Laparoscopic Access with Optical Gasless Trocar: A Single-center Experience of 7431 Procedures

Learning curve of optical trocar access during laparoscopic pelvic surgery: A prospective study

INTRODUCTION

The optical trocar access (OTA) is a modified closed technique that aims to minimize the risk of vascular or bowel injuries while reducing the likelihood of gas leakage. A learning curve (LC) effect for OTA has been invoked with n = 30 procedures being considered as a threshold to define expertise. We aim to evaluate the impact of the LC within the first thirty cases of OTA performed by a trainee.

METHODS

This is a prospective randomized study on 60 patients elected to laparoscopic gynecological surgery. Patients were randomized to have OTA insertion by a junior surgeon or by an expert. LC was evaluated by: 1) insertion time; number of: 2) corrections by the senior; 3) times the tip of the trocar stopped in the preperitoneal layer; 4) mistakes of skin incision; 5) times the tip of the trocar ends under the omentum; 6) complications. To analyze the LC within the first 30 cases, procedures were stratified in 3 groups (cases 1-10; 11-20; 21-30) for both trainee and expert and LC variables were compared.

RESULTS

Overall, mean OTA insertion time was 56 s. No major intra- and post-operative complications were recorded. Mean insertion time was statistically significantly longer for the trainee compared to the expert within the first 10 cases (91 vs 33 s respectively, P = .01). For cases 11-20 and 21-30, time advantage of the senior surgeon is less evident (P = .05). The number of times the tip of the trocar stopped in the preperitoneal layer was similar between groups, as well as times the tip of the trocar ends under the omentum.

CONCLUSIONS

OTA is a fast and simple way to achieve the pneumoperitoneum and first trocar insertion as a single step. The current series confirms the effectiveness of the technique since the beginning of the LC.

Primary entry trocar design and entry-related complications at laparoscopy in obese patients: meta-analysis

BACKGROUND

Safe primary entry at laparoscopy could present challenges in obese patients. Various techniques have been proposed in previous studies, however, the characteristics of the actual device utilized may be more influential than the technique in achieving successful abdominal entry in patients with increased BMI.

METHODS

This systematic review and meta-analysis included both randomized and non-randomized studies gathered with no date filters from MEDLINE, Embase, Scopus, Web of Science and Clinicaltrials.gov. PRISMA guidelines underpinned the conduct and reporting of the review. The meta-analysis of proportions was conducted using a generalized linear mixed model and analyses included random-effects models. The primary outcome was the proportion of first access vascular and visceral injuries incurred in the process of laparoscopic abdominal surgery in patients with a BMI >30 kg/m2. Subgroup analysis was performed for optical versus non-optically enabled devices.

RESULTS

In total, 5403 patients were analysed across 13 observational studies with a mean BMI of 45.93 kg/m2. In 216 patients from two randomized studies, the mean BMI was 39.92 kg/m2. The overall incidence using a random-effects model was 8.1 per 1000 events of visceral and vascular injuries (95 per cent c.i. 0.003 to 0.024). Heterogeneity was statistically significant at I2 = 80.5 per cent (69.6 per cent; 87.5 per cent, P< 0.0001). In a subgroup analysis, a tendency towards reduced injuries when optical devices were employed was observed with one per 100 injuries in these trocars (95 per cent c.i. 0.001 to 0.018) versus four per 100 (95 per cent c.i. -0.019 to -0.102) in non-optically enabled devices.

CONCLUSION

Injuries during primary laparoscopic entry undertaken in obese patient groups are uncommon. Due to considerable heterogeneity in the small number of examined studies, evidence was insufficient and largely of low quality to ascribe differences in the incidence of injuries to the characteristics of the primary entry trocar utilized.

Fast, Easy, and Safe Establishment of Pneumoperitoneum in Laparoscopic Surgery: The Fingertip Technique

Background and Objectives:

There is no consensus on an ideal abdominal entry in laparoscopic surgery; as such, we aimed to assess the feasibility of the fingertip technique for safe entry and the establishment of pneumoperitoneum in transperitoneal laparoscopic surgery.

Methods:

We prospectively assessed 96 consecutive patients who underwent laparoscopic transperitoneal surgery between December 2018 and September 2019. For all patients, pneumoperitoneum was performed using the fingertip technique, which we recently defined. The duration of time for initial entry, the occurrence of gas leakage, and the complications were evaluated.

Results:

The median duration of initial entry was 90 (75 – 145) seconds. Pneumoperitoneum was established on the first attempt in all patients. Some events were encountered at the time of implementation of the fingertip technique, such as subcutaneous minor bleeding (5.2%) and gas leakage (4.1%). These events were controlled with cauterization and suturing. There was no visceral or major vascular injury in any patient case.

Conclusions:

The fingertip technique is a fast, safe, and feasible method for establishing pneumoperitoneum in transperitoneal laparoscopic surgery.