Laparoscopic Peritoneal Entry Preferences Among Canadian Gynaecologists

An open comparative randomized prospective study: Direct trocar insertion vs Veress needle technique in laparoscopic surgeries

Laparoscopy is a minimally invasive technique utilized for both diagnostic and surgical approaches. Minimally invasive procedures compared to laparotomy offer the advantages of reduced hospital stay, lower morbidity, decreased pain, and faster recovery. Common methods for laparoscopic entry include Veress needle insertion (VNI), direct optical trocar entry, direct trocar insertion (DTI), and the Hasson technique. This study aims to compare the efficacy and safety of VNI and DTI in laparoscopic gynecological surgeries. An open comparative randomized prospective study was conducted involving 200 women aged 18 to 70 years, scheduled for laparoscopic surgery at 2 tertiary centers. Participants were randomized into 2 groups: 1 using VNI and other using DTI. The groups were homogeneous regarding age, parity, and body mass index. The mean age of the VNI group is 45.22 ± 11.65 and the DTI group is 44.89 ± 10.5 (P = .833). There were no statistical significance in terms of the presence of chronic diseases and history of previous abdominal surgery between the groups (P = .802 and P = .510, respectively). Entry time to the abdomen, the decrease in hemoglobin values, and hospitalization length were found to be statistically significant between the entry methods (P < .001, P = .002, and P < .001, respectively). Entry time, the decrease in hemoglobin value, and hospitalization length were higher in the VNI group. In conclusion, although there is no definitive consensus on the optimal laparoscopic entry technique, direct trocar entry is an effective alternative to the Veress needle insertion technique. Direct trocar entry is associated with shorter entry times, fewer perioperative complications, less reduction in hemoglobin levels, and shorter hospitalization duration compared to VNI.

Preferred technique of creating pneumoperitoneum for laparoscopy by pediatric surgeons

Background

Minimally invasive pediatric surgery has gained popularity over open conventional surgery as it offers benefits to both patients and health care practitioners. Creation of pneumoperitoneum is a must for any laparoscopic procedure. Different pediatric surgeons have their individual preferences regarding the technique to create pneumoperitoneum prior to laparoscopy. The aim of this study was to evaluate the preference of technique for the creation of pneumoperitoneum in pediatric laparoscopy among Indian Pediatric Surgeons. The study was designed by communication with members of the Indian Association of Pediatric Surgeons using a predefined questionnaire. 180 pediatric surgeons responded to the survey. The respondents included pediatric surgeons in institutional and private practice. The reasons behind their preference were enumerated and evaluated.

Results

Seventy-one percent of pediatric surgeons preferred the primary open technique for the creation of pneumoperitoneum. Seventeen percent exclusively used Veress needle whereas 12% were using both techniques varying from patient to patient.

Conclusion

Creation of pneumoperitoneum remains an important safety issue for all pediatric surgeons. Pediatric Surgeons in India prefer using the primary open technique for the creation of pneumoperitoneum for laparoscopic surgery.

Surgeons' requirements for a surgical support system to improve laparoscopic access

Creating surgical access is a critical step in laparoscopic surgery. Surgeons have to insert a sharp instrument such as the Veress needle or a trocar into the patient’s abdomen until the peritoneal cavity is reached. They solely rely on their experience and distorted tactile feedback in that process, leading to a complication rate as high as 14% of all cases. Recent studies have shown the feasibility of surgical support systems that provide intraoperative feedback regarding the insertion process to improve laparoscopic access outcomes. However, to date, the surgeons’ requirements for such support systems remain unclear. This research article presents the results of an explorative study that aimed to acquire data about the information that helps surgeons improve laparoscopic access outcomes. The results indicate that feedback regarding the reaching of the peritoneal cavity is of significant importance and should be presented visually or acoustically. Finally, a solution should be straightforward and intuitive to use, should support or even improve the clinical workflow, but also cheap enough to facilitate its usage rate. While this study was tailored to laparoscopic access, its results also apply to other minimally invasive procedures.

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.

Laparoscopic Entry Technique Using a Veress Needle Insertion with and without Concomitant CO2 Insufflation: A Randomized Controlled Trial

STUDY OBJECTIVE

To compare the time and number of attempts needed for successful Veress needle entry during laparoscopic surgery using concomitant versus subsequent CO₂ insufflation approaches.

DESIGN

Randomized controlled trial.

SETTING

University teaching hospital.

PATIENTS

One hundred consecutive patients scheduled for laparoscopic surgery by 2 high-volume laparoscopic surgeons were screened and randomized, and 95 of these were included in the final analysis. Ninety (45 in each group) was the precalculated priori number of patients needed to detect a 50% difference in the time (seconds) to obtain adequate insufflation with 90% power and alpha of 5%.

INTERVENTIONS

Patients were randomized to either Veress needle entry with concomitant (Con) or subsequent (Sub) CO₂ insufflation.

MEASUREMENTS AND MAIN RESULTS

Forty-six patients were randomized to the Con group and 49 to the Sub group. Patient age, body mass index, prior surgical history, presence of adhesions, and type of procedure performed were similar between both groups. The median time required for adequate insufflation in the Con group was 103.5 seconds (Q1-Q3, 80.0-130.0) compared with 113.0 seconds (Q1-Q3, 102.0-144.0) in Sub group (p = .16). Approximately 89% (95% confidence interval, 80.1%-98.1%) of patients in Con group achieved successful entry in the first attempt compared with only 67% (95% confidence interval, 54.2%-80.0%) in Sub group (p = .01). The incidence of preperitoneal insufflation and failed entry was comparable between the 2 groups. No patient developed solid organ, visceral, or vascular injuries; gas embolism; or case conversion to laparotomy in relation to the Veress needle entry technique.

CONCLUSION

Veress needle entry with concomitant CO₂ insufflation was associated with a higher rate of successful entry during the first attempt of Veress needle insertion. The total time required for insufflation and rates of complications between the 2 techniques were similar.

Direct Laparoscopic Trocar Insertion: Lessons Learned from Nine Litigated Cases

STUDY OBJECTIVE

To report circumstances and clinical and medicolegal outcomes of 9 litigated cases associated with direct trocar insertion (DTI) injuries to the bowel (7 cases) and major vessel (2 cases) during primary laparoscopic access.

DESIGN

A case series from 1990 through 2015 (Canadian Task Force Classification II-2).

PATIENTS

Nine litigated cases.

INTERVENTIONS

A retrospective review of medical and legal records of litigated cases in Canada reviewed by the primary author (G.A.V.).

MEASUREMENTS AND MAIN RESULTS

The average and range of age and body mass index of the women were 31 years (range, 14-65 years) and 25 kg/m² (range, 20-35 kg/m²), respectively. Indications for laparoscopy included diagnostic (4), laparoscopically assisted vaginal hysterectomy (3), pelvic mass (1), and laparoscopic cholecystectomy (1). DTI was performed with 10-mm trocars (5 shielded, 1 reusable, and 3 unknown). Two complications were experienced by patients of the same male surgeon (cases 2 and 9). Injuries included the small bowel (4 cases), colon (3 cases), and major vessel (2 cases). Vascular injuries resulted in permanent brain damage in 1 and near loss of limb in the other; litigation was favorable to the plaintiff in both cases. All bowel injuries presented with signs and symptoms of peritonitis within 3 postoperative days (PODs) (5 patients on POD 1, 1 patient on POD 2, and 1 patient on POD 3); however, only 2 cases were acted upon and remedied with favorable clinical and medicolegal outcomes. A delayed exploratory laparotomy resulted in significant adverse clinical outcomes (ileostomy/colostomy in 4 patients, multiple surgeries in 7 patients, and 1 death), and in all delayed actions, the medicolegal outcomes were favorable to the plaintiff.

CONCLUSION

During laparoscopic primary peritoneal access using the DTI technique, inadvertent intra-abdominal injury may be significant when major vessels are involved and when intervention is delayed in bowel injuries. These result in significant adverse clinical complications and may provoke higher litigation with more favorable outcomes for the plaintiff.

A review of the open laparoscopic Hasson technique and retrieval of adnexal specimen via umbilicus

Laparoscopic entry techniques vary amongst surgeons and gynaecologists, with gynaecologists favouring Veress needle entry. Recent RCOG/BSGE recommendations have recommended retrieval of ovarian masses via the umbilical port with resultant less postoperative pain and a faster retrieval time than with retrieval through lateral ports of the same size. This is a prospective observational study reviewing the Hasson entry technique and the introduction of retrieval of specimens via the umbilicus in patients scheduled for a laparoscopy procedure at our day surgery unit. We found no immediate or major surgical complications and all specimens were successfully retrieved through the umbilicus. Pain scores were low. We recommend the technique for extirpative gynaecological surgery. Impact Statement This study confirms that conversion from the closed Veress to the open Hasson technique is achievable in a university hospital setting. Operator confidence during the learning phase is enhanced by the use of ultrasound to locate and measure the depth of the umbilical ligament. Retrieval of benign adnexal specimens through the umbilicus was very satisfactory.

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

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

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?

Sex differences among obstetrician-gynecologists: a review of survey studies

Whether practice differences exist between the sexes is a question of clinical and educational significance. The obstetrician-gynecologist (ob-gyn) workforce has been shifting to majority women. An examination of sex differences in ob-gyn practice contributes to the discussion about how the changing workforce may impact women's healthcare. We sought to review survey studies to assess whether there are specific topics in which differences in attitudes, opinions, and practice patterns between male and female ob-gyns are apparent. We conducted a systematic review to identify all survey studies of ob-gyns from the years 2002-2012. A total of 93 studies were reviewed to identify statements of sex differences and categorized by conceptual theme. Sex differences were identified in a number of areas. In general, women report more supportive attitudes toward abortion. A number of differences were identified with regard to workforce issues, such as women earning 23% less than their male counterparts as reported in 1 study and working an average of 4.1 fewer hours per week than men in another study. Men typically provide higher selfratings than women in a number of areas. Other noted findings include men tending toward more pharmaceutical therapies and women making more referrals for medical conditions. Although a number of areas of difference were identified, the impact of such differences is yet to be determined. Additional research may help to clarify the reasons for such differences and their potential impact on patients.

TARGET AUDIENCE

Obstetricians and gynecologists, family physicians Learning Objectives: After completing this CME activity, physicians should be better able to determine how the relevance of studying sex differences among physicians, specifically ob-gyns, can help improve patient care, assess whether there are topical areas in which male and female ob-gyns have reported different beliefs, practices, attitudes, and opinions, and examine how the limitations of survey studies and systematic reviews can affect the findings of these studies and reviews.

Direct trocar insertion for laparoscopy

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSION

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

Laparoscopic entry: a review of Canadian general surgical practice

BACKGROUND

Laparoscopic surgery has gained popularity over open conventional surgery as it offers benefits to both patients and health care practitioners. Although the overall risk of complications during laparoscopic surgery is recognized to be lower than during laparotomy, inadvertent serious complications still occur. Creation of the pneumoperitoneum and placement of laparoscopic ports remain a critical first step during endoscopic surgery. It is estimated that up to 50% of laparoscopic complications are entry-related, and most injury-related litigations are trocar-related. We sought to evaluate the current practice of laparoscopic entry among Canadian general surgeons.

METHODS

We conducted a national survey to identify general surgeon preferences for laparoscopic entry. Specifically, we sought to survey surgeons using the membership database from the Canadian Association of General Surgeons (CAGS) with regards to entry methods, access instruments, port insertion sites and patient safety profiles. Laparoscopic cholecystectomy was used as a representative general surgical procedure.

RESULTS

The survey was completed by 248 of 1000 (24.8%) registered members of CAGS. Respondents included both community and academic surgeons, with and without formal laparoscopic fellowship training. The demographic profile of respondents was consistent nationally. A substantial proportion of general surgeons (> 80%) prefer the open primary entry technique, use the Hasson trocar and cannula and favour the periumbilical port site, irrespective of patient weight or history of peritoneal adhesions. One-third of surgeons surveyed use Veress needle insufflation in their surgical practices. More than 50% of respondents witnessed complications related to primary laparoscopic trocar insertion.

CONCLUSION

General surgeons in Canada use the open primary entry technique, with the Hasson trocar and cannula applied periumbilically to establish a pneumoperitoneum for laparoscopic surgery. This surgical approach is remarkably consistent nationally, although considerably variant across other surgical subspecialties. Peritoneal entry remains an important patient safety issue that requires ongoing evaluation and study to ensure translation into safe contemporary clinical practice.