Although I very much appreciated Dr. Michael Baggish’s article, “Avoiding vascular injury at laparoscopy” (October), I was disappointed that no mention was made of using towel clips to elevate the edges of the umbilicus while inserting the trocar or Veress needle perpendicularly through the base of the umbilicus.1 Since the base of the umbilicus is consistently the thinnest portion of the entire abdominal wall (approximately 1.4 cm, compared with 3 cm at the lower border of the umbilicus), it is the easiest area to traverse, even in obese patients.
Further, Dr. Baggish states, “When force is applied via trocar to the anterior abdominal wall, that structure is displaced toward the abdominal cavity in the direction of the posterior abdominal wall—even when countertraction is taken into consideration.” He estimates that displacement to be 5 cm or more. However, his statement is accurate only when the countertraction is a hand grabbing the abdominal skin. It is not true when the countertraction is provided by towel clips on the umbilicus.
I have used the towel-clip technique (as described by Roy et al) for many years, and I believe it addresses both physiologic and practical concerns.
Jim Greenberg, MD
Boston, Mass
Dr. Baggish responds:
The technique of applying countertraction with towel clips is not new. I used this technique at Johns Hopkins Hospital, as did Dr. Clifford R. Wheeless in 1968. I taught the technique in Connecticut from 1972 to 1983, and in London, England, during my sabbatical in 1992, and continue to teach and use it here in Cincinnati. I am surprised it took 33 years for Dr. Roy et al to “rediscover” it.
Nevertheless, even with towel clips applied for countertraction, the skin of the abdominal wall plunges inward during the trocar thrust. I have recorded the inward excursion on vidoetape.
Reference
- Roy GM, Bazzurini L, Solima E, Luciano AA. Safe technique for laparoscopic entry into the abdominal cavity. J Am Assoc Gynecol Laparosc. 2001;8:519-528.