Should we use visual entry techniques in patients with previous laparotomies?

Laparoscopic surgery has become the method of choice for treating an ever increasing number of gynaecological disorders that require surgery. However, primary port insertion is a potentially dangerous step especially in patients with previous laparotomies. The aim of this study is to identify whether visual entry technique has any advantage over the closed one in patients with previous laparotomies. This is a retrospective observational case control study of 2541 patients with previous laparotomies who underwent laparoscopic surgery from January 1992 to September 2003 at Vijaya Hospital, Kochi and from October 2003 to October 2015 at Department of Endoscopy, Paul’s Hospital, Kochi, India. The control group comprised of 1261 patients, operated between January 1992 and September 2003 at Vijaya Hospital, Kochi, in whom closed technique of abdominal access for primary port creation was used. The study group comprised of 1280 patients, operated between October 2003 and October 2015 at Department of Endoscopy, Paul’s Hospital, Kochi, in whom visual entry (EndoTIP) was used for primary port creation. Procedures included in both groups were total laparoscopic hysterectomy, laparoscopic myomectomy, laparoscopic ovarian cystectomy, laparoscopic conservative surgery, laparoscopic tubal reanastomosis, laparoscopic sacrocolpopexy, laparoscopic sacrocervicopexy, laparoscopic adhesiolysis and laparoscopic sterilisation. There was no evidence of intestinal or vascular injury during visual entry using a blunt EndoTIP cannula. There were three cases of bowel injury with the closed, blind entry technique using a sharp linear trocar in the control group. The p value (Chi-square test) is 0.04, which is statistically significant. Visual entry, as an approach to abdominal access in patients with previous laparotomies, wherein chances of encountering peritoneal and bowel adhesions are very high, is safer than the closed blind entry technique in preventing bowel injuries.