Ultrasound-Guided Access into the Abdomen in the Setting of Portal Hypertension: A Novel Technique

Introduction

The advancement and popularization of minimally invasive surgery have resulted in many methods for intraabdominal entry. ¹ Currently, the two principle techniques for access include the closed and open approaches. The open technique, initially described in 1970 by Harrith Hassan, involves a direct cut down through the abdomen to gain access. ² The closed technique consists of many types, one specifically involving the use of a Veress needle for blind insertion and insufflation. Despite the variability of techniques, studies fail to demonstrate a significant difference in outcomes for each method.^3–5 Regardless of the method used, access into the abdomen can prove challenging and complications related to initial insertion into the abdomen can be devastating.^6,7 Specifically, patients with portal hypertension pose a significant problem as increased retrograde flow through the paraumbilical veins can lead to engorgement, known as caput medusae. Injury can cause substantial complications, especially to deep epigastric vessels at the fascial level. Vascular injuries are difficult to manage and severely complicate a routine laparoscopic procedure.^8,9 In the current setting, traditional entry methods are used despite lack of observing underlying vessels.^10–12 In patients presenting with caput medusa in the setting of portal hypertension, using image-guided resources to avoid these vascular structures may avoid potentially devastating complications. Here, we describe ultrasound-guided access into the abdomen for an elective laparoscopic ventral hernia repair.

Case Report

This is the case of 6-year-old male with a history of living donor kidney transplant in 2012 who subsequently developed a symptomatic supraumbilical incisional hernia. The patient has autosomal recessive polycystic kidney disease, which led to end-stage renal disease, as well as congenital hepatic fibrosis resulting in portal hypertension. He was referred to pediatric surgery because of complaints of increased bulging and pain at the hernia site that gradually worsened over time. On physical examination, the patient had visible caput medusa (Fig. 1) throughout the anterior abdominal wall. Owing to his persistent symptoms, he was scheduled for an elective laparoscopic ventral hernia repair.

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FIG. 1.

Anterior abdominal wall caput medusa.

The patient was brought into the operating room and placed in the supine position. After intubation, the patient's abdomen was prepped and draped in the usual sterile manner. Ultrasound was then used to evaluate the anterior abdomen wall and locate abdominal wall vessels (Fig. 2A). Using ultrasound guidance, a 21 g micropuncture needle (Cook Medical, Inc., Bloomington, IN) was inserted just past the peritoneum in the right lower quadrant avoiding vessels and underlying bowel. In addition, using intraperitoneal fluid pockets as targets provides safe entry during needle insertion (Fig. 2B). Using the Seldinger technique, a 0.018 Cope wire (Cook Medical, Inc.) was placed through the needle, followed by a 3–4F dilator (Cook Medical, Inc.). Using the dilator, the 0.018 wire was exchanged for a stiff 0.035 Amplatz Super Stiff wire (Boston Scientific Corp., Natick, MA), which was used for serial dilations up to a 16F dilator. A VersaStep radially expandible sleeve or Veress sheath (Medtronic, Minneapolis, MN) was positioned over a 7F dilator (Fig. 3A) and placed into the abdomen, over the wire (Fig. 3B). After removal of the wire and dilator, a 5 mm Mini Step cannula and dilator (Medtronic) were safely placed without difficulty (Fig. 3C). The abdomen was insufflated and ultrasound was used again for placement of an additional 5 mm port. The area of the hernia was examined with ultrasound and vessel location was determined. A primary repair was performed with 0-Vicryl using a Carter-Thomason (CooperSurgical, Inc., Trumbull, CT) under laparoscopic and ultrasound guidance (Fig. 4A) with good result (Fig. 4B). The patient did well postoperatively and was discharged without complications.

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FIG. 2.

(A) Anterior abdominal wall; (B) ultrasound-guided intraabdominal needle insertion. V, collateral veins-caput medusae; SC, subcutaneous fat; RA, rectus muscle; P, parietal peritoneum; N, ultrasound needle; F, intraperitoneal fluid.

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FIG. 3.

(A) Seven serial dilation over wire. (B) Veress sheath over 7F dilator. (C) Veress sheath placed over a 7F dilator and inserted over the Amplatz wire into the abdomen.

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FIG. 4.

(A) Internal view of hernia repair. (B) External view of hernia repair.

Discussion

One of the major complications in laparoscopic surgery is injury at the time of entry into the abdomen. ¹³ Regardless of the entry technique, the overall vessel injury rate is low, with most injuries occurring to minor vessels at an incidence of 0.7%–2.5%.^14–16 Despite being considered minor vessels, injury to epigastric vessels and collaterals can cause significant patient morbidity.^17–19 This is especially relevant in patients presenting with portal hypertension and caput medusa. Control of bleeding in this case is often very difficult with various techniques described.^8,20,21 In the event that the injury is not identified at the time of operation, the patient may develop abdominal wall hematomas, infections, or intraabdominal bleeding. Owing to these risk factors, ensuring proper precautions during this crucial step in the operation can prevent avoidable complications.

The use of ultrasound can help to observe structures in the soft tissue otherwise invisible to the naked eye. This is of particular importance in the setting of caput medusae, by which avoiding large vessels in the anterior abdominal wall can ultimately prevent significant complications while entering the abdomen for access.

Conclusion

Use of ultrasound-guided access into the peritoneum for laparoscopic surgery is a safe and effective approach in a patient presenting with portal hypertension. This technique demonstrates an effective tool in the surgical armamentarium for entering the abdomen in patients with caput medusae.