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1 1 2 O U T P A T I E N T S U R G E R Y M A G A Z I N E O N L I N E | M A R C H 2 0 1 5 D on't forget to focus on the start of laparoscopic procedures to ensure your surgeons have clear views of the action, says Vedra A. Augenstein, MD, a general surgeon in the Carolinas HealthCare System in Charlotte, N.C. "Getting into the abdomen might be the toughest part of the case," says Dr. Augenstein. "It isn't talked about very much, because rates of poor outcomes during trocar insertion are very low, but until you're in safely, it can be challenging." She says clear views are essential during the procedure, but they're also incred- ibly important when inserting trocars in order to avoid potentially fatal injuries. "It requires a high amount of skill to control entry into the abdomen," says Dr. Augenstein. "Even during a simple case like an umbilical hernia repair, trocar mishaps can prove devastating." Although Dr. Augenstein often gains successful access using an open cut-down method to insert a small trocar that she dilates to a larger port, she says the obese and elderly present unique challenges during the beginning stages of abdominal procedures. Cutting through several layers of fat before reaching muscle in over- weight patients is inherently difficult, and inserting a trocar can be problematic because the abdominal wall is thicker and heavier. The elderly, on the other hand, don't have little fat layers inside the abdomen to protect delicate organs from injury. During difficult trocar insertions, Dr. Augenstein might opt for a spe- cialized trocar that lets her visualize layers of the abdominal wall as she places the port. She makes a 1 cm incision in the fascia and inserts a zero-degree camera through the trocar, which lets her watch as its tip passes through layers of fat and muscle. "You know exactly where you are in the abdomen," says Dr. Augenstein. "The technique still depends on feel and knowing the best angle of insertion, but you're able to recognize the lay- ers" and avoid delicate structures. — Daniel Cook TROCAR MISHAPS Insert With Care z SURGICAL SITES Vedra A. Augenstein, MD, says starting pro- cedures with optimal views is key. Carolinas HealthCare System