I palpate the edge of the ribs at the midclavicular line
at the costal margin and carefully slide a #11 blade right along the lowermost rib to create an incision only large enough to accommodate a 2-mm scope.
One trocar is inserted by Hasson technique at the midclavicular line
. Working trocars are then inserted between the anterior-axillary line and posterior-axillary line at the level midway between the costal margin and the iliac crest.
Sensory block was assessed by pinpricks in midclavicular line
bilaterally using 27-gauge hypodermic needle.
Patients taking sedatives, Patients taking anticoagulants and patients with Cirrhosis of liver diagnosed on the basis of clinical [reduced liver span of less than 8cm in midclavicular line
, palpable spleen below the costal margin along with the presence of as cites], biochemical [reduced level of serum albumin less than 3.5 g/dl], radiological [reduced liver size of less than 8cm in midclavicular line
, portal vein diameter of greater than 1.3 cm and a splenic longitudinal size of greater than 14 cm] were excluded from the study.
Four laparoscopic ports were used: two 10 mm ports (one umbilical 10 mm port for the optical system and one epigastric port for the dissector/suction device) and two 5 mm ports (one at the midclavicular line
along the right subcostal margin and one in the right flank.
Cardiovascular: Pulses are palpable and equal bilaterally; no cyanosis; no edema nor clubbing; capillary refill less than 2 seconds; PMI at the apex in the left midclavicular line
; cardiac auscultation reveals a regular heart rate and rhythm; $1 and $2 noted; no thrills, rubs, gallops, nor murmurs.
We then placed instruments through three further points, one under the xiphisternum, one under the costal margin in the midclavicular line
and another on the anterior axillary line.
Three ports--umbilical camera 10mm port, epigastric Palanivelu hydatid system 12mm port and right midclavicular line
5mm working ports were placed for right lobe hydatid disease and 4 ports -supraumbilical 10mm port camera port, epigastric Palanivelu hydatid system 12mm port, right midclavicular line
5mm working port and left midclavicular line
5mm working port were placed for left lobe hydatid disease (Fig I and II).
The highest level of sensory block was sensed by pinprick method in caudal to cephalic direction every two minute, after the procedure of subarachnoid block was complete and the time taken to achieve absence of pinprick response at T 10 level in midclavicular line
was taken as onset of sensory block.
The most preffered site for initial access is the palmer's point-a point 3 cm below the left costal margin in midclavicular line
, as one is least likely to encounter intraabdominal adhesions at this point.
The highest level of sensory block was determined in the midclavicular line
bilaterally, by pinprick test using a 20-G hypodermic needle every 2miutes till the level was stabilized for four consecutive tests.
The highest level of sensory block was evaluated by pinprick at midclavicular line
anteriorly every 5 min for 20 min after the injection, thereafter every 15 min.