LAPAROSCOPIC APPRAISAL OF THE ANATOMIC RELATIONSHIP OF THE UMBILICUS TO THE AORTIC BIFURCATION

Study Objective. To determine the cephalocaudal relationship among the umbilicus, aortic bifurcation, and iliac vessels by direct measuremen t during laparoscopy. Design. Prospective, consecutive study (Canadian Task Force classification II-1). Setting. Tertiary referral center. P atients. Ninety-seven women undergoing operative laparoscopy. interven tions. The distance from the aortic bifurcation relative to the umbili cus was measured in both the supine and Trendelenburg positions with a marked suction-irrigator probe. Patients were stratified into three g roups based on body mass index (kg/m(2)). The anatomic location of the common iliac vessels and course of the left common iliac vein were id entified in 68 women. Measurements and Main Results. The position of t he aortic bifurcation ranged from 5 cm cephalad to 3 cm caudal to the umbilicus in the supine position, and from 3 cm cephalad to 3 cm cauda l in the Trendelenburg position. In the supine position, the aortic bi furcation was located caudal to the umbilicus in only 11% of patients compared with 33% in the Trendelenburg position. This difference was s tatistically significant for the total study population (p <0.0001) an d for the nonoverweight group (p <0.07). In both positions no signific ant correlation was found between the distance from the aortic bifurca tion to the umbilicus and body mass index. Mean +/- SD distance oi the aortic bifurcation from the umbilicus in the supine position was 0.1 +/- 1.2 cm for the nonoverweight group, 0.7 +/- 1.5 cm for the overwei ght group, and 1.2 +/- 1.5 cm for the very overweight group. Respectiv e values in Trendelenburg position were 1.0 +/- 1.1, -0.4 +/- 1.2, and -0.2 +/- 1.3 cm. The common iliac artery was caudal to the umbilicus in four women. The space between common iliac arteries was always at l east partly occupied by the left common iliac vein, and was completely filled in 19 women (28%). Conclusions. The cephalocaudal relationship between the aortic bifurcation and umbilicus varies widely and is not related to body mass index in anesthetized patients. Regardless of bo dy mass index, the aortic bifurcation is more likely to be located cau dal to the umbilicus in the Trendelenburg compared with the supine pos ition. Its presumed location can be misleading during Veress needle or primary cannula insertion, and a more reliable guide is necessary for this procedure to avoid major retroperitoneal vascular injury.