Blunt versus bladed trocars in laparoscopic surgery: a systematic review and meta-analysis of randomized trials

Does the angle of trocar insertion affect the fascial defect caused? A porcine model

INTRODUCTION

With an incidence of 0-5.2%, trocar site hernias frequently occur following laparoscopy. It is unclear to what extent the angle of trocar insertion affects the size of the fascial defect caused. Hence, we performed a porcine model.

METHODS

In October 2022, a total of five female pigs were euthanized. In alternating order, three bladeless and two bladed conical 12-mm trocars were inserted at an angle of 45° on each side for 60 min twice each pig. For this purpose, an epoxy resin handmade cuboid with a central channel that runs at an angle of 45° was used. Subsequently, photo imaging and defect size measurement took place. The results were compared with those of our previously conducted and published porcine model, in which the trocars were inserted at an angle of 90°. Effects of trocar type (bladed vs. bladeless) and angle on defect size were analyzed using a mixed model regression analysis.

RESULTS

The bladeless trocars caused statistically significant smaller defects at the fascia than the bladed (23.4 (SD = 16.9) mm2 vs. 41.3 (SD = 14.8) mm2, p < 0.001). The bladeless VersaOne trocar caused the smallest defect of 16.0 (SD = 6.1) mm2. The bladed VersaOne trocar caused the largest defect of 47.7 (SD = 10.5) mm2. The defect size of the trocars used at a 45° angle averaged 30.5 (SD = 18.3) mm2. The defect size of trocars used at a 90° angle was significantly larger, averaging 58.3 (SD = 20.2) mm2 (p = 0.007).

CONCLUSION

When conical 12-mm trocars are inserted at a 45° angle, especially bladeless ones, they appear to cause small fascial defects compared with insertion at a 90° angle. This might lead also to a lower rate of trocar hernias. Bladeless trocars might cause smaller fascial defects than bladed trocars.

Collateral Benefit of Systematic Improvement in Bariatric Surgery Outcomes Following a Single Quality Improvement Project for Bleeding

The study's aim was not only to use quality improvement system techniques to improve patient care specifically for bleeding but also to track other adverse outcomes. Key drivers were identified and mapped to interventions, namely venous thromboembolism prophylaxis, root cause analysis, indications conference, and operative technique standardization. Bleeding was reduced by 88%, and overall postoperative complications also fell by 63%. A targeted quality improvement project not only was effective in improving outcomes for the specific aim of bleeding but also resulted in improvement for other patient outcomes.

To assess the safety of laparoscopy in patients with CSF catheters draining distally into the abdomen

PURPOSE

This study evaluates the safety of laparoscopic procedures in patients with cerebrospinal fluid (CSF) catheters draining distally into the abdomen.

METHODS

A systematic search across PubMed, Scopus, and Ovid databases using pertinent keywords yielded 47 relevant papers, encompassing 197 cases, for analysis.

RESULTS

In the pediatric cohort (n = 129), male (49.6%) and female (34.1%) cases were reported, while gender remained unspecified in 16.3%. Shunt indications included unspecified (126 cases) and Meningomyelocele (3 cases). Laparoscopic procedures encompassed gastric (72.1%), urologic (21.7%), and other (6.2%) indications. Peri-operative shunt management included subcostal incision and clamping (1), ICP monitoring and drainage (2), and distal shunt flow confirmation (1). The prevalent complication was mechanical obstruction (10.1%), followed by pseudocyst formation (1.5%) and infection (2.3%). In the adult cohort (n = 61), males (60.6%) and females (39.3%) with a median age of 55 years were observed. Management strategies encompassed sponge packing and mobilization (11), distal shunt flow confirmation (2), shunt clamping (3), Transcranial Doppler monitoring (2), and no manipulation (30). Shunt infection emerged as the primary complication (2). Overall, 24 patients encountered VP shunt-related complications post-laparoscopy.

CONCLUSION

This study underscores the safety of laparoscopic interventions in patients with ventriculoperitoneal or lumboperitoneal shunts when facilitated by interdisciplinary cooperation. A meticulous preoperative assessment for shunt track localization, intraoperative visualization of shunt tip with CSF flow, vigilant perioperative anesthetic monitoring, and shunt dysfunction surveillance are crucial for favorable outcomes in laparoscopic procedures for these patients.

Investigation of the Effect of Puncture Order and Position on the Difficulty of Lower and Middle Abdominal Port Placement

Objectives

Port placements at the mid-abdomen (mainstay of robotic surgery [Rob]) appear to be difficult compared to that at lower abdomen (mainstay of conventional laparoscopy [Con-Lap]). We hypothesized that the reason for this may be the difference in port puncture places.

Materials and Methods

We examined how the differences between the place and puncture order of ports affected Con-Lap cases with ports mainly placed in the lower abdomen and Rob cases with ports mainly placed in the middle abdomen. The trocar time was measured from the time when the puncture position and skin incision were determined and initiated, respectively, to the time when the port was punctured and fixed and used as the indicator of difficulty.

Results

In the Con-Lap group analysis, the trocar time of the left lower port was longer (right lower: 77 s, middle lower: 117.5 s, and left lower: 138 s, P < 0.0001). In the Rob group analysis, the trocar time of the left most port was significantly longer (right-most: 89.0 s, right-middle: 92.5 s, left-middle: 121.0 s, and left-most: 197.0 s; P < 0.0001). In addition, the total trocar time was significantly longer in the first puncture at the right-middle port in the Rob group (right-most first: 8.4 min, right-middle first: 12.4 min, and left-middle first: 8.5 min, P = 0.0063).

Conclusion

In the mid-abdomen port placement, mainstay of Rob cases, the puncture order, and port site have a significant impact on the difficulty of the procedure. It is preferable to avoid initially puncturing the right-middle port in case of the Rob.

Is fascial closure required for a 12-mm trocar? A comparative study on trocar site hernia with long-term follow up

BACKGROUND

Despite the infrequency of trocar site hernias (TSHs), fascial closure continues to be recommended for their prevention when using a ≥ 10-mm trocar.

AIM

To identify the necessity of fascial closure for a 12-mm nonbladed trocar incision in minimally invasive colorectal surgeries.

METHODS

Between July 2010 and December 2018, all patients who underwent minimally invasive colorectal surgery at the Minimally Invasive Surgery Unit of Siriraj Hospital were retrospectively reviewed. All patients underwent cross-sectional imaging for TSH assessment. Clinicopathological characteristics were recorded. Incidence rates of TSH and postoperative results were analyzed.

RESULTS

Of the 254 patients included, 70 (111 ports) were in the fascial closure (closed) group and 184 (279 ports) were in the nonfascial closure (open) group. The median follow up duration was 43 mo. During follow up, three patients in the open group developed TSHs, whereas none in the closed group developed the condition (1.1% vs 0%, P = 0.561). All TSHs occurred in the right lower abdomen. Patients whose drains were placed through the same incision had higher rates of TSHs compared with those without the drain. The open group had a significantly shorter operative time and lower blood loss than the closed group.

CONCLUSION

Routine performance of fascial closure when using a 12-mm nonbladed trocar may not be needed. However, further prospective studies with cross-sectional imaging follow-up and larger sample size are needed to confirm this finding.

Bladed and bladeless conical trocars do not differ in terms of caused fascial defect size in a Porcine Model

INTRODUCTION

Trocar insertion during laparoscopy may lead to complications such as bleeding, bowel puncture and fascial defects with subsequent trocar site hernias. It is under discussion whether there is a difference in the extent of the trauma and thus in the size of the fascia defect between blunt and sharp trocars. But the level of evidence is low. Hence, we performed a Porcine Model.

METHODS

A total of five euthanized female pigs were operated on. The average weight of the animals was 37.85 (Standard deviation SD 1.68) kg. All pigs were aged 90 ± 5 days. In alternating order five different conical 12-mm trocars (3 × bladeless, 2 × bladed) on each side 4 cm lateral of the mammary ridge were placed. One surgeon performed the insertions after conducting a pneumoperitoneum with 12 mmHg using a Verres' needle. The trocars were removed after 60 min. Subsequently, photo imaging took place. Using the GSA Image Analyser (v3.9.6) the respective abdominal wall defect size was measured.

RESULTS

The mean fascial defect size was 58.3 (SD 20.2) mm2. Bladed and bladeless trocars did not significant differ in terms of caused fascial defect size [bladed, 56.6 (SD 20) mm2 vs. bladeless, 59.5 (SD 20.6) mm2, p = 0.7]. Without significance the insertion of bladeless trocars led to the largest (Kii Fios™ First entry, APPLIEDMEDICAL©, 69.3 mm2) and smallest defect size (VersaOne™ (COVIDIEN©, 54.1 mm2).

CONCLUSION

Bladed and bladeless conical 12-mm trocars do not differ in terms of caused fascial defect size in the Porcine Model at hand. The occurrence of a trocar site hernia might be largely independent from trocar design.

Safety considerations in laparoscopic surgery: A narrative review

Laparoscopic surgery has many advantages over open surgery. At the same time, it is not without its risks. In this review, we discuss steps that could enhance the safety of laparoscopic surgery. Some of the important safety considerations are ruling out pregnancy in women of the childbearing age group; advanced discussion with the patient regarding unexpected intraoperative situations, and ensuring appropriate equipment is available. Important perioperative safety considerations include thromboprophylaxis; antibiotic prophylaxis; patient allergies; proper positioning of the patient, stack, and monitor(s); patient appropriate pneumoperitoneum; ergonomic port placement; use of lowest possible intra-abdominal pressure; use of additional five-millimetre (mm) ports as needed; safe use of energy devices and laparoscopic staplers; low threshold for a second opinion; backing out if unsafe to proceed; avoiding hand-over in the middle of the procedure; ensuring all planned procedures have been performed; inclusion of laparoscopic retrieval bags and specimens in the operating count; avoiding 10-15 mm ports for placement of drains; appropriate port closures; and use of long-acting local anaesthetic agents for analgesia. Important postoperative considerations include adequate analgesia; early ambulation; careful attention to early warning scores; and appropriate discharge advice.

LongTerm Outcomes of Three-Port Laparoscopic Right Hemicolectomy Versus Five-Port Laparoscopic Right Hemicolectomy: A Retrospective Study

Purpose

The aim of this study is to compare the long-term outcomes of three-port laparoscopic right hemicolectomy (TPLRC) and five-port laparoscopic right hemicolectomy (FPLRC) with retrospective analysis.

Methods

A total of 182 patients who accepted laparoscopic right hemicolectomy with either three ports (86 patients) or five ports (96 patients) from January 2012 to June 2017 were non-randomly selected and analyzed retrospectively.

Results

More lymph nodes were harvested in the TPLRC group than in the FPLRC group [17.5 (7), 14 (8) ml, p < 0.001]. There was less blood loss in the TPLRC group [50 (80) vs. 100 (125) ml, p = 0.015]. There were no significant differences in the other short-term or oncological outcomes between the two groups. The overall survival and disease-free survival were equivalent.

Conclusions

TPLRC is recommendable as it guarantees short- and long-term equivalent outcomes compared with FPLRC.

Totally extra-peritoneal repair versus trans-abdominal pre-peritoneal repair for the laparoscopic surgical management of sportsman's hernia: A systematic review and meta-analysis

BACKGROUND

Open and laparoscopic modalities are employed for treatment of sportsman's hernia with totally extra-peritoneal (TEP) and trans-abdominal pre-peritoneal (TAPP) laparoscopic approaches both currently being utilised. At present, neither subtype has demonstrated a beneficial superiority for sportsman's hernia repair, as concluded in the most recent systematic review comparing the outcomes of each technique. The aim of this review was to evaluate current evidence to ascertain whether there was a difference in laparoscopic techniques following sportsman's hernia repair.

METHODS

A systematic literature search was performed according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement standards. Databases searched included PubMed, Scopus and Web of Science to identify all randomised controlled trials (RCTs) and observational studies Risk of bias was assessed using the Cochrane risk of bias tool and Newcastle-Ottawa scale for RCTs and observational studies, respectively.The assessed outcomes included median time to return to sporting activity, complications and the degree of postoperative pain reduction within three months. Random effects model was used to calculate pooled proportion data where feasible. Subgroup analyses were also performed.

RESULTS

28 studies were identified including 2 RCTs and 26 observational studies. No significant differences were observed between techniques in the primary or secondary outcomes. Significant heterogeneity was observed in all outcomes. This was more pronounced for return to sporting activity meaning that meta-analysis was not feasible in this domain. Median time to return to sporting activity was 28 days for both techniques.

CONCLUSIONS

There is no observed difference in the primary and secondary outcomes in either technique. An RCT comparing TEP and TAPP repair is needed to provide definitive data on this matter.

Incidence and risk factors for umbilical trocar site hernia after laparoscopic TAPP repair. A single high-volume center experience

BACKGROUND

Trocar site hernia (TSH) is often underestimated after minimally invasive surgery. Scarce information is available about the incidence of TSH in patients undergoing laparoscopic hernioplasty. We aimed to evaluate the incidence and risk factors of umbilical TSH after laparoscopic TAPP hernioplasty in patients with and without an associated umbilical hernia.

METHODS

A retrospective analysis of a prospectively collected database of all patients who underwent laparoscopic inguinal TAPP repair during 2013-2018 was performed. After TAPP repair, the umbilical fascia was closed either by a figure-of-eight stitch with absorbable suture (G1) or by umbilical hernioplasty if it was present (G2). Multivariate logistic regression analysis was used to determine the TSH risk factors. Comparative evaluation regarding demographics, and operative and postoperative variables was performed.

RESULTS

A total of 535 laparoscopic TAPP repairs were included. There were 359 (67.1%) patients in G1 and 176 in G2 (32.9%). Surgical site infection was higher in G2 (G1: 0.6% vs G2: 5.7%, p = 0.001). Overall TSH rate was 3.9% after a mean follow-up of 20 (12-41) months. Performing a concomitant umbilical repair significantly increased the risk of umbilical TSH (G1: 2.2% vs G2: 7.4%, p = 0.004). TSH rates in G2 were similar in patients with simple suture or mesh repairs (p = 0.88). Rectus abdominis diastasis (OR 37.8, 95% CI:8.22-174.0, p < 0.001) and inguinal recurrence (OR 13.5, 95% CI:2.04-89.5, p = 0.007) were independent risk factors for TSH.

CONCLUSION

Although trocar site hernia after laparoscopic TAPP repair has a low incidence, its risk is significantly increased in patients with a concomitant umbilical hernia repair, rectus abdominis diastasis, and/or inguinal recurrence.

Operative Technique for Laparoscopic Placement of Continuous Ambulatory Peritoneal Dialysis Catheter

Background: Peritoneal dialysis (PD) is an increasingly utilized treatment modality for renal replacement therapy that affords medical and lifestyle benefits to the patient and financial savings to the health care system. Successful long-term use of PD is reliant upon an optimally functioning catheter. Many potential catheter-related complications can be avoided through utilizing optimal placement technique. As widespread use of PD as a renal replacement modality continues to increase, the need for a safe, standardized, catheter placement technique has become more evident. Objectives: To present a succinct synopsis of the rationale and elements of our current surgical management strategy for patients undergoing evaluation for PD and to provide a detailed stepwise description of our operative technique for PD catheter placement. This review describes potential pitfalls that may prevent optimal catheter function and describes each step taken to prevent potential complications. This description is combined with intraoperative photographs to highlight key steps. Conclusion: Following a defined reproducible stepwise approach, laparoscopic placement of continuous ambulatory peritoneal dialysis catheters can be performed safely and known potential complications hindering optimal catheter function can be addressed prophylactically.

Primary unilateral not complicated inguinal hernia: our choice of TAPP, why, results and review of literature

BACKGROUND

Currently, three different techniques are favored for repair of an inguinal hernia: (1) The suture repair described by Shouldice. (2) An open mesh repair according to Lichtenstein. (3) Laparo-endoscopic techniques TAPP and TEP. The aim of the presented paper was to describe the ranking of the Transabdominal Preperitoneal Patch Plasty (TAPP) in comparison to the other techniques for inguinal hernia repair.

METHODS

The manuscript is based on the experiences gained in more than 15,000 TAPPs and numerous own studies as well. The technique of TAPP is described in detail and also the results which can be achieved with special reference to primary unilateral inguinal hernias in male patients. Moreover, a systematic review of the literature is done for the comparison with the other techniques.

RESULTS

According to own experiences, 98% of all patients with an inguinal hernia admitted for surgery to Marienhospital Stuttgart could be operated on using the TAPP technique. The recurrence rate and the rate of severe chronic pain in this setting were below 1%. Due to the limited quality of most of the published studies an evidence-based comparison which is the best of the currently most recommended techniques is questionable. Therefore, when comparing TAPP with TEP, no definite conclusion about superiority of one technique over the other is possible. Both techniques are safe and effective if properly performed. The guidelines recommend that the surgeon should use the technique he had learned best and is familiar with. The comparison between TAPP and the Shouldice repair shows less pain and a higher effectivity after TAPP. The recurrence rate after Lichtenstein repair and after TAPP is similar, but pain and recovery time are significantly less after TAPP.

CONCLUSION

Analyzing the own abundant experiences and the reports in the literature, the TAPP technique has the potential to become the standard operative technique for repair of inguinal hernias in future. However, due to the low level of evidence of most of the studies definite conclusions are difficult to draw at this point of time.

Laparoscopic Insertion of Various Shaped Trocars in a Porcine Model

BACKGROUND AND OBJECTIVE

The number of laparoscopic procedures increases annually with an estimated 3% of complications, one third of them linked to Verres' needle or trocar insertion. The safety and efficacy of ports insertion during laparoscopic surgery may be related the technique but also to trocar design. This study aims to compare physical parameters of abdominal wall penetration for 5 different trocars.

METHODS

Eleven pigs were studied. Five different commercially available trocars were randomically inserted at the midline. Real-time video recording of the insertions was achieved to measure the excursion of the abdominal wall and the time and distance the cutting surface of the bladed trocars was exposed inside the abdominal cavity. An especially designed hand sensor was developed and placed between the trocar and the hand of the surgeon to record force required for abdominal wall perforation.

RESULTS

Greater deformations and forces occurred in nonbladed as compared to bladed trocars, and in conical trocars as compared to pyramidal pointed ones, except for peritoneum perforation. Greater distance and time of blade exposure occurred in pyramidal laminae as compared to conical.

CONCLUSION

The bladed trocars have lower forces and deformations in their introduction, and should be those that cause less injury and are more suitable for first entry. Conical and pyramidal trocars with the same blade size showed similar force, deformation, time, and distance of exposed blade.

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.

Delayed presentation of iatrogenic ventriculoperitoneal shunt transection following laparoscopic weight loss surgery in a patient with idiopathic intracranial hypertension

Idiopathic intracranial hypertension is strongly associated with central obesity and consequential raised intra-abdominal pressure. If left untreated it poses significant risk to vision and can eventually cause blindness. Owing to its pathophysiology, this condition is managed by both medical and surgical specialities. When medical management fails neurosurgeons commonly treat idiopathic intracranial hypertension by permanent cerebrospinal fluid peritoneal shunting. Weight reduction surgery provides patients who are obese with a multitude of benefits and it is not uncommon for the general surgeon to be presented with a patient with idiopathic intracranial hypertension and a cerebrospinal fluid peritoneal shunt in place. This provides a potential challenging situation in weight-loss surgical procedures. We describe an interesting case where laparoscopic bariatric surgery resulted in transection of the abdominal catheter with a delayed presentation of recurrent symptoms and an abdominal cerebrospinal fluid collection in a patient with idiopathic intracranial hypertension. We discuss how this could be avoided and its management.

Routine blood group and antibody screening prior to emergency laparoscopy

Introduction Studies show that rates of blood transfusion associated with general surgical laparoscopy are low. Currently, there are no national guidelines in the UK regarding blood group and antibody screening (G&S) for patients undergoing emergency laparoscopy. The aim of this study was to assess whether using G&S before emergency laparoscopic general surgery routinely is worthwhile by identifying rates of perioperative transfusion. Methods Data were collected retrospectively on all emergency laparoscopic procedures at a single district general hospital between January 2014 and 31 December 2016. Emergency laparoscopic general surgical cases were included and gynaecological cases excluded. Records were reviewed to ascertain whether G&S was performed, whether antibodies were detected and whether patients were transfused. Results A total of 562 emergency laparoscopic cases were performed. The median age was 28 years (range: 6-95 years). Laparoscopic appendicectomy (n=446), diagnostic laparoscopy (n=47) and laparoscopic cholecystectomy (n=25) were the most common procedures. Of the total patient cohort, 514 (91.5%) and 349 (70.1%) had a first and second G&S respectively while 30 (5.3%) had no G&S. Four patients (0.71%) had antibodies detected. One patient (0.18%) received a transfusion. This patient had undergone laparoscopic repair of a perforated duodenal ulcer and there was no major intraoperative haemorrhage but he was transfused perioperatively for chronic anaemia. Conclusions These results demonstrate a low rate of blood transfusion in emergency laparoscopic general surgery. The majority of these patients had a low risk of major intraoperative haemorrhage and we therefore argue that G&S was not warranted. We propose a more targeted approach to the requirement for preoperative G&S and the use of O negative blood in the event of acute haemorrhage from major vessel injury.

Advances in laparoscopic surgery in urology

In the past 10 years, laparoscopy has been challenged by robotic surgery; nevertheless, laparoscopic techniques are subject to continuous change. Ultrahigh definition is the next development in video technology, it delivers fourfold more detail than full high definition resulting in improved fine detail, increased texture, and an almost photographic emulsion of smoothness of the image. New 4K ultrahigh-definition technology might remove the current need for the use of polarized glasses. New devices for laparoscopy include advanced sealing devices, instruments with six degrees of freedom, ergonomic platforms with armrests and a chest support, and camera holders. A manually manipulated robot-like device is still at the experimental stage. Robot-assisted surgery has substantially revolutionized laparoscopy, increasing its distribution; however, robot-assisted surgery is associated with considerable costs. All technical improvements of laparoscopic surgery are extremely valuable to further simplify the use of classical laparoscopy.

Single-site Nissen fundoplication versus laparoscopic Nissen fundoplication

Background:

Advances in minimally invasive surgery have led to the emergence of single-incision laparoscopic surgery (SILS). The purpose of this study is to assess the feasibility of SILS Nissen fundoplication and compare its outcomes with traditional laparoscopic Nissen fundoplication.

Methods:

This is a retrospective study of 33 patients who underwent Nissen fundoplication between January 2009 and September 2010.

Results:

There were 15 SILS and 18 traditional laparoscopic Nissen fundoplication procedures performed. The mean operative time was 129 and 182 minutes in the traditional laparoscopic and single-incision groups, respectively (P = .019). There were no conversions in the traditional laparoscopic group, whereas 6 of the 15 patients in the SILS group required conversion by insertion of 2 to 4 additional ports (P = .0004). At short-term follow-up, recurrence rates were similar between both groups. To date, there have been no reoperations.

Conclusions:

SILS Nissen fundoplication is both safe and feasible. Short-term outcomes are comparable with standard laparoscopic Nissen fundoplication. Challenges related to the single-incision Nissen fundoplication include overcoming the lengthy learning curve and decreasing the need for additional trocars.

Trocar types in laparoscopy

BACKGROUND

Laparoscopic surgery has led to great clinical improvements in many fields of surgery; however, it requires the use of trocars, which may lead to complications as well as postoperative pain. The complications include intra-abdominal vascular and visceral injury, trocar site bleeding, herniation and infection. Many of these are extremely rare, such as vascular and visceral injury, but may be life-threatening; therefore, it is important to determine how these types of complications may be prevented. It is hypothesised that trocar-related complications and pain may be attributable to certain types of trocars. This systematic review was designed to improve patient safety by determining which, if any, specific trocar types are less likely to result in complications and postoperative pain.

OBJECTIVES

To analyse the rates of trocar-related complications and postoperative pain for different trocar types used in people undergoing laparoscopy, regardless of the condition.

SEARCH METHODS

Two experienced librarians conducted a comprehensive search for randomised controlled trials (RCTs) in the Menstrual Disorders and Subfertility Group Specialised Register, Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE, PsycINFO, CINAHL, CDSR and DARE (up to 26 May 2015). We checked trial registers and reference lists from trial and review articles, and approached content experts.

SELECTION CRITERIA

RCTs that compared rates of trocar-related complications and postoperative pain for different trocar types used in people undergoing laparoscopy. The primary outcomes were major trocar-related complications, such as mortality, conversion due to any trocar-related adverse event, visceral injury, vascular injury and other injuries that required intensive care unit (ICU) management or a subsequent surgical, endoscopic or radiological intervention. Secondary outcomes were minor trocar-related complications and postoperative pain. We excluded trials that studied non-conventional laparoscopic incisions.

DATA COLLECTION AND ANALYSIS

Two review authors independently conducted the study selection, risk of bias assessment and data extraction. We used GRADE to assess the overall quality of the evidence. We performed sensitivity analyses and investigation of heterogeneity, where possible.

MAIN RESULTS

We included seven RCTs (654 participants). One RCT studied four different trocar types, while the remaining six RCTs studied two different types. The following trocar types were examined: radially expanding versus cutting (six studies; 604 participants), conical blunt-tipped versus cutting (two studies; 72 participants), radially expanding versus conical blunt-tipped (one study; 28 participants) and single-bladed versus pyramidal-bladed (one study; 28 participants). The evidence was very low quality: limitations were insufficient power, very serious imprecision and incomplete outcome data. Primary outcomesFour of the included studies reported on visceral and vascular injury (571 participants), which are two of our primary outcomes. These RCTs examined 473 participants where radially expanding versus cutting trocars were used. We found no evidence of a difference in the incidence of visceral (Peto odds ratio (OR) 0.95, 95% confidence interval (CI) 0.06 to 15.32) and vascular injury (Peto OR 0.14, 95% CI 0.0 to 7.16), both very low quality evidence. However, the incidence of these types of injuries were extremely low (i.e. two cases of visceral and one case of vascular injury for all of the included studies). There were no cases of either visceral or vascular injury for any of the other trocar type comparisons. No studies reported on any other primary outcomes, such as mortality, conversion to laparotomy, intensive care admission or any re-intervention. Secondary outcomesFor trocar site bleeding, the use of radially expanding trocars was associated with a lower risk of trocar site bleeding compared to cutting trocars (Peto OR 0.28, 95% CI 0.14 to 0.54, five studies, 553 participants, very low quality evidence). This suggests that if the risk of trocar site bleeding with the use of cutting trocars is assumed to be 11.5%, the risk with the use of radially expanding trocars would be 3.5%. There was insufficient evidence to reach a conclusion regarding other trocar types, their related complications and postoperative pain, as no studies reported data suitable for analysis.

AUTHORS' CONCLUSIONS

Data were lacking on the incidence of major trocar-related complications, such as visceral or vascular injury, when comparing different trocar types with one another. However, caution is urged when interpreting these results because the incidence of serious complications following the use of a trocar was extremely low. There was very low quality evidence for minor trocar-related complications suggesting that the use of radially expanding trocars compared to cutting trocars leads to reduced incidence of trocar site bleeding. These secondary outcomes are viewed to be of less clinical importance.Large, well-conducted observational studies are necessary to answer the questions addressed in this review because serious complications, such as visceral or vascular injury, are extremely rare. However, for other outcomes, such as trocar site herniation, bleeding or infection, large observational studies may be needed as well. In order to answer these questions, it is advisable to establish an international network for recording these types of complications following laparoscopic surgery.

[Specific complications of minimally invasive surgery]

Minimally invasive surgery (MIS) is fundamentally different from open surgery regarding positioning of the patient, access routes and instrumentation. Each of these aspects is associated with its own specific morbidity, such as positioning-related complications, trocar-induced lesions, hypercapnia-associated phenomena and thermal damage. The growing experience of surgeons and technological progress have increased patient safety to a maximum and have resulted in an impressive spread of MIS in the various fields of surgery including the most common, such as cholecystectomy and hernia repair and special fields, such as bariatric, thoracic and oncological surgery. This narrative review summarizes the current knowledge on the inherent complications of MIS.

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.

Laparoscopy in trauma: An overview of complications and related topics

The introduction of laparoscopy has provided trauma surgeons with a valuable diagnostic and, at times, therapeutic option. The minimally invasive nature of laparoscopic surgery, combined with potentially quicker postoperative recovery, simplified wound care, as well as a growing number of viable intraoperative therapeutic modalities, presents an attractive alternative for many traumatologists when managing hemodynamically stable patients with selected penetrating and blunt traumatic abdominal injuries. At the same time, laparoscopy has its own unique complication profile. This article provides an overview of potential complications associated with diagnostic and therapeutic laparoscopy in trauma, focusing on practical aspects of identification and management of laparoscopy-related adverse events.

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?