Safe technique for laparoscopic entry into the abdominal cavity

Direct trocar insertion vs. Veress needle technique in laparoscopic surgeries. A systematic review and meta-analysis

AIM

To compare the safety and efficacy between Veress needle insertion and direct trocar insertion in laparoscopic surgeries.

METHODS

Relevant clinical trials were retrieved from major databases; Web of Science, Cochrane CENTRAL, PubMed, and SCOPUS. The following outcomes were pooled for analysis: failed entry, extraperitoneal insufflation, vascular lesion, omental lesion and visceral lesion, site bleeding, reintervention, subcutaneous emphysema, solid organ lesion, and infection of the trocar site. A fixed-effects model was used to analyze homogeneous outcomes, whereas random-effects models were used to analyze heterogeneous outcomes.

RESULTS

We included a total of twelve clinical trials. The pooled analysis showed that the Veress needle was accompanied by a significant increase in the incidences of extraperitoneal insufflation (RR = 0.204; 95% Cl [0.136, 0.307], P=0.001), omental lesion (RR=0.444 95% Cl [0.239, 0.825], P=0.01), and failed entry (RR=0.169 95% Cl [0.101, 0.284], P=0.001). There is no significant difference between both cohort regarding the vascular lesion (RR=0.847 95% Cl [0.259, 2.777), P=0.7), infection of the trocar site (RR=0.583 95%Cl [0.106, 3.216], P=0.5, and visceral lesion (RR=1.308 95% Cl [0.314, 5.438], P=0.7.

CONCLUSION

The DTI was accompanied by a significantly lower incidence of complications such as extraperitoneal insufflation, failed entry, omental lesion, and subcutaneous emphysema. On the other hand, both cohorts showed similar results regarding; vascular lesions, visceral lesions, reintervention, site bleeding, and solid organ lesion.

The shortest distance between the skin and the peritoneal cavity is obtained with fascial elevation: a preliminary prospective laparoscopic entry study

The purpose of this study was to prospectively compare the measurement of skin-to-fascia distances in the neutral state, during manual elevation and by fascial elevation in patients who underwent laparoscopic surgery. In 53 patients, the distance between the skin and anterior wall of the rectus sheath was measured prospectively in following three different ways: (1) in neutral position, (2) during manual elevation and (3) during elevation of the fascia using forceps following an infraumbilical vertical skin incision. In all patients, subcutaneous tissue up to the fascia was dissected after a vertical skin incision. The skin-to-fascia distance of 30.9 mm (14.0-52.0 mm) in the neutral position decreased to 11.1 mm (0.0-26.0 mm) during the fascial elevation, while the mean distance increased to 40.1 mm (19-70 mm) during manual elevation (p < 0.001). In the closed laparoscopic entry technique in which a Veress needle is inserted into the peritoneum through a small incision, the needle should be introduced from the shortest distance between the skin and the peritoneum. Lifting the fascia with a proper surgical instrument in suitable patients could enable us to achieve this goal.

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.

Prospective Observational Study of Comparison Between Direct and High-Pressure Primary Trocar Entry in Gynaecological Laparoscopy in Teaching Hospital

Background

Laparoscopic port entry is crucial and vital step in any laparoscopic surgery. As laparoscopy is widely used, complications related to it are also increasing which are not seen in conventional laparotomy.

Aim

The present study was undertaken to compare the ease of primary trocar entry after pneumoperitoneum at 20 mmHg pressure and direct trocar entry without pneumoperitoneum.

Methods

Total 100 nulliparous patients who presented for elective gynaecologic laparoscopic surgery were enrolled for the study. In operating theatre, randomization of patients was done using a sealed envelope technique which divides patients into two equal groups and assigned as either low-pressure group or high-pressure group. Verres needle insertion and trocar entry was done by fellowship trainee in laparoscopy assisted by senior laparoscopy surgeon.

Result

In high-pressure group we had trocar entry in first attempt in 80% of patient, second attempt in 20% where as in direct trocar entry group required first attempt in 88%, second attempt in 10% and third attempt in 2%. Time taken for trocar entry between two groups was significantly different requiring 4.42 ± 0.55 min for high pressure and 1.2 ± 0.28 min for direct trocar entry.

Conclusion

The study concluded that high-pressure trocar entry requires more time; require less attempts, easier and surgeon will be more comfortable in repeating the same technique than direct trocar entry.

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.

Guideline No. 412: Laparoscopic Entry for Gynaecological Surgery

OBJECTIVE

To evaluate the benefits and risks of laparoscopic surgery and provide clinical direction on entry techniques, technologies, and their associated complications in gynaecological surgery.

TARGET POPULATION

All patients, including pregnant women and women with obesity, undergoing laparoscopic surgery for various gynaecological indications.

OPTIONS

The laparoscopic entry techniques and technologies reviewed in formulating this guideline included the closed (Veress needle-pneumoperitoneum-trocar) technique, direct trocar insertion, open (Hasson) technique, visual entry systems, and disposable shielded and radially expanding trocars.

OUTCOMES

Implementation of this guideline should optimize decision-making in the selection of entry technique for laparoscopic surgery.

EVIDENCE

We searched English-language articles from September 2005 to December 2019 in PubMed/MEDLINE, Embase, Science Direct, Scopus, and Cochrane Library using the following MeSH search terms alone or in combination: laparoscopic entry, laparoscopy access, pneumoperitoneum, Veress needle, open (Hasson), direct trocar, visual entry, shielded trocars, radially expanded trocars, and laparoscopic complications.

VALIDATION METHODS

The authors rated the quality of evidence and strength of recommendations using the Canadian Task Force on Preventive Health Care approach (Appendix A).

INTENDED AUDIENCE

Surgeons performing laparoscopic gynaecological surgery.

SUMMARY STATEMENTS

RECOMMENDATIONS.

Clinical Perspective Concerning Abdominal Entry Techniques

OBJECTIVE

Entry into the abdomen during operative laparoscopy is a source of some controversy regarding the safest and most useful method. The objective of this review is to describe, compare, and contrast the most popular entry techniques.

DATA SOURCES

Data were collected from the historical starting point until present day from English language journal articles and book chapters.

METHODS OF STUDY SELECTION

Descriptive accounts dating back to the start of laparoscopy in the 1970s and spanning to present day well-designed randomized controlled trials and Cochrane reviews were compiled to evaluate the evidence for the effectiveness and safety of abdominal entry techniques.

TABULATION, INTEGRATION, AND RESULTS

The most common sites of entry are the umbilicus and the left upper quadrant. Between the Veress needle, direct trocar insertion, and open entry there is no high-quality evidence to suggest that any of these offers a universal safety advantage. The Veress needle is still the most used among gynecologists and facilitates primary trocar placement. Direct trocar entry under laparoscopic visualization may be underused, is faster, and may result in fewer failed entries. Open (Hasson) entry can be more technically challenging, but may be best for patients with suspected intra-abdominal adhesions.

CONCLUSION

Surgeon comfort is critical in choosing the entry site, method, and equipment. Surgeon familiarity with entry-failure troubleshooting, possible complications, and management is essential because major entry complications are rare in modern laparoscopy but critical because the essential steps of recognition and management can be lifesaving.

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.

Laparoscopic entry techniques: What is the controversy?

OBJECTIVE

To review reported complications related to the different laparoscopic entry techniques in the human and veterinary literature and describe the benefits and limitations of each technique.

STUDY DESIGN

Literature review of 57 peer-reviewed articles.

METHODS

An electronic database search identified human and veterinary literature describing complications related to entry technique during laparoscopy.

RESULTS

Open- and closed-entry techniques may result in trauma of abdominal organs or vasculature. During laparoscopy in man, injury to bowel and major vasculature is reported in 0.02% and 0.04% of procedures with open- or closed-entry techniques, respectively. Designs of Veress needles and trocar cannula assemblies have been developed to improve ease and safety. Early complications, defined as those observed at the time of port entry into the abdominal cavity, result from the puncture of a blood vessel leading to substantial visible hemorrhage. Late complications are detected 24 or 48 hours after surgery and result from the puncture of a loop of intestine that was not detected at the time of initial surgery. The major reasons for iatrogenic trauma in man are related to anatomical factors and the presence of adhesions. No explanation for cause of complications was identified for animals.

CONCLUSION

There is no consensus in the human or veterinary literature about the best entry technique for laparoscopy. The rate of complications related to entry technique in small animals is not known because the data are underreported.

CLINICAL SIGNIFICANCE

Complications related to entry techniques are expected in both man and animals. Improvements in techniques and equipment design are being developed to minimize risk.

Aiming for complete safety of first trocar insertion of laparoscopic surgery: usefulness of preoperative ultrasonography of umbilical region

AIM

Vascular or intestinal injuries at the time of the first trocar insertion can cause serious complications during laparoscopic surgeries. In this study, we evaluate the usefulness of ultrasound scans of the umbilical region as well as intraumbilical conditions to help prevent serious complications.

METHODS

The subjects included 430 cases who underwent laparoscopic gynecologic surgeries. The umbilical ultrasound scan was performed after tracheal intubation to observe the intestinal movements associated with respiration. Structures of the umbilical region as well as peristalsis and the movement of the intestinal tract were observed. Then, the thickness of the subcutaneous fat (between the umbilical skin surface and the rectus fascia) and the preperitoneal fat (between the rectus fascia and the peritoneum) were measured. The relationship between body mass index (BMI), insertion time of the first trocar and ultrasound measurements were analyzed.

RESULTS

The anatomical structures of the umbilical region (the subcutaneous tissue and the preperitoneal fat) were clearly observed in all cases. The BMI score had a significant relationship with subcutaneous fat thickness (r = 0.547), but remarkably not with preperitoneal fat thickness (r = 0.174). There was no significant relationship between BMI and insertion time. However, insertion time of the first trocar had a significant relationship with preperitoneal fat thickness (r = 0.534).

CONCLUSIONS

Preoperative ultrasonography of the umbilical region is asimple process, and it is helpful inpreventing serious complications caused by the first trocar insertion. We have found that preperitoneal fat thickness seems to be an important factor in predicting the potential difficulty of the first trocar insertion.

The Effect of Age and Body Mass Index on the Surgical Anatomy of Supraumbilical Port Insertion: Implications for Laparoscopic and Robotic Surgery

BACKGROUND

Minimally invasive surgery is the preferred approach for performing many gynecologic procedures. Occasionally, supraumbilical port placement may be preferable to optimize visibility and maneuverability although the risks of complications are less well characterized compared to umbilical entry.

METHODS

We conducted a retrospective review of computed tomograms from 92 patients to evaluate the anatomic considerations for umbilical and supraumbilical port entry based on patient age, body mass index (BMI), parity, abdominal wall thickness, and distance to the great vessels.

RESULTS

Supraumbilical entry was not associated with differences in distance to the great vessels compared to the umbilicus. However, supraumbilical location and BMI were associated with greater abdominal wall thickness. Age and BMI were associated with greater distance to the great vessels, while age was associated with thinner abdominal wall. Multiple linear regression confirmed independent effects of age and BMI. No association between parity and distance to retroperitoneal vessels was observed.

CONCLUSION

Younger patients may be at increased risk for great vessel injury and pre-peritoneal insufflation. Obese patients may be at risk for pre-peritoneal insufflation, while patients with BMI < 30, particularly with a skin-to-aorta distance < 7 cm, may be at an increased risk for great vessel injury. Surgeons should consider these factors when considering supraumbilical port entry.

Trocar Injuries in 17,446 Laparoscopic Gastric Bypass-a Nationwide Survey from the Scandinavian Obesity Surgery Registry

BACKGROUND

Although, the vast majority of bariatric procedures worldwide are performed laparoscopically, there is no consensus on the best technique to enter the first trocar, a potentially dangerous maneuver. Three principally different techniques exist: initial pneumoperitoneum by Verres needle, open Hasson technique, and direct placement of an optical trocar. In this nationwide survey, we have studied the presently used technique to place the first trocar and identified any intraabdominal injuries in 2012-2014.

METHODS

A questionnaire concerning techniques for placing the first trocar and identified intraabdominal injuries was sent to all 41 centers performing laparoscopic Roux en-Y gastric bypass (LRYGB) in Sweden. Total number of procedures were collected from the national quality registry, Scandinavian Obesity Surgery Registry (SOReg), also searched for reports on intraabdominal injuries.

RESULTS

During the present study period, 17,446 LRYGBs were performed. Twelve intraabdominal injuries (0.07 %) were found: bleedings from the omentum, small bowel mesentery and liver (n = 8), and gastric or small bowel perforation (n = 4). The injuries were evenly distributed between the Veress technique and direct placement of an optical trocar, while no injuries occurred with the Hasson technique. Concerning placement of the first trocar, initial pneumoperitoneum with Veress needle was most common (59 %), followed by direct placement of an optical trocar (30 %). This indicates a switch from 2009-2010 (Veress 45 % and optical trocar 45 %, p < 0.001).

CONCLUSIONS

Twelve intraabdominal injuries (0.07 %) were found in this nationwide survey. The most common technique for placing the first trocar had switched from directly placing an optical trocar to prior establishment of pneumoperitoneum.

Is there any difference between the distances created by towel clamp lifting and towel clamp plus manual lifting of the anterior abdominal wall for direct trocar entry in laparoscopic gynecologic surgery? A prospective interventional study

Objective:

Most surgeons prefer to perform anterior abdominal wall lifting during abdominal entry to avoid damage to intestines or main vessels. Anterior abdominal wall lifting is assumed to prevent vital organ injuries by creating an adequate distance prior to entry into the peritoneal cavity. In this study, we compared the distance created for trocar entry into the peritoneal cavity with towel clamp lifting and towel clamp plus manual elevation of the anterior abdominal wall.

Material and Methods:

Forty patients who underwent various laparoscopic procedures were enrolled. The study was performed in two steps: first the anterior abdominal wall was lifted using towel clamps (TC group), next the anterior abdominal wall was lifted via maximal manual elevation from the lower abdomen in addition to towel clamps (TCM group). The insertion distance of a plastic ruler into the abdomen was measured from the parietal peritoneum to the intra-abdominal structure in both groups.

Results:

There was a statistically significant difference between the two groups (TC group 3.9±1.5 cm vs. TCM group 4.5±1.5 cm, p<0.001). Correlation analysis of the relationship of distance with BMI in the study groups revealed a strong negative linear correlation [TC group vs. body mass index (BMI); r=-0.719, p<0.001 and TCM group vs. BMI, r=-0.749, p<0.001]. Correlation analysis of the relationship between the study groups and parity number revealed a weak negative linear correlation (TC group vs. parity number, r=-0.071, p=0.76 and the TCM group vs. parity number, p=0.61), which did not reach statistical significance.

Conclusion:

The recruitment of both towel clamps and manual elevation in anterior abdominal wall lifting provides significantly greater distance for trocar entry in laparoscopic surgery.

The relationship between the umbilicus and the aortic bifurcation in Turkish women: implications for laparoscopic entry

PURPOSE

We aimed to determine the location and vertical distance of the umbilicus relative to the aortic bifurcation using computed tomography (CT), and assess their relationship with BMI among Turkish women and their implications for laparoscopic entry.

METHODS

This cross-sectional study included a total of 209 women undergoing abdominopelvic CT; the vertical distance between the aortic bifurcation and the umbilicus was evaluated on coronal sections. The distance between the skin and the parietal peritoneum was measured from the umbilical pit to the peritoneum, and the distance between the skin and the aorta was measured from the umbilical pit to the surface of the aortic bifurcation. The measurements were performed along the sagittal plane. The age, height, and weight of the patients were recorded. For comparison, women were divided into three groups according to BMI.

RESULTS

The aortic bifurcation was located above (cephalic to) the umbilicus in 30 patients in the non-obese group (48.4%), 54 patients in the overweight group (55.7%), and 34 patients (68%) in the obese group. The mean distances between the umbilicus and the parietal peritoneum were 15.1 ± 6.4, 19 ± 5.5, 27.2 ± 10.8 mm, respectively, in the non-obese group, overweight group, and obese group. The mean distances between the umbilicus and the aorta were 85.8 ± 26.3, 110 ± 2.9, 132.1 ± 26.7 mm, respectively, in the non-obese group, overweight group, and obese group.

CONCLUSIONS

The location of the umbilicus relative to the aortic bifurcation can vary according to age, BMI and ethnicity or nationality of patients; therefore, a surgeon should not stick to a particular angle of insertion during laparoscopic entry. It is better for surgeons to know their unique patient population.

Exploring the umbilical and vaginal port during minimally invasive surgery

This article focuses on the anatomy, literature, and our own experiences in an effort to assist in the decision-making process of choosing between an umbilical or vaginal port. Umbilical access is more familiar to general surgeons; it is thicker than the transvaginal entry, and has more nerve endings and sensory innervations. This combination increases tissue damage and pain in the umbilical port site. The vaginal route requires prophylactic antibiotics, a Foley catheter, and a period of postoperative sexual abstinence. Removal of large specimens is a challenge in traditional laparoscopy. Recently, there has been increased interest in going beyond traditional laparoscopy by using the navel in single-incision and port-reduction techniques. The benefits for removal of surgical specimens by colpotomy are not new. There is increasing interest in techniques that use vaginotomy in multifunctional ways, as described under the names of culdolaparoscopy, minilaparoscopy-assisted natural orifice surgery, and natural orifice transluminal endoscopic surgery. Both the navel and the transvaginal accesses are safe and convenient to use in the hands of experienced laparoscopic surgeons. The umbilical site has been successfully used in laparoscopy as an entry and extraction port. Vaginal entry and extraction is associated with a lower risk of incisional hernias, less postoperative pain, and excellent cosmetic results.

Initial closed trocar entry for laparoscopic surgery: Technique, umbilical cosmesis, and patient satisfaction

Background/Aims:

Despite the benefits of laparoscopic surgery, which is being performed with increasing frequency, complications that do not occur during laparotomy are sometimes encountered. Such complications commonly occur during the initial trocar insertion, making this a procedural step of critical importance.

Methods:

In 2002, we experienced, upon initial trocar insertion, a serious major vascular injury (MVI) that led to hemorrhagic shock, and we thus modified the conventional closed entry method to an approach that we have found to be safe. We began developing the method by first measuring, in a patient undergoing laparoscopic cystectomy, the distance between the inner surface of the abdominal wall and the anterior spine when the abdominal wall was lifted manually for trocar insertion and when it was lifted by other methods, and we determined which method provided the greatest distance. We then devised a new approach, summarized as follows: The umbilical ring is elevated with Kocher forceps. The umbilicus is everted, and the base is incised longitudinally. This allows penetration of the abdominal wall at its thinnest point, and it shortens the distance to the abdominal cavity. A bladeless trocar (Step trocar) is used to allow insertion of the Veress needle. We began applying the new entry technique in July 2002, and by December 2014, we had applied it to 9676 patients undergoing laparoscopic gynecology surgery.

Results:

All entries were performed successfully, and no MVI occurred. The umbilical incision often resulted in an umbilical deformity, but in a questionnaire-based survey, patients generally reported satisfaction with the cosmetic outcome.

Conclusion:

A current new approach provides safe outcome with a minor cosmetic problem.

Jain point: A new safe portal for laparoscopic entry in previous surgery cases

INTRODUCTION

The present study was performed to assess the safety and feasibility of a new laparoscopic entry site in cases suspected of adhesions due to previous surgery.

MATERIALS AND METHODS

It is a retrospective study undertaken at a tertiary care referral center for advanced gynecological laparoscopic surgery from January 2011 to December 2014.

RESULTS

In 624 patients with a history of previous abdominal surgeries, the laparoscopic entry site was through a newly devised point. It is a point in the left paraumbilical region at the level of umbilicus, in a straight line drawn vertically upward from a point 2.5 cm medial to anterior superior iliac spine. Intra-abdominal adhesions were found in 487 (78.0%) patients, and umbilical adhesions in 404 (64.7%) patients with past abdominal surgeries.

CONCLUSION

There were no significant entry-related, intra-operative, or postoperative complications with the use of this entry point. It is also suitable as a main working port during the course of surgery.

Differences in early complications between circular and linear stapled gastrojejunostomy in laparoscopic gastric bypass

BACKGROUND

Laparoscopic gastric bypass (LGBP) is the most common bariatric procedure worldwide. The gastrojejunostomy can be stapled with a circular or linear stapler, each with their own specific advantages. We have evaluated differences in postoperative complications between the two techniques.

METHODS

We studied operative data and postoperative complications in 560 patients (79.8 % females, median age 42, BMI 42.5) operated with LGBP between 2008 and 2012 at our center. The gastrojejunostomy was initially performed using a circular stapler (CS) in 288 patients and later by linear stapler (LS) in 272. Complications, operative time, and length of stay were retrieved from our database. The risk of developing a port site infection was evaluated with multivariate logistic regression.

RESULTS

Port site infections were more common with CS than LS, 5.2 and 0.4 %, respectively (p < 0.01). Multivariate analysis demonstrated CS to be an independent risk factor for port site infections (OR 16.3 (2.09-126), p < 0.01), as well as for stomal ulcers (OR 10.1, 1.15-89, p = 0.04). Major postoperative complications remained unchanged (anastomotic leak 1.0 vs. 1.1 %, abscess 0.7 vs. 0.4 %), while operative time and length of stay were found to be shorter using the LS (122 vs. 83 min, p < 0.001 and 4 vs. 3 days, p < 0.001).

CONCLUSIONS

The linear stapled technique yielded lower incidence of port site infections, probably by avoiding the passage of a contaminated circular stapler through the abdominal wall. No difference in major complications was seen, but operative time was shorter using a linear stapler instead of a circular stapler.

Aortic injuries during laparoscopic gastric bypass for morbid obesity in Sweden 2009-2010: a nationwide survey

BACKGROUND

In Sweden, bariatric surgery has increased more than tenfold in the past decade, from 700 to 8,600 procedures annually, and laparoscopic gastric bypass (LRYGB) dominates (92% of all procedures). This expansion makes safety issues crucial. The aim of this nationwide survey was to identify aortic injuries in LRYGB.

METHODS

All 41 centers performing LRYGB in Sweden were asked if an aortic injury had occurred during the years 2009-2010. Techniques for entering the first trocar and way of establishing pneumoperitoneum were evaluated. The total number of procedures was collected from the national quality registry, Scandinavian Obesity Surgery Registry (SOReg), and the National Patient Register.

RESULTS

During the study period, 11,744 LRYGBs were performed. The analysis revealed 5 aortic injuries, all occurring in patients in whom an optical trocar had been placed before establishing pneumoperitoneum. Outcomes varied from no major sequelae to bilateral lower limb amputation and death. Based on the total number of LRYGBs, the risk for an aortic injury was .043% overall and .091% when an optical trocar was used.

CONCLUSION

Aortic injury is a rare but serious complication in laparoscopic gastric bypass. In this survey, optical trocars constructed to reduce the risk of intraabdominal damage had been used in all 5 cases.

UREKA: umbilical ring easy kannula access

The umbilical ring easy kannula access appears to provide a safe portal of laparoscopic entry in pediatric patients with few complications.

Background and Objectives:

Standard techniques of laparoscopic access involve creating an abdominal wall defect and can result in complications. We describe the umbilical ring easy kannula access (UREKA) technique, evaluating safety and a decrease in complications related to port placement.

Methods:

UREKA is performed via a supra- or infraumbilical incision followed by circumferential dissection of the umbilical stalk. The umbilical skin is dissected free from the fascia, exposing the umbilical ring. Pneumoperitoneum is established either before or after placement of a dilating port through the open ring. We reviewed all laparoscopic procedures performed by one pediatric surgeon over 14 months using UREKA.

Results:

Ninety-four patients underwent laparoscopic surgery with initial port placement via UREKA. Appendectomy (n=57) was the most common procedure, followed by fundoplication (15) and cholecystectomy (10). No intestinal, solid organ, vascular, or bladder injuries related to port placement occurred. The only postoperative complication was a superficial wound infection in a 135-kg patient following cholecystectomy, treated successfully with oral antibiotics alone.

Conclusion:

The umbilical ring persists to some degree in all pediatric patients and provides a safe portal of entry for laparoscopic surgery. UREKA has few complications and is a straightforward, reproducible technique for gaining initial laparoscopic access.

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: 1. Left upper quadrant (LUQ, Palmer's) laparoscopic entry should be considered in patients with suspected or known periumbilical adhesions or history or presence of umbilical hernia, or after three failed insufflation attempts at the umbilicus. (II-2 A) Other sites of insertion, such as transuterine Veress CO(2) insufflation, may be considered if the umbilical and LUQ insertions have failed or have been considered and are not an option. (I-A) 2. The various Veress needle safety tests or checks provide very little useful information on the placement of the Veress needle. It is therefore not necessary to perform various safety checks on inserting the Veress needle; however, waggling of the Veress needle from side to side must be avoided, as this can enlarge a 1.6 mm puncture injury to an injury of up to 1 cm in viscera or blood vessels. (II-1 A) 3. The Veress intraperitoneal (VIP-pressure </= 10 mm Hg) is a reliable indicator of correct intraperitoneal placement of the Veress needle; therefore, it is appropriate to attach the CO(2) source to the Veress needle on entry. (II-1 A) 4. Elevation of the anterior abdominal wall at the time of Veress or primary trocar insertion is not routinely recommended, as it does not avoid visceral or vessel injury. (II-2 B) 5. The angle of the Veress needle insertion should vary according to the BMI of the patient, from 45 degrees in non-obese women to 90 degrees in obese women. (II-2 B) 6. The volume of CO(2) inserted with the Veress needle should depend on the intra-abdominal pressure. Adequate pneumoperitoneum should be determined by a pressure of 20 to 30 mm Hg and not by predetermined CO(2) volume. (II-1 A) 7. In the Veress needle method of entry, the abdominal pressure may be increased immediately prior to insertion of the first trocar. The high intraperitoneal (HIP-pressure) laparoscopic entry technique does not adversely affect cardiopulmonary function in healthy women. (II-1 A) 8. The open entry technique may be utilized as an alternative to the Veress needle technique, although the majority of gynaecologists prefer the Veress entry. There is no evidence that the open entry technique is superior to or inferior to the other entry techniques currently available. (II-2 C) 9. Direct insertion of the trocar without prior pneumoperitoneum may be considered as a safe alternative to Veress needle technique. (II-2) 10. Direct insertion of the trocar is associated with less insufflation-related complications such as gas embolism, and it is a faster technique than the Veress needle technique. (I) 11. Shielded trocars may be used in an effort to decrease entry injuries. There is no evidence that they result in fewer visceral and vascular injuries during laparoscopic access. (II-B) 12. Radially expanding trocars are not recommended as being superior to the traditional trocars. They do have blunt tips that may provide some protection from injuries, but the force required for entry is significantly greater than with disposable trocars. (I-A) 13. The visual entry cannula system may represent an advantage over traditional trocars, as it allows a clear optical entry, but this advantage has not been fully explored. The visual entry cannula trocars have the advantage of minimizing the size of the entry wound and reducing the force necessary for insertion. Visual entry trocars are non-superior to other trocars since they do not avoid visceral and vascular injury. (2 B).

Effect of body habitus and parity on the initial Veres intraperitoneal CO2 insufflation pressure during laparoscopic access in women

STUDY OBJECTIVES

Since most gynecologists use the Veres/trocar entry, and because the Veres intraperitoneal (VIP) pressure appears to be the most reliable indicator of correct Veres needle placement, the objective of this study was to determine the effect of height, weight, body mass index (BMI), parity, and age on the initial Veres intraperitoneal CO2 insufflation pressure during laparoscopic access in women.

DESIGN

Prospective observational cohort study (Canadian Task Force classification II-1).

SETTING

University affiliated teaching hospital.

PATIENTS

We prospectively collected data on 356 women undergoing laparoscopy for a variety of indications by the senior author (G.A.V.). The median and (range) for height, weight, BMI, parity, and age were 1.64 m (1.45-1.85 m), 65 kg (40-120 kg), 24.3 kg/m2 (16-47 kg/m2), 1 (0-5) and 34 years (18-87 yrs), respectively.

INTERVENTION

Under general endotracheal anesthesia including muscle relaxants and with the patient in appropriate stirrups in the horizontal position, a nondisposable Veres needle was inserted at the umbilicus or left upper quadrant (Palmer's point) with CO2 flowing at 1 L/min. The initial Veres intraperitoneal insufflation pressure was recorded once the Veres needle was believed to be in the peritoneal cavity.

MEASUREMENTS AND MAIN RESULTS

The mode and the median VIP pressure was 4 mm Hg with a range of 2 to 10 mm Hg. With multivariate analysis, the VIP pressure correlated positively with the weight (r = 0.518, p <.001) and BMI (r = 0.545, p <.001) and negatively with the parity (r = -0.179, p <.001) of women. The correlation of the VIP pressure with height and age was r = 0.029 (p = .591) and r = -0.044 (p = .411), respectively.

CONCLUSION

A VIP pressure < or =10 mm Hg indicates intraperitoneal placement of the Veres needle. The VIP pressure correlates positively with the weight and BMI and negatively with the parity of women. There is no correlation of the VIP pressure with women's height and age.

Safe and rapid laparoscopic access--a new approach

Despite numerous recent technical advances in minimally invasive surgical technique, the potential exists for serious morbidity during initial laparoscopic access. Safe access depends on adhering to well-recognized principles of trocar insertion, knowledge of abdominal anatomy, and recognition of hazards imposed by previous surgery. Applying these principles, we describe a safe, rapid, and cost-effective technique for laparoscopic access using readily available instruments. This technique emphasizes identification and incision of the point at which the midline abdominal fascia is fused with the base of the umbilicus, and the importance of the application of countertraction directly at the point of insertion. This method allows penetration under direct vision with minimal controlled axial force, and without the requirement for fascial sutures or other cumbersome aspects of the traditional open technique. While previous reports describe techniques for laparoscopic access entry based on similar anatomic and surgical principles, we describe an alternative method not yet discussed in the surgical literature.