Laparoscopic surgery following abdominal wall reconstruction: description of a novel method for safe entry

Abstract

We report a technique for safe laparoscopic access for gynaecological surgery in women who have had their abdominal wall reconstructed by plastic surgery. The abdominal wall incisions for placement of the trocars are made in the abdominoplasty scars and are cosmetically acceptable. In a limited series there appears to be no excess morbidity.In our cancer centre, we are seeing more women who have been advised to have ovarian ablation for adjuvant treatment of their breast cancer. An increasing number of these women have undergone primary reconstruction of the breast when having their definitive surgical treatment of the cancer. The transverse rectus abdominis myocutaneous flap is considered the 'gold standard' for breast reconstruction. This, allied with the escalating incidence of breast cancer 2 and a preferred use for surgical ovarian ablation for hormonal manipulation especially in ER-positive breast cancers, presented us with the need to manage women who had abdominal plastic surgery. Abdominoplasty and reconstructive surgery to the abdominal wall are considered contraindications to laparoscopic surgery, as the usual landmarks for entry are altered and there is significant scarring. A report suggested that the laparoscopic approach was possible, 3 although this either used an approach through the relocated umbilicus or used Palmer's point in the left upper quadrant.Following the use of the rectus abdominis as part of the breast reconstruction, the anterior abdominal wall is scarred by the abdominoplasty scar. The neo-umbilicus is relocated away from the original congenital cicatrix at the condensation of the rectus aponeurosis to a more cosmetically correct position and is often refashioned. Thus, it is not necessarily helpful either as a landmark or as an easy portal for entry as in normal laparoscopy. In addition, a nonabsorbable mesh has often been inserted to prevent hernia formation. The significant scarring, the mesh and the relocation of the umbilicus (an important landmark for most laparoscopy) are the contraindications for laparoscopic surgery. We felt that the use of the left upper quadrant entry (Palmer's point) may jeopardise the vascular pedicle for the transverse rectus abdominis myocutaneous flap used for the right breast reconstruction (left superior epigastric pedicle). We have therefore developed the described technique. The women were warned of the risks of laparoscopic surgery given the above concerns about scarring. All women gave informed consent for the procedure including the novel technique. TechniqueWomen who have been advised by the multidisciplinary breast team to have oophorectomy as part of their treatment are referred to our unit for discussion and surgery. In addition, there are women referred who have had plastic surgery and have coincidental gynaecological pathology. The procedure is described including possible complications and informed consent obtained. Under general anaesthetic, the woman is placed supine on the operating table and catheterised. A subcutaneous injection ...

Failed pneumoperitoneum for laparoscopic surgery following autologous Deep Inferior Epigastric Perforator (DIEP) flap breast reconstruction: a case report

“…Difficulties associated with performing laparoscopy in patients who have undergone prior abdominal wall surgery, such as abdominoplasty [ 1 , 2 , 4 , 25 ], umbilical hernia repair [ 26 ] and transverse rectus abdominis myocutaneous flap-based breast reconstruction [ 27 ], along with techniques to overcome such challenges, have been described previously. First, the altered abdominal wall anatomy resulting from previous surgery makes safe and proper trocar placement challenging.…”

“…In such cases, alternate stable landmarks can be used for reference, such as the xiphoid bone or the left subcostal pararectus region, Palmer’s point [ 28 ]. In addition, others employ alternate techniques for trocar placement, such as the modified open Hasson technique or the use of direct visual entry systems [ 25 , 27 , 29 , 30 ].…”

Difficulties of Bariatric Surgery after Abdominoplasty

“…Some alternative methods for laparoscopic trocar placement were described for patients following transverse rectus abdominis myocutaneous flap reconstruction. For this group of patients, great care should be given to avoid injury to blood supply of the flap [5, 6]. …”

“…This problem could be overcome by counter traction with towel clamps and perforation of fibrosis with a scalpel in one of our cases. After abdominoplasty, the anatomic points for trocar placement changed [5]. The umbilicus is the preferred anatomic landmark to determine midline, but after abdominoplasty reconstructed umbilicus may be relocated left or right side of its original location.…”