Complications Related to the Initial Trocar Insertion of 3 Different Techniques: A Systematic Review and Meta-analysis

Broad subcutaneous emphysema with airway obstruction during robot-assisted partial nephrectomy: A case report and literature review

Introduction

Subcutaneous emphysema is a relatively common complication in laparoscopic surgery. However, airway obstruction secondary to subcutaneous emphysema is rare.

Case presentation

A 63-year-old woman with a 56-mm left renal tumor underwent a robot-assisted partial nephrectomy. The operative time was 155 min, the insufflation time was 108 min, and the estimated blood loss was 70 mL. The pneumoperitoneum pressure was maintained at 12 mmHg, except at 15 mmHg for 19 min during tumor resection. The end-tidal CO2 was <47 mmHg throughout the procedure. Postoperatively, broad subcutaneous emphysema from the thigh to the eyelid was observed. Computed tomography revealed airway obstruction, and extubation was aborted. On postoperative day 1, emphysema around the trachea and neck improved and the intubation tube was successfully removed.

Conclusion

Both laryngeal emphysema and physical compression secondary to emphysema can cause airway obstruction. To reduce gas-related complications, the risk of developing subcutaneous emphysema should be properly assessed during robot-assisted laparoscopic surgery.

Abdominal access in laparoscopic surgery of obese patients: a novel abdominal access technique

BACKGROUND

An important step in laparoscopic surgery is abdominal access. Several abdominal access techniques have been described to reduce complications. We compare our novel abdominal access technique (MESAD) with other abdominal access techniques, particularly to reduce complications in obese patients.

OBJECTIVE

Compare the MESAD method and other methods we use for abdominal access in gynecologic laparoscopic surgery of obese patients DESIGN: Retrospective SETTING: Gynecology department in university hospital PATIENTS AND METHODS: Patients who underwent abdominal access by the MESAD technique, the Veress needle technique, and the Hasson technique were included in our study. In addition to demographic data, minor and major complications, number of unsuccessful attempts, conversion to another technique, and abdominal access times were collected from all patient files.

MAIN OUTCOME MEASURES

Clinical data and complications SAMPLE SIZE: 66 patients, 26 by MESAD technique, 24 by the Veress needle technique, and 16 by the Hasson technique.

RESULTS

There were two major complications (one in the Veress group and one in the Hasson technique group) and 7 minor complications. No significant difference was found between the groups in terms of complications (P=.477, P=.476, respectively). The fastest technique for abdominal access was in the MESAD technique whereas the slowest was in the Hasson (P<.001). The failure of abdominal access and subsequent conversion to another technique was most common in the Veress group. However, no significant difference was found between the groups (P=.092).

CONCLUSIONS

The MESAD technique is an easy method to both learn and teach. We think that the low major-minor complication rates in the MESAD technique will allow surgeons to reduce their anxiety at the first entry and to perform a more comfortable operation.

LIMITATIONS

Retrospective CONFLICT OF INTEREST: None.

In Situ Team-Based Simulation Training to Close the Loop on Event Reporting

Reporting adverse events is often stigmatized in medicine. Adverse events are underreported. Underreporting has been linked to fear, the time required to complete a report, and a belief that reporting may not result in improvement.1 The reluctance to report is multidimensional and may relate to guilt, fear of punishment of self or others, fear of embarrassment, fear of litigation, and lack of confidence to effect change. Central to this fear is the widely held belief that errors and adverse events are due to carelessness and that blame must be assigned—often to the provider “at fault” or at the sharp end of the process. However, reporting of events offers an invaluable opportunity to identify latent systems issues and review and redesign error-trapping procedures and workflows. Without measurement, it is challenging to leverage adverse events as catalysts for targeted process improvement. Mandated reporting at the state and national levels is an influential catalyst to enhance data collection of adverse events. Aggregated data across varied practice settings are powerful. Mandated reporting alleviates some of the fear associated with reporting and increases reporting volume and relevance.

How to reduce the risk of organ injuries during surgical instrument insertion in laparoscopic surgery: Pushing/pressing force analysis using forceps with sensors

INTRODUCTION

In laparoscopic surgery, surgical instruments are inserted from a trocar to the target organ in a blind fashion, which carries a risk of organ injury. To clarify the risks associated with surgical instrument insertion, we measured grip strength and pushing/pressing force during surgical instrument insertion in laparoscopic surgery.

METHODS

Using forceps with sensors inside a trocar, 10 urologists performed a laparoscopic procedure in pigs, in which they were asked to touch the abdominal wall. The surgeons closed their eyes during the procedure and stopped moving the forceps when they felt them come into contact with the abdominal wall. They were ordered to grip the forceps strongly or softly and to move them rapidly or slowly during the procedure. Grip strength and the pushing/pressing force when the forceps hit the abdominal wall were measured and analyzed.

RESULTS

The mean pushing/pressing force when the surgeons gripped the forceps strongly and moved them rapidly (strong/rapid), strongly/slowly, softly/rapidly, and softly/slowly were 2.8, 2.0, 1.7, and 1.1 N, respectively. The pushing/pressing force was significantly greater when the surgeons gripped the forceps strongly, regardless of the forceps speed (P < .001). The pushing/pressing force was significantly greater when the surgeons moved the forceps rapidly, regardless of grip strength (P < .001).

CONCLUSIONS

When surgeons insert laparoscopic instruments through trocars, the instruments should be gripped softly and moved slowly to avoid organ injuries.

Presentation of an open entry technique for laparoscopy through a congenital defect in the umbilical fascia

OBJECTIVE

We present and describe a modification of the Hasson open entry technique to gain access to the abdominal cavity for laparoscopy in which a congenital defect in the umbilical fascia is identified for entry into the peritoneum and insertion of the primary port.

METHODS

A single centre, prospective, observational, pilot study has been conducted with no change in clinical practice. Data regarding the success of the technique, time to laparoscope insertion, complications and patient risk factors were collected and presented.

RESULTS

The team enrolled 114 patients that had the St Helier technique attempted for entry in the abdominal cavity. Entry was achieved for all patients. The technique had 82.5 % success rate while this reduced to 65 % in patients with previous laparoscopies. The mean time to insertion of the laparoscope was 220 s, and there was no significant difference in success with variation in BMI. We recorded no minor or significant intra-operative complications. The superficial wound infection rate was 2.6 % with no other postoperative complications identified at 6-week follow-up.

CONCLUSIONS

The presented technique is a safe and successful method of laparoscopic entry with a presumed shorter time until laparoscope insertion than other techniques used. The absence of complications could be attributed to the avoidance of sharp dissection of the umbilical fascia. The less invasive nature could reduce risks of hematoma, infection or hernia that are associated with the standard entry techniques used. Formal studies of long-term outcomes are required, as well as evaluating use in emergency and contaminated cases.

Veress Needle Creation of a Pneumoperitoneum: Is It Risky? Results of the First Belgian Group for Endoscopic Surgery-Snapshot Study

Background: Every laparoscopic procedure starts with the creation of a pneumoperitoneum. The open trocar introduction and the use of a Veress needle (VN) are the two most frequent techniques used. The aim of this study was to evaluate safety of the techniques used to create pneumoperitoneum in laparoscopic abdominal surgery by Belgian minimally invasive surgeons. Materials and Methods: This is a prospective study including all consecutive patients undergoing a laparoscopic surgical procedure for a 2-month period. Primary endpoint was access-related problems during creation of a pneumoperitoneum. Access-related problems were registered using a special smartphone application, facilitating data recording and patient registration. Results: Overall, 9 out of 212 invited surgeons (4.2%) actively registered patients during the study period. A total number of 342 patients were included with 6 access-related problems (1.8%) and conversion to open surgery was necessary in 16 patients (4.7%). Most reported access-related problem was failure to establish a pneumoperitoneum secondary to insufflation of the omentum. There were no major access-related complications. There was no conversion in the group of patients who had an access-related problem. Conclusion: VN entry to create a pneumoperitoneum is safe. In a short study period, gathering data by surgeons willing to participate in a snapshot study is easy and facilitated by a web-based application.

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.