the procedure.
The resident doctors in training, and even their seniors often do not
realize that it can be very dangerous. They go through the prescribed
steps, sometimes skipping a few, and not always adhering to the rules
of safety.
“Your Veress’ needle is oblique. It
is directed towards retroperitoneal pelvic vessels. Bring it back to
midline” I admonish “or you will cause a vascular injury. I am
that careful because I know women can die of it. They don’t believe
it because they don’t believe it can happen and that I must be just
nagging. They correct the direction somewhat, only to go obliquely
again in a minute or two. The other day a second year resident was
performing laparoscopy. An Assistant Professor was assisting, guiding
every step. I had already corrected the direction of the Veress’
needle twice. Then she inserted the trocar and cannula, passing it an
angle with the midline before I could stop her. I had a premonition
of danger. Then she hooked up the endoscopy camera to the telescope.
There was no blood anywhere, which was a good sign. I washed up and
had a look inside the patient’s abdomen, moving the telescope all
around.
“What is that you see there?” I
asked.
“…..”
I zoomed in.
“It is an injury. But is not bleeding
actively” the Assistant Professor said. It was penetrating injury
in the parietal peritoneum and underlying tissues close to the right
pelvic brim. He was right, it was not bleeding actively.
“What is that just medial to it?” I
asked. They all looked carefully.
“Those are arterial pulsations” he
said.
“If the tip of the trocar had been
five millimeters lateral, it would have punctured the vessel and
produced an instant hemoperitoneum, and possibly death of the woman”
I said.
“Yes, Sir.”
Now look carefully at the positions of
the telescope and watch the field on the monitor” I said. I focused
first on the vessel, and then brought the telescope to midline. I
repeated the maneuver a couple of times.
“Did you notice through what angle
the telescope moved from midline to be directed to the vessel?” I
asked.
“About five degrees.”
“Now do you realize you can cause a
catastrophic vascular injury just by deviating from midline by 5
degrees?”
“Yes, Sir.”
I was happy I had taught them something
that they would remember for ever. I was also happy about the novel
method of teaching I had used without actually thinking and planning.
Nothing lasts forever. My happiness
lasted for one month. Then the Veress’ needle got directed again
away from midline. I think God must be moving these vulnerable
structures away from the tips of Veress’ needles and trocars
temporarily, like the trees and buildings moved from the flying bus
in the Harry Potter series.
