Systematic review of the safety and effectiveness of methods used to establish pneumoperitoneum in laparoscopic surgery

State of art of robotic prostatectomy: the way we do it in Catalonia, Spain

INTRODUCTION AND OBJECTIVE

Robotic-assisted laparoscopic prostatectomy (PLAR) seems to improve functional outcomes, however there is not a consensus of a standard procedure. The aim of this study was to identify the PLAR "state of art" in Catalonia, Spain.

MATERIAL AND METHODS

This was a cross-sectional survey-based study conducted among urologists across Catalonia, Spain. The survey was distributed through online platforms and the professional urology society. All statistical analyses were performed using Stata software, v20.

RESULTS

59 urologists completed the survey, revealing PLAR as the most commonly used technique (79.7%). Most urologist (70%) create the pneumoperitoneum using a controlled incision with direct access and 78.3% use the Airseal technology. The intraperitoneal approach is performed in >90% of cases. Endopelvic fascia preservation is not routinely performed. 34.5% of the survey not perform the dorsal vein complex suture. All preserves the bladder neck when oncologically safe. Nerve-vascular bundles bleeding control is performed using standard coagulation or suturing. 34% performed posterior reconstruction. Only use hemostatic devices when evident bleeding and 70% does not routinely left a drainage. Multivariable analysis showed that center volume had a significant independent association with dorsal venous complex suturing (OR 0.073, 95%CI 0.07-0.826), nerve-vascular bundles suturing hemostasis (OR 11.67, 95%CI 1.07-127.60) and endopelvic fascia preservation (OR 13.64, 95%CI 1.087-201.27), but there was no correlation with time the bladder catheter or days hospitalized.

CONCLUSIONS

The study provides an overview of the state of PLAR in Catalonia, Spain, showing significant variability and reflecting a commitment to advancing surgical technology and patient care.

Injuries incurred from minimally invasive access for abdominal surgery

BACKGROUND

Injuries during initial port placement in minimally invasive abdominal surgery are rare but can cause major morbidity. We aimed to characterize the incidence, consequence, and risk factors for injury occurring on initial port placement.

METHODS

This is a retrospective review of a General Surgery quality collaborative database with supplementary input from the Morbidity and Mortality conference database at our institution between 6/25/2018 and 6/30/2022. Patient characteristics, operative details, and postoperative course were assessed. Cases with an injury on entry were compared to cases without an injury to identify risk factors for injury.

RESULTS

8844 minimally invasive cases were present between the two databases. Thirty-four injuries (0.38%) occurred during initial port placement. Seventy-one percent of injuries were bowel injuries (full or partial thickness) and the majority (79%) of injuries were recognized during the index operation. Median surgeon experience for the cases with an injury was 9 years (IQR 4.25-14.5) compared to 12 years of experience for all surgeons contributing to the database (p = 0.004). Previous laparotomy was also significantly correlated with the rate of injury on entry (p = 0.012). There was no significant difference in the rate of injury based on method of entry (cut-down: 19 (55.9%), optical entry without Veress: 10 (29.4%), Veress followed by optical entry: 5 (14.7%), p = 0.11). BMI > 30 kg/m² (injury: 16/34 vs no injury: 2538/8844, p = 0.847) was not associated with an injury. Fifty-six percent (19/34) of patients with an injury on initial port placement required laparotomy at some point in their hospital course.

CONCLUSIONS

Injuries are rare during initial port placement for minimally invasive abdominal surgery. In our database, history of a previous laparotomy was a significant risk factor for an injury and appears to be more consequential than commonly implicated factors such as technique, patient body habitus, or surgeon experience.

Gastric Injury at Laparoscopy for Gynecologic Indications: A Systematic Review

OBJECTIVE

This systematic review aims to identify causes of increased risk for and location and mechanism of gastric injury at laparoscopy for gynecologic indications and determine optimal management.

DATA SOURCES

A prospectively registered systematic review (PROSPERO: CRD42021237999) was undertaken and performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Databases searched included Cochrane Central Register of Controlled Trials, Cochrane Database of Systematic Reviews, Medline, Embase, Web of Science, SCOPUS, and Google Scholar from 1960 to 2021.

METHODS OF STUDY SELECTION

All study types were included involving female patients of any age with gastric injury at laparoscopy for gynecologic indication.

TABULATION, INTEGRATION, AND RESULTS

A total of 6294 articles were screened, from which 67 studies were selected for a full-text review. Twenty-eight articles were included, which contained 42 cases drawn from 7 observational studies, 4 case series, and 17 case reports. Of these, 93% (39/42) were at the time of laparoscopic entry, with Veress entry technique used in 79% of these cases (31/39). Eighteen cases reported an entry point, with 77% (14/18) occurring at the periumbilical entry point and 11% (2/18) occurring at Palmer's point. Of the cases with reported etiology for gastric distention or displacement, 64% (9/14) were owing to anesthetic cause. The most common sites of gastric injury were on the anterior stomach wall (n = 8) and the greater curvature (n = 5). Among patients with reported management (32/42), a similar proportion were managed conservatively (11) when compared with repair through laparotomy (13) or laparoscopy (8). All injuries were detected intraoperatively with no reported short-term sequelae.

CONCLUSION

This systematic review of the literature reveals that gastric injury at laparoscopy for gynecologic indications is a rare complication predominantly occurring during laparoscopic entry, most commonly at the periumbilical entry point. When detected intraoperatively, conservative management, laparoscopic, or open repair in the appropriate patient has been performed with no short-term sequelae. The limitations of this review include paucity of cases, detail, and timeline of publications.

Systematic review and meta-analysis of Veress needle entry versus direct trocar entry in gynecologic surgery

Objective

Although many studies have been performed, no consensus exists as to the ideal entry for laparoscopic gynecologic surgery. We sought out to compare the safety of direct trocar insertion with that of the Veress needle entry technique in gynecologic laparoscopic surgery.

Design

Systematic review with meta-analysis.

Setting

We searched Medline, ClinicalTrials.Gov, PubMed, Cochrane CENTRAL, SCOPUS, and Web of Science from their inception through 31 July 2021 for relevant studies. We included only controlled trials and ultimately seven trials were included in our meta-analysis.

Participants

Inclusion criteria included women undergoing gynecological laparoscopic surgery.

Intervention

The intervention of direct trocar insertion technique compared with Veress needle entry technique.

Main outcome measures

We compared five different outcomes associated with the efficacy and complications of laparoscopic entry.

Results

The pooled analysis showed that Veress needle entry was associated with a significant increase in the incidences of extraperitoneal insufflation (RR=0.177, 95% Cl (0.094 to 0.333), p<0.001), omental injury (RR=0.418, 95% Cl (0.195 to 0.896), p<0.001), failed entry (RR=0.173, 95% Cl (0.102 to 0.292), p<0.001), and trocar site infection (RR=0.404, 95% Cl (0.180 to 0.909), p<0.029). There was no significant difference between the two groups regarding the visceral injury (RR=0.562, 95% Cl (0.047 to 6.676), p<0.648).

Conclusions

When excluding all data apart from gynecologic surgery, the Veress needle entry technique may have an increased incidence of some, but not all complications of laparoscopic entry. It may also have a higher incidence of failed entry compared with direct entry techniques. Care should be taken in extrapolating these general results to specific surgeon experience levels.

Trial registration number

CRD42021273726

A negative pressure-based visualization technique for abdominal Veress needle insertion

PURPOSE

Abdominal Veress needle insertion is commonly performed to generate a pneumoperitoneum during laparoscopy. Various safety tests are conducted to confirm accurate needle tip positioning into the abdominal cavity. However, these occasionally yield unclear results and do not help directly visualize the peritoneum puncture. We validated a negative pressure-based technique that helps instantly visualize the moment of the Veress needle entry into the abdominal cavity.

METHODS

This study included 761 patients who underwent laparoscopic hernioplasty between 2003 and 2021 that entailed pneumoperitoneum creation using a Veress needle. They were divided into conventional technique (CON) and negative pressure visualization technique (NPV) groups. The patients were propensity score-matched (1:1) to minimize selection bias. To determine whether the technique gave a clear result to the surgeon and precisely informed the moment of entry, failed entry and emphysematous complications were compared between the groups.

RESULTS

The propensity score-matching yielded 105 pairs in the matched CON and NPV groups. Failed entry did not occur in the NPV group, whereas it occurred in 8 patients (7.6%) in the CON group (p = 0.004). No patient experienced extraperitoneal emphysema in the matched NPV group, whereas 7 patients (6.7%) in the CON group did (p = 0.007). The groups did not differ in the incidence of omental or mesenteric emphysema.

CONCLUSION

The NPV eliminated the incidence of failed entry and decreased the incidence of extraperitoneal emphysema, indicating that it could simply and adequately inform the moment of needle entry into the abdominal cavity.

Method for safe Verres needle entry at the umbilicus, with modification for first trocar entry to reduce the complication rate of first entry

Background

Initial intraperitoneal access and first trocar entry are responsible for nearly half of all complications of laparoscopic surgery. The purpose of this article is to detail our method of initial intraperitoneal access with Veress needle and first trocar at the umbilicus used over the past 28 years.

Patients and Methods

Since 1990, a single surgeon performed laparoscopic surgery in 7600 patients. From 1992 onward, 6975 patients underwent laparoscopic surgery. On assessment, 739 cases (10.6%) were found unsuitable for Veress needle entry at the umbilicus. The remaining, 6236, patients form the study group for this article. Every patient was operated in the identical, repetitive manner. Every detail was considered important. The method of the first trocar entry is modified to minimise complications of this manoeuvre.

Results

The average time from cleaning umbilicus again to Veress needle tip in peritoneum was 1 min 40 s (25 s-7 min). Out of the 4228 patients in whom no adhesions were observed at first trocar entry (Group 1), the Veress needle insertion was successful at first attempt in 3829 (90.5%) patients, at second attempt in 322 (7.6%) and at third attempt in 30 (0.7%). In the 2008 patients with significant adhesions observed after first trocar entry (Group 2), successful insertion of the Veress needle was achieved at first attempt in 1700 (84.6%) patients, at second attempt in 182 (9%) and at third attempt in 19 (0.9%). In this group, there was one bowel injury (0.05%) and 3 (0.15%) minor vascular injuries. There was no mortality in either group. In the overall series, the Veress needle was successfully introduced in 6082 of the 6236 patients (97.5%) and 154 patients (2.4%) failed Veress needle entry. The incidence of bowel injury in the series was 0.016% and that of minor vascular injuries was 0.048%.

Conclusions

Initial intraperitoneal access must be performed with utmost caution after adequate training and proctorship. This paper stresses with meticulous attention to every detail, this safe, method of initial intraperitoneal access leads to low complication rates.

A novel abdominal wall entry suction device to increase Veress needle safety: A prospective cohort pilot study

Background

In laparoscopic surgery, the Veress needle technique is most often used to initiate a pneumoperitoneum. Although low, entry-related injuries of the intestines and major vascular structures occur in 0.04–0.1% of cases. Up to 50% of these injuries remain undiagnosed at the time of surgery, resulting in mortality rates between 2.5 and 30%. In an effort to minimize such injuries we objectively assessed a novel abdominal wall entry suction device (AWESD) that was hypothesized to lift the abdominal wall and create an additional post-peritoneum safe margin for safer Veress needle introduction.

Materials and methods

A prospective pilot study was conducted in which CT-scans with and without AWESD application (centered above the umbilicus) were assessed to determine its effect on the distance from the linea alba to the intestines, vena cava and abdominal aorta. Paired measurements were subjected to the Wilcoxon signed rank test.

Results

Twelve participants were included. The AWESD significantly increased the median distance towards the intestines in the axial and sagittal plane (P = 0.01 and P = 0.006) from 0.93 (Inter Quartile Range (IQR): 0.33–1.51) and 0.85 (IQR: 0.32–1.47) to 1.35 (IQR: 0.39–2.27) and 1.25 (IQR: 0.42–2.10) centimeters, respectively. Similarly, for the median axial distances towards the vena cava and abdominal aorta (both P = 0.002) that were increased from 10.00 (IQR: 7.18–11.12) and 9.33 (IQR: 6.55–10.28) to 13.23 (IQR: 11.76–14.31) and 12.49 (IQR: 10.98–13.32) centimeters, respectively.

Conclusion

The AWESD significantly increased the distances between the peritoneum and main intra-abdominal structures. However, conclusions on subsequent increased safety cannot be drawn as high-volume studies are required to determine its clinical relevance.

•

Veress needle related injuries are rare but associated with high mortality rates.

•

A novel abdominal entry suction device to increase Veress needle safety was studied.

•

The device increased the distance between peritoneum and intra-abdominal structures.

•

The increased distance was greatest for the vena cava and abdominal aorta.

•

Despite the increased distances, the devices' clinical relevance remains unknown.

No. 193-Laparoscopic Entry: A Review of Techniques, Technologies, and Complications

OBJECTIVE

To provide clinical direction, based on the best evidence available, on laparoscopic entry techniques and technologies and their associated complications.

OPTIONS

The laparoscopic entry techniques and technologies reviewed in formulating this guideline include the classic pneumoperitoneum (Veress/trocar), the open (Hasson), the direct trocar insertion, the use of disposable shielded trocars, radially expanding trocars, and visual entry systems.

OUTCOMES

Implementation of this guideline should optimize the decision-making process in choosing a particular technique to enter the abdomen during laparoscopy.

EVIDENCE

English-language articles from Medline, PubMed, and the Cochrane Database published before the end of September 2005 were searched, using the key words laparoscopic entry, laparoscopy access, pneumoperitoneum, Veress needle, open (Hasson), direct trocar, visual entry, shielded trocars, radially expanded trocars, and laparoscopic complications.

VALUES

The quality of evidence was rated using the criteria described in the Report of the Canadian Task Force on the Periodic Health Examination. RECOMMENDATIONS AND SUMMARY STATEMENT.

A Modified Open Primary Laparoscopic Surgery Port Placement through Umbilical Tube

Background:

A safe, reliable technique for primary trocar introduction is important for laparoscopic surgery. In resource-constrained settings where there is paucity of needed equipment and cost is prohibitive, a method utilizing fewer instruments will be useful.

Aim:

This study aims to describe a method of primary trocar introduction that utilizes any available port.

Methods:

A supra- or infra-umbilical incision is made into an everted tubular umbilicus. The linear alba is incised and the resultant opening bluntly developed, after which any available port is inserted using the trocar as a guide. The trocar is withdrawn while the sleeve is pushed in.

Results:

One hundred and three successful insertions were affected in 107 patients with age range of 1–75 years, with no significant gas leaks.

Conclusion:

This modified open approach is a simple and reliable way of primary port insertion. Access is gained easily in different age groups and umbilicus types.

Laparoscopic entry techniques

BACKGROUND

Laparoscopy is a common procedure in many surgical specialties. Complications arising from laparoscopy are often related to initial entry into the abdomen. Life-threatening complications include injury to viscera (e.g. bowel, bladder) or to vasculature (e.g. major abdominal and anterior abdominal wall vessels). No clear consensus has been reached as to the optimal method of laparoscopic entry into the peritoneal cavity.

OBJECTIVES

To evaluate the benefits and risks of different laparoscopic entry techniques in gynaecological and non-gynaecological surgery.

SEARCH METHODS

We searched the Cochrane Gynaecology and Fertility (CGF) Group trials register, CENTRAL, MEDLINE, Embase, PsycINFO, and trials registers in January 2018. We also checked the references of articles retrieved.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) that compared one laparoscopic entry technique versus another. Primary outcomes were major complications including mortality, vascular injury of major vessels and abdominal wall vessels, visceral injury of bladder or bowel, gas embolism, solid organ injury, and failed entry (inability to access the peritoneal cavity). Secondary outcomes were extraperitoneal insufflation, trocar site bleeding, trocar site infection, incisional hernia, omentum injury, and uterine bleeding.

DATA COLLECTION AND ANALYSIS

Two review authors independently selected studies, assessed risk of bias, and extracted data. We expressed findings as Peto odds ratios (Peto ORs) with 95% confidence intervals (CIs). We assessed statistical heterogeneity using the I² statistic. We assessed the overall quality of evidence for the main comparisons using GRADE methods.

MAIN RESULTS

The review included 57 RCTs including four multi-arm trials, with a total of 9865 participants, and evaluated 25 different laparoscopic entry techniques. Most studies selected low-risk patients, and many studies excluded patients with high body mass index (BMI) and previous abdominal surgery. Researchers did not find evidence of differences in major vascular or visceral complications, as would be anticipated given that event rates were very low and sample sizes were far too small to identify plausible differences in rare but serious adverse events.Open-entry versus closed-entryTen RCTs investigating Veress needle entry reported vascular injury as an outcome. There was a total of 1086 participants and 10 events of vascular injury were reported. Four RCTs looking at open entry technique reported vascular injury as an outcome. There was a total of 376 participants and 0 events of vascular injury were reported. This was not a direct comparison. In the direct comparison of Veress needle and Open-entry technique, there was insufficient evidence to determine whether there was a difference in rates of vascular injury (Peto OR 0.14, 95% CI 0.00 to 6.82; 4 RCTs; n = 915; I² = N/A, very low-quality evidence). Evidence was insufficient to show whether there were differences between groups for visceral injury (Peto OR 0.61, 95% CI 0.06 to 6.08; 4 RCTs; n = 915: I² = 0%; very low-quality evidence), or failed entry (Peto OR 0.45, 95% CI 0.14 to 1.42; 3 RCTs; n = 865; I² = 63%; very low-quality evidence). Two studies reported mortality with no events in either group. No studies reported gas embolism or solid organ injury.Direct trocar versus Veress needle entryTrial results show a reduction in failed entry into the abdomen with the use of a direct trocar in comparison with Veress needle entry (OR 0.24, 95% CI 0.17 to 0.34; 8 RCTs; N = 3185; I² = 45%; moderate-quality evidence). Evidence was insufficient to show whether there were differences between groups in rates of vascular injury (Peto OR 0.59, 95% CI 0.18 to 1.96; 6 RCTs; n = 1603; I² = 75%; very low-quality evidence), visceral injury (Peto OR 2.02, 95% CI 0.21 to 19.42; 5 RCTs; n = 1519; I² = 25%; very low-quality evidence), or solid organ injury (Peto OR 0.58, 95% Cl 0.06 to 5.65; 3 RCTs; n = 1079; I² = 61%; very low-quality evidence). Four studies reported mortality with no events in either group. Two studies reported gas embolism, with no events in either group.Direct vision entry versus Veress needle entryEvidence was insufficient to show whether there were differences between groups in rates of vascular injury (Peto OR 0.39, 95% CI 0.05 to 2.85; 1 RCT; n = 186; very low-quality evidence) or visceral injury (Peto OR 0.15, 95% CI 0.01 to 2.34; 2 RCTs; n = 380; I² = N/A; very low-quality evidence). Trials did not report our other primary outcomes.Direct vision entry versus open entryEvidence was insufficient to show whether there were differences between groups in rates of visceral injury (Peto OR 0.13, 95% CI 0.00 to 6.50; 2 RCTs; n = 392; I² = N/A; very low-quality evidence), solid organ injury (Peto OR 6.16, 95% CI 0.12 to 316.67; 1 RCT; n = 60; very low-quality evidence), or failed entry (Peto OR 0.40, 95% CI 0.04 to 4.09; 1 RCT; n = 60; very low-quality evidence). Two studies reported vascular injury with no events in either arm. Trials did not report our other primary outcomes.Radially expanding (STEP) trocars versus non-expanding trocarsEvidence was insufficient to show whether there were differences between groups in rates of vascular injury (Peto OR 0.24, 95% Cl 0.05 to 1.21; 2 RCTs; n = 331; I² = 0%; very low-quality evidence), visceral injury (Peto OR 0.13, 95% CI 0.00 to 6.37; 2 RCTs; n = 331; very low-quality evidence), or solid organ injury (Peto OR 1.05, 95% CI 0.07 to 16.91; 1 RCT; n = 244; very low-quality evidence). Trials did not report our other primary outcomes.Other studies compared a wide variety of other laparoscopic entry techniques, but all evidence was of very low quality and evidence was insufficient to support the use of one technique over another.

AUTHORS' CONCLUSIONS

Overall, evidence was insufficient to support the use of one laparoscopic entry technique over another. Researchers noted an advantage of direct trocar entry over Veress needle entry for failed entry. Most evidence was of very low quality; the main limitations were imprecision (due to small sample sizes and very low event rates) and risk of bias associated with poor reporting of study methods.

Tuberculous peritonitis diagnosed using laparoscopy with assistance of a central venous catheter

Laparoscopy with peritoneal biopsy is a tool for rapid and accurate diagnosis of tuberculous peritonitis (TBP). However, laparoscopic procedures are not risk-free; complications include injuries to the gastrointestinal tract and major blood vessels. The purpose of the present study was to introduce a novel method for safe and straightforward laparoscopic diagnosis of TBP. A case series of 12 patients with TBP diagnosed between October 2012 and November 2013 at our hospital is presented. The patients underwent a novel method of laparoscopy involving the use of a central venous catheter (CVC). The diagnosis was confirmed by biopsy and histology. The efficacy of the method for TBP diagnosis was evaluated by the time taken for the procedure and the rate of successful completion. The safety of the method was evaluated by recording all intra- and post-operative adverse events encountered. The mean age of the patients was 41 years and 33% were male. The mean operation time was 50.6 min and the median duration of hospital stay was 7 days. In all cases, diagnostic laparoscopy was successfully performed. Targeted biopsies were taken from all of the patients and revealed caseous granulomatous inflammation. All patients tolerated the procedure without significant bleeding or digestive tract perforation. In conclusion, the present case series demonstrated a novel method of diagnostic laparoscopy with CVC that is a feasible and straightforward procedure for TBP diagnosis.

Comparison of two methods of laparoscopic trocar insertion (Hasson and Visiport) in terms of speed and complication in urologic surgery

BACKGROUND

Nowadays, diverse approaches have been existed for laparoscopic procedures. The most common laparoscopic entry methods included close and direct entry laparoscopy and open (Hasson) laparoscopy. There is no evidence regarding the superiority in safety and initial speed for the use of open and optical laparoscopic entry. Therefore, the sight of current study was to evaluate comparative survey of two methods of laparoscopic trocar insertion (Hasson and VisiportTM) in terms of speed and complications in urologic surgery.

METHODS

This expertized base clinical trial study was conducted on 100 patients who underwent urological laparoscopy in Alzahra Hospital, Isfahan, Iran. These patients were randomly divided to two groups (n = 50). One group underwent open laparoscopy and another group Visiport optical trocar. Speed and Complications of urologic surgery was extracted from medical records. Independent T test was used for doing of analysis.

RESULTS

The mean age of patients in Hasson and Visiport laparoscopic group was 41.4 ± 11.2 and 41.6 ± 15 years old, respectively (p = 0.91). The mean time for initial trocar placement in patients who underwent Visiport trocar system and Hasson laparoscopic technique was 37.7 ± 15.59 and 95.4 ± 31.75 seconds. There was gratifying difference between two techniques of laparoscopic trocar insertion (Hasson and Visiport) in terms of speed (p = 0.000). In addition, complications were observed in 8% of patients who underwent Visiport trocar system. However, no complications were observed in Hasson laparoscopy group.

CONCLUSION

Visiport optical trocar technique is faster for initial trocar placement than open laparoscopy. However it is associated with complications compared to open laparoscopy. Therefore, there is evidence of benefit in terms of speed for initial trocar placement and harm based on complications in Visiport trocar system.

Bowel injury following gynecological laparoscopic surgery

Background

Bowel injury remains a serious complication of gynecological laparoscopic surgery. We aimed to review the literature on this topic, combined with personal experiences, so as to give recommendations on how to avoid and manage this complication.

Methods

We performed a narrative review on bowel injury following gynecological laparoscopic surgery using PubMed covering prevention, diagnosis, and management. Search terms used were laparoscopy, gynaecology, injury, bowel, prevention, treatment.

Results

Important principles of prevention include proper pre-operative evaluation and increased laparoscopic surgical skills and knowledge. High clinical suspicion is crucial for early diagnosis. Diagnostic workup of suspected cases includes serial abdominal examination, measuring inflammatory markers, and performing imaging studies including abdominal ultrasound and CT scan. When bowel injury is recognized during the first laparoscopic procedure then laparoscopic primary suturing could be tried although laparotomy may be needed. When diagnosis is delayed, then laparotomy is the treatment of choice. The role of robotic surgery and three-dimensional laparoscopic gynecological surgery on bowel injury needs to be further assessed.

Conclusion

Early recognition of bowel injury is crucial for a favorable clinical outcome. A combined collaboration between gynecologists and general surgeons is important for timely and proper decisions to be made.

Transperitoneal Subcostal Access for Urologic Laparoscopy: Experience of a Large Chinese Center

Objective. To present our experience of using transperitoneal subcostal access, Palmer's point (3 cm below the left costal margin in the midclavicular line), and its right corresponding site, in urologic laparoscopy. Methods. We used Palmer's point and the right corresponding site for initial access in 302 urologic surgeries (62 cases with prior surgeries). The record of these cases was reviewed. Results. Success rate of initial access is 99.4%, and complication rate of puncturing is only 3.4% with no serious complication. In the cases with prior surgeries, there were only two cases with access complication on the right side (minor laceration of liver). For people with BMI more than 30 kg/m² (12, 3.9%), the success rate was also 100 percent. Conclusions. Palmer's point and the corresponding right location are feasible, effective, and safe for initial access in urologic laparoscopic surgeries. This entry technique should be used routinely in urologic laparoscopic surgeries.

Laparoscopic access overview: Is there a safest entry method?

BACKGROUND

Laparoscopy is a minimally invasive technique to access the abdominal cavity, for diagnostic or therapeutic applications. Optimizing the access technique is an important step for laparoscopic procedures. The aim of this study is to assess the outcomes of different laparoscopic access techniques and to identify the safest one.

METHODS

Laparoscopic access questionnaire was forwarded via e-mail to the 60 centers who are partners in working group for laparoscopic and robotic surgery of the Italian Urological Society (SIU) and their American and European reference centers.

RESULTS

The response rate was 68.33%. The total number of procedures considered was 65.636. 61.5% of surgeons use Veress needle to create pneumoperitoneum. Blind trocar technique is the most commonly used, but has the greatest number of complications. Optical trocar technique seems to be the safest, but it's the less commonly used. The 28,2% of surgeons adopt open Hasson's technique. Total intra-operative complications rate was 3.3%. Open conversion rate was 0.33%, transfusion rate was 1.13%, and total post-operative complication rate was 2.53%.

CONCLUSION

Laparoscopic access is a safe technique with low complication rate. Most of complications can be managed conservatively or laparoscopically. The choice of access technique can affect the rate and type of complications and should be planned according to surgeon experience, safety of each technique and patient characteristics. All access types have perioperative complications. According with our study, optical trocar technique seems to be the safest.

Early hospital readmission after laparoscopic cholecystectomy

INTRODUCTION

Laparoscopic cholecystectomy (LC) now has become the golden standard in the treatment of symptomatic gallstone cholecystitis.

AIM

This retrospective analysis was conducted to clarify the reasons of early return to the hospital after discharge following a procedure like LC that has been frequently performed in daily surgical practice.

MATERIALS AND METHODS

This study covers 586 patients, who were called to follow-ups and thus evaluated, of 676 patients who had had LCs at Meram Medical School's General Surgery Clinic between January 2010 and May 2011.

FINDINGS

The rate of representation to the hospital during the early phase following LC was found to be 2.4% in our study. It was observed that 71% of returning patients had presented to the hospital with complaints of abdominal pain.

DISCUSSION

We believe that the rate of 2.4% early return to the hospital in our series is a bit high when all the complications are taken into consideration. This retrospective analysis, however, has shown that this rate can further be decreased by taking simple measures.

Major vascular injury in laparoscopic urology

BACKGROUND AND OBJECTIVES

Major vascular injury is the most devastating complication of laparoscopy, occurring most commonly during the laparoscopic entry phase. Our goal is to report our experience with major vascular injury during laparoscopic entry with closed- and open-access techniques in urologic procedures.

METHODS

All 5347 patients who underwent laparoscopic urologic procedures from 1996 to 2011 at our hospital were included in the study. Laparoscopic entry was carried out by either the closed Veress needle technique or the modified open Hasson technique. Patients' charts were reviewed retrospectively to investigate for access-related major vascular injuries.

RESULTS

The closed technique was used in the first 474 operations and the open technique in the remaining 4873 cases. Three cases of major vascular injury were identified among our patients. They were 3 men scheduled for nephrectomy without any history of surgery. All injuries occurred in the closed-access group during the setup phase with insertion of the first trocar. The injury location was the abdominal aorta in 2 patients and the external iliac vein in 1 patient. Management was performed after conversion to open surgery, control of bleeding, and repair of the injured vessel.

CONCLUSIONS

Given the high morbidity and mortality rates associated with major vascular injury, its clinically higher incidence in laparoscopic urologic procedures with the closed-access technique leads us to suggest using the open technique for the entry phase of laparoscopy. Using the open-access technique may decrease laparophobia and encourage a higher number of urologists to enter the laparoscopy field.

Modified Open Laparoscopy Using a 5-mm Laparoscope

BACKGROUND

In an effort to minimize injuries associated with closed laparoscopic entry, many surgeons use a 10-mm standard open laparoscopy technique. Disadvantages of this open technique are that it requires a larger incision, fascial sutures, and does not always achieve an airtight seal. Although 5-mm laparoscopics with excellent optics are available, little has been written about open techniques using them.

TECHNIQUE

We report a modified 5-mm open laparoscopy technique without fascial sutures. The fascia is elevated with small Kocher forceps and incised in the midline. The peritoneum is bluntly perforated with a hemostat-directed cephalad, and a blunt trocar with a sleeve is inserted in this direction. After rotating the sleeve toward the pelvis, a 5-mm laparoscope is placed into the abdomen before insufflation.

EXPERIENCE

We have performed approximately 350 laparoscopies with only one major complication of a perforated transverse colon densely adherent beneath the umbilicus in a woman without previous abdominal surgery. Minor carbon dioxide leakage was uncommon and no wound infections or hernias occurred.

CONCLUSION

This 5-mm modified open laparoscopic entry technique minimizes some of the disadvantages associated with conventional open and closed 10-mm laparoscopic techniques while avoiding blind placement of sharp instruments into the peritoneal cavity.

Trocar in conventional laparoscopic and robotic-assisted surgery as a major cause of iatrogenic trauma to the patient

All laparoscopic procedures, laparoscopic or robotic-assisted, start with a trocar entry. Unfortunately unknown to most, this is an extremely important part of the surgery, as 80% of major vascular injuries and 50% of intestinal injuries occur during this procedure. Laparoscopic first entry is often delegated to trainees with little experience, wrongly assuming that laparoscopic entry is similar to incisional entry at laparotomy. This may result in patient death (mortality of major vascular injuries is 11% and unrecognized intestinal injuries is 5%) or significant temporary or permanent morbidity.

Laparoscopic entry techniques

BACKGROUND

Laparoscopy is a common procedure in many surgical specialities. Complications arising from laparoscopy are often related to initial entry into the abdomen. Life-threatening complications include injury to viscera e.g. the bowel or bladder, or to vasculature e.g. major abdominal and anterior abdominal wall vessels. Minor complications can also occur, such as postoperative wound infection, subcutaneous emphysema, and extraperitoneal insufflation. There is no clear consensus as to the optimal method of laparoscopic entry into the peritoneal cavity.

OBJECTIVES

To evaluate the benefits and risks of different laparoscopic entry techniques in gynaecological and non-gynaecological surgery.

SEARCH METHODS

This updated review has drawn on the search strategy developed by the Cochrane Menstrual Disorders and Subfertility Group. In addition, MEDLINE, EMBASE, CENTRAL and PsycINFO were searched through to September 2014.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) in which one laparoscopic entry technique was compared with another.

DATA COLLECTION AND ANALYSIS

Two authors independently selected studies, assessed risk of bias, and extracted data. We expressed findings as Peto odds ratios (Peto ORs) with 95% confidence intervals (CIs). We assessed statistical heterogeneity using the I² statistic. We assessed the overall quality of evidence for the main comparisons using GRADE methods.

MAIN RESULTS

The review included 46 RCTs including three multi-arm trials (7389 participants) and evaluated 13 laparoscopic entry techniques. Overall there was no evidence of advantage using any single technique for preventing major vascular or visceral complications. The evidence was generally of very low quality; the main limitations were imprecision and poor reporting of study methods. Open-entry versus closed-entry There was no evidence of a difference between the groups for vascular (Peto OR 0.14, 95% CI 0.00 to 6.82, three RCTs, n = 795, I(2) = n/a; very low quality evidence) or visceral injury (Peto OR 0.61, 95% CI 0.06 to 6.08, three RCTs, n = 795, I(2) = 0%; very low quality evidence). There was a lower risk of failed entry in the open-entry group (Peto OR 0.16, 95% CI 0.04 to 0.63, n = 665, two RCTs, I(2) = 0%; very low quality evidence). This suggests that for every 1000 patients operated on, 31 patients in the closed-entry group will have failed entry compared to between 1 to 20 patients in the open-entry group. No events were reported in any of the studies for mortality, gas embolism or solid organ injury. Direct trocar versus Veress needle entry There was a lower risk of vascular injury in the direct trocar group (Peto OR 0.13, 95% CI 0.03 to 0.66, five RCTs, n = 1522, I(2) = 0%; low quality evidence) and failed entry (Peto OR 0.21, 95% CI 0.14 to 0.30, seven RCTs, n = 3104; I ²= 0%; moderate quality evidence). This suggests that for every 1000 patients operated on, 8 patients in the Veress needle group will experience vascular injury compared to between 0 to 5 patients in the direct trocar group; and that 64 patients in the Veress needle group will experience failed entry compared to between 10 to 20 patients in the direct trocar group. The vascular injury significance is sensitive to choice of statistical analysis and may be unreliable. There was no evidence of a difference between the groups for visceral (Peto OR 1.02, 95% CI 0.06 to 16.24, four RCTs, n = 1438, I(2) = 49%; very low quality evidence) or solid organ injury (Peto OR 0.16, 95% Cl 0.01 to 2.53, two RCTs, n = 998, I(2) = n/a; very low quality evidence). No events were recorded for mortality or gas embolism. Direct vision entry versus Veress needle entry There was no evidence of a difference between the groups in the rates of visceral injury (Peto OR 0.15, 95% CI 0.01 to 2.34, one RCT, n = 194; very low quality evidence). Other primary outcomes were not reported. Direct vision entry versus open-entry There was no evidence of a difference between the groups in the rates of visceral injury (Peto OR 0.13, 95% CI 0.00 to 6.50, two RCTs, n = 392; low quality evidence), solid organ injury (Peto OR 6.16, 95% CI 0.12 to 316.67, one RCT, n = 60, I(2) = n/a; very low quality evidence), or failed entry (Peto OR 0.40, 95% CI 0.04 to 4.09, one RCT, n = 60; low quality evidence). Vascular injury was reported, however no events occurred. Our other primary outcomes were not reported. Radially expanding (STEP) trocars versus non-expanding trocars There was no evidence of a difference between the groups for vascular injury (Peto OR 0.24, 95% Cl 0.05 to 1.21, two RCTs, n = 331, I(2) = 0%; low quality evidence), visceral injury (Peto OR 0.13, 95% CI 0.00 to 6.37, two RCTs, n = 331, I(2) = n/a; low quality evidence), or solid organ injury (Peto OR 1.05, 95% CI 0.07 to 16.91, one RCT, n = 244; very low quality evidence). Other primary outcomes were not reported. Comparisons of other laparoscopic entry techniquesThere was a higher risk of failed entry in the group in which the abdominal wall was lifted before Veress needle insertion than in the not-lifted group (Peto OR 4.44, 95% CI 2.16 to 9.13, one RCT, n = 150; very low quality evidence). There was no evidence of a difference between the groups in rates of visceral injury or extraperitoneal insufflation. The studies had small numbers and excluded many patients with previous abdominal surgery, and women with a raised body mass index. These patients may have unusually high complication rates.

AUTHORS' CONCLUSIONS

Overall, there is insufficient evidence to recommend one laparoscopic entry technique over another.An open-entry technique is associated with a reduction in failed entry when compared to a closed-entry technique, with no evidence of a difference in the incidence of visceral or vascular injury.An advantage of direct trocar entry over Veress needle entry was noted for failed entry and vascular injury. The evidence was generally of very low quality with small numbers of participants in most studies; our findings should be interpreted with caution.

The integration of minimally invasive surgery in surgical practice in a Canadian setting: results from 2 consecutive province-wide practice surveys of general surgeons over a 5-year period

BACKGROUND

Although minimally invasive surgery (MIS) has been quickly embraced, the introduction of advanced procedures appears more complex. We assessed the evolution of MIS in the province of Quebec over a 5-year period to identify areas for improvement in the modern surgical era.

METHODS

We developed, test-piloted and conducted a self-administered questionnaire among Quebec general surgeons in 2007 and 2012 to examine stated MIS practice, MIS training and barriers and facilitators to the use of MIS.

RESULTS

Response rates were 51.3% (251 of 489) in 2007 and 31.3% (153 of 491) in 2012. A significant increase was observed for performance of most advanced MIS procedures, especially for colectomy for benign (66.0% v. 84.3%, p < 0,001) and malignant diseases (43.3% v. 77.8%, p < 0,001) and for rectal surgery for malignancy (21.0% v. 54.6%, p < 0.001). More surgeons practised 3 or more advanced MIS procedures in 2012 than in 2007 (82.3% v. 64.3%, p < 0,001). At multivariate analysis, the 2007 survey administration was associated with fewer surgeons practising advanced MIS (odds ratio 0.13, 95% confidence interval 0.06-0.29). In 2012, more respondents stated they gained their skills during residency (p = 0.028).

CONCLUSION

From 2007 to 2012 there was a significant increase in advanced MIS procedures practised by general surgeons in Québec. This technique appears well established in current surgical practice. The growing place of MIS in residency training seems to be a paramount part of this development. Results from this study could be used as a baseline for studies focusing on ways to further improve the MIS practice.

Avoiding and managing vascular injury during robotic-assisted radical prostatectomy

There has been an increase in the number of urologic procedures performed robotically assisted; this is the case for radical prostatectomy. Currently, in the USA, 67% of prostatectomies are performed robotically assisted. With this increase in robotic urologic surgery it is clear that there are more surgeons in their learning curve, where most of the complications occur. Among the complications that can occur are vascular injuries. These can occur in the initial stages of surgery, such as in accessing the abdominal cavity, as well as in the intraoperative or postoperative setting. We present the most common vascular injuries in robot-assisted radical prostatectomy, as well as their management and prevention. We believe that it is of vital importance to be able to recognize these injuries so that they can be prevented.

Coming to terms with the fact that the evidence for laparoscopic entry is as good as it gets

Entry to the peritoneal cavity for laparoscopic surgery is associated with defined morbidity, with all entry techniques associated with substantial complications. Debate over the safest entry technique has raged over the last 2 decades, and yet, we are no closer to arriving at a scientifically valid conclusion regarding technique superiority. With hundreds of thousands of patients required to perform adequately powered studies, it is unlikely that appropriately powered comparative studies could be undertaken. This review examines the risk of complications related to laparoscopic entry, current statements from examining bodies around the world, and the medicolegal ramifications of laparoscopic entry complications. Because of the numbers required for any complications study, with regard to arriving at an evidence-based decision for laparoscopic entry, we ask: is the current literature perhaps as good as it gets?

Reducing trocar movement in operative laparoscopy through use of a fixator

STUDY OBJECTIVE

To evaluate trocar stability using a fixation device to control trocar insertion depth and in particular to provide greater stability during laparoscopic procedures, and to evaluate the effects of using a fixator to control mobility of trocars.

DESIGN

Non-blinded prospective study (Canadian Task Force classification II-2).

SETTING

University hospital department of gynecology, obstetrics, and gynecological oncology.

PATIENTS

Forty-three patients scheduled to undergo gynecologic laparoscopic intervention with planned operative time >10 minutes.

INTERVENTIONS

In all procedures, 5-mm working trocars bearing a plain (smooth) sleeve were used. The fixator device, consecutively either on the left or right side, was attached to 1 of 2 side trocars before insertion. In 18 patients, an unsutured fixator was used (FX-US subgroup). In the remaining 25 patients, the device was sutured to the skin via specially designed suturing ports (FX-S subgroup). The position of both trocars in the groups with a fixator (FX group) and without a fixator (NFX group) in the abdominal wall was evaluated at the start of the procedure and every 10 minutes intraoperatively.

MEASUREMENTS AND MAIN RESULTS

In the FX group, there was significantly decreased trocar movement compared with the NFX group (mean [SD] 0.02 [0.6] cm vs 0.84 [4.4] cm). In addition, in the NFX group, the trocar tended to slip into the abdomen during the operation, whereas in the FX group, trocars tended to slip out. Of 43 ports, 11 (25.6%) had to be either reinserted or readjusted at some point during the operation. In 2 procedures, reinsertion of the trocar at exactly the same location was impossible. In the FX-US subgroup, there was 1 incidence of trocar dislocation, whereas there were no dislocations in the FX-S subgroup. The difference in the effect between the 2 study arms, fixator unsutured and fixator sutured, was expected to produce only a small benefit in the sutured fixator arm; however, the benefit was greater than anticipated.

CONCLUSION

Use of a fixator significantly reduces plain (smooth) sleeve trocar movement and prohibits complete dislocation or slippage of the port, and suturing the device to the skin further minimizes trocar movement. Trocar stabilization via a fixation device may lead to shorter operative time and reduce problems associated with trocar slippage or dislocation.

A comparison of three different entry techniques in gynecological laparoscopic surgery: a randomized prospective trial

OBJECTIVE

Laparoscopic entry techniques vary and still remain debated. We conducted a randomized control trial to compare three entry techniques.

STUDY DESIGN

Women aged 18-70 years, nominated for laparoscopic surgery at University of Rome Campus Bio-Medico, were randomized into three different groups: Veress needle (VER), Direct trocar insertion (DIR) and Open technique (OP). For each group, minor complications (extra-peritoneal insufflation, trocar site bleeding, omental injury and surgical site infection), failed entry and time of entry of the main trocar were evaluated. Major complications were also considered. Between-group comparisons were performed using chi-square test. Significance P value was <0.05.

RESULTS

A series of 595 consecutive procedures were included: 193 in the VER group, 187 in the DIR group and 215 in the OP group. Minor complications occurred in 36 cases: extraperitoneal insufflation (n=6) in the VER group only, site bleeding (n=2 in the VER group, n=2 in the DIR group and n=1 in the OP group), site infection (n=5 in the VER and n=6 in OP group), and omental injury (n=6 in the VER group and n=3 in the DIR group). Failed entry occurred in 4 cases of the VER group and 1 case of the DIR group. Mean time of entry was 212.4, 71.4 and 161.7s for the VER, DIR and OP groups respectively. Among major complications, one bowel injury resulted following the Veress technique.

CONCLUSIONS

In our series, DIR and OP entry presented a lower risk of minor complications compared with VER. In addition, time of entry was shorter in DIR than with OP entry.

Evaluation of Effects of Intraperitoneal CO2 Pressure in Laparoscopic Operations on Kidney, Pancreas, Liver and Spleen in Dogs

Background

During laparoscopy, insufflation of an inert gas in the peritoneal cavity creates a working space to facilitate surgery. The space should be large enough to facilitate surgery without increasing intra-abdominal pressure (IAP) over a threshold limit (usually 15 mm Hg).

Objectives

This experimental study was performed to evaluate the effects of increasing in intra-abdominal pressure on internal organs.

Materials and Methods

Twenty female mixed breed dogs (20 ± 3 kg, 18 ± 1.2 months) were selected. They were randomly divided to two groups (n = 10). The intra-abdominal pressure was maintained 12 mm Hg and 20 mm Hg during the operation in control group and in test group respectively.

Results

Histopathologic evaluations revealed more pathological changes at the kidney of all the dogs in test group in comparison to control group.

Conclusions

Our findings revealed that organs that their blood supplies are related to one single or two arteries and their blood drainage are related to one or two veins are more sensitive to increased intra-abdominal pressure.

Laparoscopy in colorectal surgery

Laparoscopic colorectal surgery may be comparable with open techniques when considering oncological and long-term follow-up outcomes; however, there are a few operative complications specific to laparoscopic colorectal surgery. This article reviews the array of complications and discusses them in detail.

Comparison of two entry methods for laparoscopic port entry: technical point of view

Laparoscopic entry is a blind procedure and it often represents a problem for all the related complications. In the last three decades, rapid advances in laparoscopic surgery have made it an invaluable part of general surgery, but there remains no clear consensus on an optimal method of entry into the peritoneal cavity. The aim of this paper is to focus on the evolution of two used methods of entry into the peritoneal cavity in laparoscopic surgery.

Direct trocar insertion for laparoscopy

BACKGROUND

The Veress needle (VN) technique for establishing pneumoperitoneum in laparoscopic surgery is widely used and yet is associated with slow insufflation rates and potentially life-threatening complications. Although these complications have been rarely reported, they represent a major source of morbidity and mortality from laparoscopic procedures and a major reason for conversion to open surgery. The open laparoscopy (OL) is an alternative to the VN technique, being relatively safer, even if considered cumbersome by many authors. Recently, the direct trocar insertion (DTI) technique of establishing pneumoperitoneum has been reported as an alternative to both techniques, but it is largely confined to gynecologic procedures. We report a case-series study where we evaluate the patients who underwent a DTI entry for laparoscopy during a recent 5-year period, focusing attention on feasibility, safety, and the benefits of DTI.

METHODS

This is a case series of 2175 different laparoscopic procedures (1456 [66.9%] scheduled cases and 719 [33%] emergencies). In 2091 (96.1%) of them (1425 [68.1%] scheduled cases and 666 [31.8%] emergencies), pneumoperitoneum was established with DTI, either in the umbilicus or in Palmer's point.

RESULTS

There were no injuries, either minor or major. Peritoneal access and the creation of a laparoscopic workplace were obtained quickly and efficiently by DTI.

CONCLUSION

Our results suggest that DTI is a fast, safe, and reliable alternative to traditional techniques for pneumoperitoneum establishment and should be regarded as a part of the surgical armamentarium of a trained laparoscopic surgeon.

The safety of direct trocar versus Veress needle for laparoscopic entry: a meta-analysis of randomized clinical trials

OBJECTIVE

This study assessed the safety of direct trocar insertion (DTI) versus Veress needle followed by primary trocar insertion (VN).

METHODS

Ovid MEDLINE(®), Cochrane Library, Google Scholar, Scopus, and the reference lists of published articles were searched up to September 2011 to identify randomized clinical trials comparing DTI with VN. This meta-analysis was restricted to randomized studies comparing the safety of these two laparoscopic entry techniques.

RESULTS

Seven randomized studies consisting of 2940 women (VN, n=1525; DTI, n=1415) were identified. The data on the safety of two entry techniques were abstracted, integrated, and analyzed with the meta-analysis method and are presented as pooled relative risk (RR) with 95% confidence intervals (CI). There were 4 cases of a major complication in the VN group in contrast to none in the DTI group. Pooled results failed to show a statistically significant difference in the risk of major complications between the two groups. A significantly higher risk of minor complications was detected in the VN group (RR [95% CI]=10.78 [6.27-18.51]). Among minor complications, preperitoneal injuries (46.73 [11.55-189.10]) and omental injuries (4.51 [2.12-9.62]) were the two most common complications in the VN group. There were significantly increased risks of multiple insertions (more than two attempts) (2.99 [2.11-4.23]) and failed entry (2.21[1.07-4.56]) in the VN group.

CONCLUSION

This meta-analysis suggests that the commonly used VN entry technique carries a significantly increased risk of minor complications. In addition, the likelihood of multiple insertions and failed entry are significantly higher in the VN group.

Laparoscopic entry techniques

BACKGROUND

Laparoscopy is a common procedure in gynaecology. Complications associated with laparoscopy are often related to entry. Life-threatening complications include injury to the bowel, bladder, major abdominal vessels, and an anterior abdominal-wall vessel. Other less serious complications can also occur, such as post-operative infection, subcutaneous emphysema and extraperitoneal insufflation. There is no clear consensus as to the optimal method of entry into the peritoneal cavity. This is an update of a Cochrane review first published in 2008.

OBJECTIVES

To evaluate the benefits and risks of different laparoscopic techniques in gynaecological and non-gynaecological surgery.

SEARCH METHODS

This review has drawn on the search strategy developed by the Cochrane Menstrual Disorders and Subfertility Group. In addition, MEDLINE, EMBASE, CENTRAL and PsycINFO were searched through to February 2011.

SELECTION CRITERIA

Randomised controlled trials were included when one laparoscopic entry technique was compared with another.

DATA COLLECTION AND ANALYSIS

Data were extracted independently by the first three authors. Differences of opinion were registered and resolved by the fourth author. Results for each study were expressed as odds ratio (Peto OR) with 95% confidence interval (CI).

MAIN RESULTS

The review included 28 randomised controlled trials with 4860 individuals undergoing laparoscopy and evaluated 14 comparisons. Overall there was no evidence of advantage using any single technique in terms of preventing major vascular or visceral complications. Using an open-entry technique compared to a Veress Needle demonstrated a reduction in the incidence of failed entry, Peto OR 0.12 (95% CI 0.02 to 0.92). There were three advantages with direct-trocar entry when compared with Veress Needle entry, in terms of lower rates of failed entry (Peto OR 0.21, 95% Cl 0.14 to 0.31), extraperitoneal insufflation (Peto OR 0.18, 95% Cl 0.13 to 0.26), and omental injury (Peto OR 0.28, 95% CI 0.14 to 0.55).There was also an advantage with radially expanding access system (STEP) trocar entry when compared with standard trocar entry, in terms of trocar site bleeding (Peto OR 0.31, 95% Cl 0.15 to 0.62). Finally, there was an advantage of not lifting the abdominal wall before Veress Needle insertion when compared to lifting in terms of failed entry, without an increase in the complication rate (Peto OR 4.44, 95% CI 2.16 to 9.13). However, studies were limited to small numbers, excluding many patients with previous abdominal surgery and women with a raised body mass index who may have unusually high complication rates.

AUTHORS' CONCLUSIONS

An open-entry technique is associated with a significant reduction in failed entry when compared to a closed-entry technique, with no difference in the incidence of visceral or vascular injury.Significant benefits were noted with the use of a direct-entry technique when compared to the Veress Needle. The use of the Veress Needle was associated with an increased incidence of failed entry, extraperitoneal insufflation and omental injury; direct-trocar entry is therefore a safer closed-entry technique.The low rate of reported complications associated with laparoscopic entry and the small number of participants within the included studies may account for the lack of significant difference in terms of major vascular and visceral injury between entry techniques. Results should be interpreted with caution for outcomes where only single studies were included.

[Inguinal and femoral hernia repair]

With an incidence of 200,000 new cases per year in Germany, inguinal hernia has a significant socioeconomic impact. The 2009 guidelines from the European Hernia Society established treatment recommendations. Hernia repair is based on reinforcing the posterior wall of the inguinal canal by suture or mesh repair by an anterior or posterior approach. Lightweight mesh reduces recurrence rates and is the treatment of choice even in primary hernias. Laparoscopic hernia repair is associated with specific risks but is superior in postoperative pain and earlier return to work.

Use of a No. 11 blade scalpel and reusable blunt trocar to establish pneumoperitoneum: description of a safe and inexpensive technique

First access is crucial in laparoscopic surgery because of its potentially life-threatening complications. A number of procedures using a variety of instruments have been previously described; however, the safest approach remains uncertain. Herein, we describe a simple and inexpensive method for direct trocar insertion using reusable instruments that was developed over 10 years in a series of 4721 consecutive gynecologic laparoscopic procedures. Observed data revealed that the technique is feasible, rapidly performed, and safe, with a likely cost savings, using a small set of reusable instruments. This procedure should be compared with other access methods in randomized studies to confirm the observed advantages.

Use of modeling to identify vulnerabilities to human error in laparoscopy

This article describes an exercise to investigate the utility of modeling and human factors analysis in understanding surgical processes and their vulnerabilities to medical error. A formal method to identify error vulnerabilities was developed and applied to a test case of Veress needle insertion during closed laparoscopy. A team of 2 surgeons, a medical assistant, and 3 engineers used hierarchical task analysis and Integrated DEFinition language 0 (IDEF0) modeling to create rich models of the processes used in initial port creation. Using terminology from a standardized human performance database, detailed task descriptions were written for 4 tasks executed in the process of inserting the Veress needle. Key terms from the descriptions were used to extract from the database generic errors that could occur. Task descriptions with potential errors were translated back into surgical terminology. Referring to the process models and task descriptions, the team used a modified failure modes and effects analysis (FMEA) to consider each potential error for its probability of occurrence, its consequences if it should occur and be undetected, and its probability of detection. The resulting likely and consequential errors were prioritized for intervention. A literature-based validation study confirmed the significance of the top error vulnerabilities identified using the method. Ongoing work includes design and evaluation of procedures to correct the identified vulnerabilities and improvements to the modeling and vulnerability identification methods.

Ergonomics and Technical Aspects of Minimal Access Surgery in Acute Surgery

BACKGROUND

Following the general trend in the evolution of minimal access surgery (MAS), the place of laparoscopy for diagnostic and therapeutic procedures in the emergency setting is well defined. As for all laparoscopic procedures, the ergonomic and technical aspects of MAS in acute surgery are important issues.

METHODS

Review of the literature.

RESULTS

The ergonomic and technical aspects of emergency laparoscopy include the surgeon's and the patient's position; the operating room setup, including the table, the monitor, and the specific equipment; patient preparation adapted as required to potential changes necessary as adapted to the pathology and conversion; the trocar setup, also adapted to the organ and pathology. Specific needs and variations can be necessary, dependent on the patient status, body build, and the pathology being treated. The operating room used for acute surgery should be adapted to evolving laparoscopic techniques, as well as new intraoperative diagnostic and therapeutic modalities.

CONCLUSION

High-tech equipment and associated procedures have modified the needs for a modern operating room setup. Laparoscopic procedures for emergency surgery must make use of well-known ergonomic principles and be adapted to the patient and the pathology.

Primary access-related complications in laparoscopic cholecystectomy via the closed technique: experience of a single surgical team over more than 15 years

BACKGROUND

Laparoscopic cholecystectomy (LC), a common laparoscopic procedure, is a relatively safe invasive procedure, but complications can occur at every step, starting from creation of the pneumoperitoneum. Several studies have investigated procedure-related complications, but the primary access- or trocar-related complications generally are underreported, and their true incidence may be higher than studies show. Major vascular or visceral injury resulting from blind access to the abdominal cavity, although rare, has been reported. Of the two methods for creating pneumoperitoneum, the open access technique is reported to have the lower incidence of these injuries. The authors report their experience with the closed method and show that if performed with proper technique, it can be as rapid and safe as other techniques. However, injuries still happen, and the search for the predisposing factors must be continued.

METHODS

Between January 1992 and December 2007, a retrospective study examined 15,260 cases of LC performed for symptomatic gallstone disease in the authors' institution by a single team of surgeons. The primary access-related injuries in these cases were retrospectively analyzed.

RESULTS

In 15,260 cases of LC, 63 cases of primary access-related complications were identified, for an overall incidence of 0.41%. Major injuries in 11 cases included major vascular and visceral injuries, and minor injuries in 52 cases included omental and subcutaneous emphysema. For the closed method, the findings showed an overall incidence of 0.14% for primary access-related vascular injuries and 0.07% for visceral injuries.

CONCLUSION

Primary access-related complications during LC are common and can prove to be fatal if not identified early. The incidence of these injuries with closed methods is no greater than with open methods. No evidence suggests abandonment of the closed-entry method in laparoscopy.