Educational content from recorded physician discussions — not medical advice. Talk to your (or your child's) care team about your situation.
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What the experts said
In a 10-year-old, spk_0 uses Veress needle through the fascia for peritoneal access.
Dissection and clamp passage (passing a hemostat through the umbilicus, removing it, then inserting the needle) is used by spk_0 only in four-week-old infants with pyloric stenosis, not in older children.
For extirpative operations like cholecystectomy, spk_0 uses Hasson technique.
Single-incision appendectomy can be performed in the obese 90th percentile and above pediatric population with outcomes comparable to three-trocar technique in terms of wound issues.
When using a wound protector during single-port appendectomy, the appendix never touches tissue as it is extracted, making wound complications comparable to or better than multi-port technique.
In obese teenagers, the distance between the posterior fascia at the umbilicus and the aorta is very short, with intestines lying on top.
Veress needles that produce a loud audible click after passing the peritoneum are preferred by some surgeons for confirmation of entry.
Veress needle insertion should not exceed more than a millimeter or two beyond the audible click of peritoneal entry.
The left upper quadrant does not contain iliac vessels, making it a safer access site than midline where iliac vein injury is a risk.
Step trocars are not designed to be placed with the sheath in place because the large step-off in diameter can deflect the abdominal wall and cause injury.
When using step trocars, the Veress needle should be inserted first to safely insufflate, then the Veress needle with sheath should be inserted to place the sheath.
The sheath adds obstruction when inserting the Veress needle, making insertion smoother without the sheath.
In neonates, an infra-umbilical incision is made to avoid cannulating the umbilical vein, which enters through the center of the umbilicus.
The umbilical vein travels up through the center of the umbilicus; an infra-umbilical incision should avoid the obliterated orifice at the base of the umbilicus.
Lifting the umbilical stump with a clamp and inserting the Veress needle perpendicular to the now-vertical fascia (angled superiorly) is a technique to avoid the umbilical vein.
CO2 embolization via the umbilical vein is a recently recognized complication that was not widely known until about a year ago.
CO2 embolization presents with bradycardia, hypotension, and drop in end-tidal CO2.
Clinically significant CO2 embolization results in 25% mortality.
Immediate treatment for CO2 embolization includes desufflation, Trendelenburg positioning, and central venous line placement to aspirate gas.
Several cases of CO2 embolization have required emergent ECMO at the start of pyloromyotomy.
spk_0 now uses a sheathed technique but always inserts the trocar before insufflating, inspects with the telescope to confirm peritoneal entry, then begins insufflation.
Optical trocar (Optiview) is useful when not accessing through the umbilicus.
Keith Jorgenson taught the technique of inserting the trocar angled toward the spleen.
Scott Bollinger stated that performing the same technique repeatedly minimizes complications, while trying new techniques increases injury risk.
Steve Rothenberg states that two months is the age after which the umbilical vein is no longer a concern, though the source of this cutoff is unclear.
Steve Rothenberg presented 12 cases of CO2 embolization at IPEG, and he reports knowing of 15 total cases.
Transesophageal echocardiography has been discussed as an urgent diagnostic tool for suspected CO2 embolization.
Steve Rothenberg believes CO2 embolization can occur even without direct needle or trocar placement in the vein, possibly by damaging the vein during passage and allowing CO2 to enter the venous system during peritoneal insufflation.
Steve Rothenberg's opinion is that infra-umbilical Hasson approach is safer, and all other techniques (not using infra-umbilical incision) are at risk for CO2 embolization.