Background

Laparoscopic surgery has revolutionised the way gynaecological conditions are managed.  It has many benefits such as less postoperative pain, shorter hospital stay and reduced minor complications (1).  This was facilitated by the advent of video cameras and instruments which allowed access into the peritoneal cavity.  Despite no consensus on the best entry technique, there are numerous studies and guidelines to assist surgeons to make a choice.  The knowledge of different techniques is crucial as half of major complications occur at the time of initial entry (2).  Hence, one could say that the success of laparoscopic surgery lies first and foremost with the safe abdominal entry.  The closed technique with a Veress needle is most commonly used by gynaecologists worldwide (3).  However, one should not hesitate to adopt a different approach as guided by clinical indications.

This case demonstrates the use of the open technique, Hasson, in a patient with a large ovarian cyst with a previous laparotomy.

Case

A 48 year-old female had a laparoscopic left salpingo-oophrectomy performed for a 30cm left ovarian cyst with normal tumour markers.  She previously had laparotomy and right salpingectomy for ectopic pregnancy.   

Upon the successful entry by using the open technique, pneumoperitoneum was created with cardon dioxide.  Five accessory ports were used to secure a surgical field.  This enabled an evacuation of a significant amount of clear fluid, 6L, from the left ovarian cyst before salpingo-oophrectomy was performed.

Her postoperative recovery was uneventful and she was discharged the following day.

Conclusion 

In order for the actual laparoscopic procedure to take place, successful entry into the peritoneal cavity must occur.  Two commonly used techniques are the closed technique using a Veress needle or open Hasson technique.  The Veress needle allows a quick entry and has been more widely adopted by gynaecologists.  However, this is associated with an increased risk of major vascular complications compared to the open technique.  The Hasson takes place under a direct vision which makes this more useful if there are concerns for adhesions.  The disadvantage is a longer operative time. 

For this patient, the Hasson was chosen in view of a large cyst size and previous laparotomy.  Inadvertent puncture of the cyst was avoided by employing the direct visual approach. This allowed inspection of the integrity and nature of the cyst prior to removal.  The benign clinical appearance of the cyst was proven histologically.

This illustrates the importance of being familiar with pros and cons of different entry techniques in order to yield a successful beginning to laparoscopic surgery.