Laparoscopic entry: a review of techniques, technologies, and complications

Transumbilical laparoscopy for pneumoperitoneum establishment: a comprehensive multicentre evaluation affirming safety, feasibility, and a range of clinical benefits

Introduction

Transumbilical laparoscopy (TUL) has emerged as a promising technique for establishing pneumoperitoneum in laparoscopic cholecystectomy, offering potential safety, feasibility, and clinical benefits. This retrospective multicentre study aims to evaluate the efficacy and outcomes of TUL in the management of gallbladder diseases.

Methods

A retrospective analysis was conducted on a cohort of 2,543 patients who underwent TUL between 2011 and 2021 across various medical institutions in Italy. Data collection included demographic, clinical, intraoperative, and postoperative parameters. Standardized protocols were followed for preoperative and postoperative management. The TUL technique involved precise anatomical incision and trocar placement.

Results

The study demonstrated favorable outcomes associated with TUL, including a low conversion rate to open surgery (0.55%), minimal intraoperative complications (0.16%), and short hospital stays (average 2.4 days). The incidence of incisional hernias was notably low (0.4%). Comparison with existing literature revealed consistent findings and provided unique insights into the advantages of TUL.

Discussion

Despite limitations, such as the absence of a control group and the retrospective nature of the study, the findings contribute valuable insights to the literature. They inform surgical decision-making and advance patient care in laparoscopic cholecystectomy for gallbladder diseases.

Conclusion

Transumbilical laparoscopy shows promise as a safe and feasible technique for establishing pneumoperitoneum in laparoscopic cholecystectomy. The study's findings support its clinical benefits, including low conversion rates, minimal complications, and short hospital stays. Further research, including prospective studies with control groups, is warranted to validate these results and optimize patient outcomes.

Safety of Laparoscopic Entry Points in Patients With a History of Abdominal Surgery: A Research Article

INTRODUCTION

This study aimed to assess the safety of laparoscopic entry sites in patients with previous abdominal surgery who subsequently required re-operation.

MATERIAL AND METHODS

This is a prospective study wherein the data of 118 patients who had undergone previous abdominal surgery and were subsequently re-operated at our center (Bakırköy Doctor Sadi Konuk Research and Study Hospital) were collected from October 2015 to October 2016. Careful attention was paid to gathering information regarding patients' age, parity, body mass index (BMI), type of previous surgery, type of incision made during previous surgery, and medical history. For this study, the abdomen was topographically divided into nine parts. During the operation, all quadrants were examined and evaluated for adhesion and the content of adhesion.

RESULTS

Adhesions were found in 44% (55 out of 118) of the patients, while 56% (66 patients) had no adhesions in the abdomen. The majority of cases (74%) had a history of cesarean section, and 87% had a Pfannenstiel incision. Adhesions were reported in 37.5% (33 out of 88) of the patients with a previous history of cesarean section. A significant proportion of subjects with adhesion (83%) had anterior abdominal wall adhesions, including only the omentum, whereas 11.5% (six subjects) had umbilical adhesions. Subjects with a history of umbilical hernia repair had more adhesions.

DISCUSSION

The present study sought to assess the safety of laparoscopic entry points in individuals with prior abdominal surgery. The rise in laparoscopic surgeries, favored for reduced wound infections and quicker recovery times, brings forth concerns about potential complications in those with previous abdominal operations. Historically, postoperative adhesions have been observed in a significant number of patients after gynecological procedures. Our research, however, found a lower adhesion rate, which could be due to the smaller size of our sample and fewer gynecological cases. Existing adhesions can complicate subsequent surgeries, increasing operational times and posing injury risks. Adhesions also elevate healthcare costs and patient morbidity and mortality. Moreover, complications like Trocar-related injuries, including damage to major organs, are pivotal. While certain trocar insertion techniques may have fewer complications, our results align with previous findings suggesting higher adhesion rates after non-gynecological surgeries. Therefore, alternative entry points or methods, such as the palmer site or direct trocar entry, are recommended for those with an abdominal surgery history. Notably, our study's limited sample size may affect its generalizability, urging future studies for broader insights. Comprehensive pre-surgery assessments are crucial to anticipate complications. Our research supports that laparoscopic surgeries are safe for many with prior abdominal surgery, but for certain patients, non-umbilical entry sites are advised to further mitigate risks.

CONCLUSION

The umbilicus is one of the safest entry sites for primary trocar insertion in patients with a history of Pfannenstiel incision. However, the probability of umbilical adhesions is high in patients who have undergone umbilical mesh repair, median incision, or major abdominal surgery. In these patients, surgeons should prefer other laparoscopic entry sites, especially Palmer's point, rather than the umbilicus.

Injuries incurred from minimally invasive access for abdominal surgery

BACKGROUND

Injuries during initial port placement in minimally invasive abdominal surgery are rare but can cause major morbidity. We aimed to characterize the incidence, consequence, and risk factors for injury occurring on initial port placement.

METHODS

This is a retrospective review of a General Surgery quality collaborative database with supplementary input from the Morbidity and Mortality conference database at our institution between 6/25/2018 and 6/30/2022. Patient characteristics, operative details, and postoperative course were assessed. Cases with an injury on entry were compared to cases without an injury to identify risk factors for injury.

RESULTS

8844 minimally invasive cases were present between the two databases. Thirty-four injuries (0.38%) occurred during initial port placement. Seventy-one percent of injuries were bowel injuries (full or partial thickness) and the majority (79%) of injuries were recognized during the index operation. Median surgeon experience for the cases with an injury was 9 years (IQR 4.25-14.5) compared to 12 years of experience for all surgeons contributing to the database (p = 0.004). Previous laparotomy was also significantly correlated with the rate of injury on entry (p = 0.012). There was no significant difference in the rate of injury based on method of entry (cut-down: 19 (55.9%), optical entry without Veress: 10 (29.4%), Veress followed by optical entry: 5 (14.7%), p = 0.11). BMI > 30 kg/m² (injury: 16/34 vs no injury: 2538/8844, p = 0.847) was not associated with an injury. Fifty-six percent (19/34) of patients with an injury on initial port placement required laparotomy at some point in their hospital course.

CONCLUSIONS

Injuries are rare during initial port placement for minimally invasive abdominal surgery. In our database, history of a previous laparotomy was a significant risk factor for an injury and appears to be more consequential than commonly implicated factors such as technique, patient body habitus, or surgeon experience.

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.

Jain point laparoscopic entry in contraindications of Palmers point

BACKGROUND

This study was conducted to assess the efficacy of the Jain point to overcome the contraindications of Palmer's point. The Jain point lies on the left side of the abdomen at the L4 level, 10-13 cm lateral to the umbilicus. Due to its anatomical location, the Jain point is free from adhesions because postsurgical adhesions are encountered usually in the midline or the right side.

METHODS

This is a retrospective study conducted at a high-volume tertiary care referral center for advanced gynecological laparoscopic surgery, enrolling 8,586 patients who underwent laparoscopy at the center from January 2011 to March 2022. In this paper, we analyze 2,519 patients with a history of previous surgeries, who were operated using the Jain point.

RESULTS

In the 2,519 patients with a history of previous surgeries, the Jain point port was found to be adhesion free, regardless of the location of the scars, the number and type of previous surgeries, and those in whom Palmer's point was contraindicated. No major complications were reported, except for one case (0.04%) of small bowel injury, which was managed intraoperatively. The Jain point continued to function as the main ergonomic working port.

CONCLUSION

The Jain point offers an alternate safe entry port in previous surgery cases for laparoscopic surgeons of various specialties, like general surgeons, urologists, oncologists, and bariatric surgeons, to overcome the contraindications of Palmer's point. The Jain point also acts as the main ergonomic working port, whereas Palmer's point becomes redundant after initial entry.

Gastric Injury at Laparoscopy for Gynecologic Indications: A Systematic Review

OBJECTIVE

This systematic review aims to identify causes of increased risk for and location and mechanism of gastric injury at laparoscopy for gynecologic indications and determine optimal management.

DATA SOURCES

A prospectively registered systematic review (PROSPERO: CRD42021237999) was undertaken and performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Databases searched included Cochrane Central Register of Controlled Trials, Cochrane Database of Systematic Reviews, Medline, Embase, Web of Science, SCOPUS, and Google Scholar from 1960 to 2021.

METHODS OF STUDY SELECTION

All study types were included involving female patients of any age with gastric injury at laparoscopy for gynecologic indication.

TABULATION, INTEGRATION, AND RESULTS

A total of 6294 articles were screened, from which 67 studies were selected for a full-text review. Twenty-eight articles were included, which contained 42 cases drawn from 7 observational studies, 4 case series, and 17 case reports. Of these, 93% (39/42) were at the time of laparoscopic entry, with Veress entry technique used in 79% of these cases (31/39). Eighteen cases reported an entry point, with 77% (14/18) occurring at the periumbilical entry point and 11% (2/18) occurring at Palmer's point. Of the cases with reported etiology for gastric distention or displacement, 64% (9/14) were owing to anesthetic cause. The most common sites of gastric injury were on the anterior stomach wall (n = 8) and the greater curvature (n = 5). Among patients with reported management (32/42), a similar proportion were managed conservatively (11) when compared with repair through laparotomy (13) or laparoscopy (8). All injuries were detected intraoperatively with no reported short-term sequelae.

CONCLUSION

This systematic review of the literature reveals that gastric injury at laparoscopy for gynecologic indications is a rare complication predominantly occurring during laparoscopic entry, most commonly at the periumbilical entry point. When detected intraoperatively, conservative management, laparoscopic, or open repair in the appropriate patient has been performed with no short-term sequelae. The limitations of this review include paucity of cases, detail, and timeline of publications.

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.

A New Laparoscopic Entry Point in Patients With Previous Laparotomy: A Prospective Comparative Study

INTRODUCTION

Intraperitoneal access and establishing pneumoperitoneum for laparoscopy is a critical step especially in patients who underwent previous laparotomy due to the higher risk of visceral or vascular injuries. In this study, we propose a new entry point for safe laparoscopic access in cases having previous laparotomy.

MATERIALS AND METHODS

This is a prospective controlled randomized trial conducted between January 2016 and January 2022 in Ain Shams University Hospitals. It included 232 patients who underwent laparoscopic procedures after previous laparotomy. They were randomly divided into 2 equal groups. In group 1, laparoscopic access was carried out by an optical trocar through the new point situated in the subxiphoid region 1 cm below the costal margin and centered 2.5 cm from the midline on either side. In group 2, laparoscopic access was performed by an optical subumbilical trocar after Verres needle insufflation in Palmer point. The primary end points were success and safety of entry, measured by the number of entry attempts and the incidence of bowel and vascular injuries. The secondary end point was the entry time.

RESULTS

In group 1, safe entry into the abdomen was achieved without visceral or vascular injury. In the 3 cases, minor liver injuries occurred. In group 2, 2 major vascular injuries and 5 bowel injuries occurred. There was a significant difference in procedure time (55±7.2 s in group 1 vs. 192±11.6 s in group 2).

CONCLUSION

The suggested entry point is fast, safe, and reliable in patients having previous laparotomy.

Comparison of Two Entry Methods and Their Cosmetic Outcomes in Creating Pneumoperitoneum: A Prospective Observational Study

Background  The main challenge in laparoscopic surgery is creating pneumoperitoneum using various surgical techniques. Every procedure has its own advocates. The aim of this study was to determine the cosmetic outcomes of the two of the major surgical techniques (open—Hasson technique versus closed—Veress technique) used in laparoscopic surgery.

Methods  This was a prospective, observational, comparative study conducted from October 2017 to September 2018 in 132 patients, who presented to our center and fulfilled our selection criteria. For all the patients, pneumoperitoneum was performed using either open (Hasson) or closed technique (Veress). A database was created for all the patients and the technique dependent cosmetic outcomes were assessed and reported.

Results  There were a total of 66 patients in each group (open and closed). The mean age of the open group was 51.56±11.42 years and closed group was 54.36±14.78 years, respectively. The major comorbidities found in both the groups were diabetes mellitus (6/66, group A; 7/66, group B) and hypertension (3/66, group A; 4/66, group B). In open group, umbilical (58/66, p =0.001) and in closed group infraumbilical (35/66, p =0.001) were the most commonly used incisions.

Conclusion  As benefits outweigh the risks, the better cosmetic outcomes were observed in patients underwent closed technique over open technique ( p <0.05).

Systematic review and meta-analysis of Veress needle entry versus direct trocar entry in gynecologic surgery

Objective

Although many studies have been performed, no consensus exists as to the ideal entry for laparoscopic gynecologic surgery. We sought out to compare the safety of direct trocar insertion with that of the Veress needle entry technique in gynecologic laparoscopic surgery.

Design

Systematic review with meta-analysis.

Setting

We searched Medline, ClinicalTrials.Gov, PubMed, Cochrane CENTRAL, SCOPUS, and Web of Science from their inception through 31 July 2021 for relevant studies. We included only controlled trials and ultimately seven trials were included in our meta-analysis.

Participants

Inclusion criteria included women undergoing gynecological laparoscopic surgery.

Intervention

The intervention of direct trocar insertion technique compared with Veress needle entry technique.

Main outcome measures

We compared five different outcomes associated with the efficacy and complications of laparoscopic entry.

Results

The pooled analysis showed that Veress needle entry was associated with a significant increase in the incidences of extraperitoneal insufflation (RR=0.177, 95% Cl (0.094 to 0.333), p<0.001), omental injury (RR=0.418, 95% Cl (0.195 to 0.896), p<0.001), failed entry (RR=0.173, 95% Cl (0.102 to 0.292), p<0.001), and trocar site infection (RR=0.404, 95% Cl (0.180 to 0.909), p<0.029). There was no significant difference between the two groups regarding the visceral injury (RR=0.562, 95% Cl (0.047 to 6.676), p<0.648).

Conclusions

When excluding all data apart from gynecologic surgery, the Veress needle entry technique may have an increased incidence of some, but not all complications of laparoscopic entry. It may also have a higher incidence of failed entry compared with direct entry techniques. Care should be taken in extrapolating these general results to specific surgeon experience levels.

Trial registration number

CRD42021273726

Computer-aided Veress needle guidance using endoscopic optical coherence tomography and convolutional neural networks

During laparoscopic surgery, the Veress needle is commonly used in pneumoperitoneum establishment. Precise placement of the Veress needle is still a challenge for the surgeon. In this study, a computer-aided endoscopic optical coherence tomography (OCT) system was developed to effectively and safely guide Veress needle insertion. This endoscopic system was tested by imaging subcutaneous fat, muscle, abdominal space, and the small intestine from swine samples to simulate the surgical process, including the situation with small intestine injury. Each tissue layer was visualized in OCT images with unique features and subsequently used to develop a system for automatic localization of the Veress needle tip by identifying tissue layers (or spaces) and estimating the needle-to-tissue distance. We used convolutional neural networks (CNNs) in automatic tissue classification and distance estimation. The average testing accuracy in tissue classification was 98.53 ± 0.39%, and the average testing relative error in distance estimation reached 4.42 ± 0.56% (36.09 ± 4.92 μm).

Initial entry via the left upper quadrant with an optical trocar in laparoscopic bariatric surgery

INTRODUCTION

Laparoscopic bariatric surgery (BS) is not readily performed in Japan. To facilitate safe initial access to the abdominal cavity, we insert an optical viewing trocar at a unique site in the left upper quadrant (LUQ). Herein, we describe the technique, its advantages, and outcomes.

MATERIALS AND SURGICAL TECHNIQUE

Briefly, the optical trocar is inserted just below the left subcostal margin, 8 cm from the midline. On insertion, layers of the abdominal wall are visualized on the monitor. Depending on the angle of insertion, five, seven, or eight layers are seen.

DISCUSSION

In assessing our initial entry technique, used in 21 obese patients undergoing laparoscopic sleeve gastrectomy, we found median insertion time to be 25 seconds. There were no related complications. In nearly all (20/21) patients, the abdominal wall was visualized as seven layers: subcutaneous fat, anterior rectus sheath, rectus abdominis muscle, posterior rectus sheath, transverse abdominis muscle, transversalis fascia, and peritoneum. Understanding the layers of the abdominal wall visualized during optical trocar insertion in the LUQ will provide for safe and rapid initial entry in patients undergoing laparoscopic BS and can further the widespread acceptance of laparoscopic BS.

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.

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.

Complications in laparoscopic and robotic-assisted surgery: definitions, classifications, incidence and risk factors - an up-to-date review

Almost all gynecological and general-surgical operations are - or can be - performed laparoscopically. In comparison to an abdominal approach, the minimally invasive access offers several advantages; however, laparoscopy (both conventional and robotic-assisted) can be associated with a number of approach-specific complications. Although the majority of them are related to the laparoscopic entry, adverse events may also occur due to the presence of pneumoperitoneum or the use of laparoscopic instruments. Unfortunately, a high proportion of complications (especially affecting the bowel and ureter) remain unrecognized during surgery. This narrative review provides comprehensive up-to-date information about definitions, classifications, risk factors and incidence of surgical complications in conventional and robotic-assisted laparoscopy, with a special focus on gynecology. The topic is discussed from various perspectives, e.g. in the context of stage of surgery, injured organs, involved instruments, and in relation to malpractice claims.

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.

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.

Tips and Tricks to Improve Ergonomics, Efficacy, Versatility, and Overcome Limitations of Micro Percutaneous Nephrolithotomy

Percutaneous Nephrolithotomy (PCNL) has evolved over the decades from Standard to Mini to Ultramini PCNL to Micro-perc, with miniaturisation being the dominant theme and supine approach gaining momentum world over.

Aim: In literature, miniaturised PCNL with microperc needle access system has raised concerns of intrarenal pressure and has some limitations with its success for larger stones. Our tips and tricks explain how to overcome these pitfalls by utilising the full construct of the needle system to its maximum potential. These will in turn help make the procedure versatile, precise, ergonomical, and enhance a surgeon's experience with improved outcomes for patients especially in large renal stones.

Materials and Methods: We describe the limitations of microperc needle access as stated in literature and proposals by the co-authors using microperc for miniaturised access on how to overcome the same.

Results: A simplified table describing the limitations and tips and tricks on overcoming these is provided for quick reference.

Conclusion: As Technological advancements and techniques for miniaturised access in urolithiasis improve, we believe our suggestions will help surgeons overcome the quoted limitations of microperc needle access for miniaturised PCNL, making this a versatile, safe and efficacious technique even in large and complex stones. A multi centre trial will be the best way to validate the suggestions proposed in this article.

Complications of Veress Needle Versus Open Technique in Abdominal Surgeries

Introduction

In any laparoscopic procedure, the first and most important step is abdominal entry. This is followed by the creation of pneumoperitoneum, which is essential for lifting the abdominal wall off of the internal organs and visualizing the entered space. However, the entry and establishment of pneumoperitoneum are not without risks and complications, the most serious of which include vascular injuries and bowel perforations in all the different techniques used. The most commonly used techniques for abdominal entry are the closed (Veress) and open (Hasson) techniques, the choice of which varies according to the surgeon’s preference and other regional and local factors.

Aim

To compare the outcomes between the open technique and the Veress needle for accessing the peritoneum during laparoscopic surgery.

Methodology

This was a retrospective cohort study that aimed to compare the outcomes between the Veress needle and the open technique for entering the peritoneum in laparoscopic surgeries. A chart review was used as an instrument to collect data. The study was conducted in King Abdul-Aziz Medical City, Riyadh, Saudi Arabia. All patients who underwent abdominal laparoscopic surgery from 2006 to 2016 were included.

Results

We analyzed 365 patients who underwent laparoscopic abdominal surgery. The mean age of the patients was 32.6 years. The most common postoperative complication occurring during the admission period was abdominal pain (40.5%). Postoperative complications during admission were significantly associated with the type of needle used (χ2=10.641; p=0.001).

Conclusion

The type of technique used for entry and peritoneal access was associated with the occurrence of postoperative complications in abdominal surgeries. Thus, the choice of open or Veress technique for peritoneal access should be individualized based on factors such as patient sex, clinical diagnosis, and most importantly, the surgeons’ experience and preference.

Palmer's test usefulness in the correct positioning of the Veress needle and the reduction of complications during laparoscopic access maneuvers

AIM

Abdominal cavity access accounts for 50% of complications during laparoscopic surgery. Different safety maneuvers have been used to try to diminish these. Our study aims to establish the usefulness of Palmer's test in the correct positioning of the Veress needle and the reduction of complications during laparoscopic access maneuvers, when used in addition to the determination of intraabdominal pressure.

METHODS

Prospective observational analytic multi-centered cohort study with 370 patients undergoing gynecologic laparoscopy between July 2014 and November 2019, comparing the additional use of Palmer's test in 185 patients (Palmer-Test-Yes, PTY), with intraabdominal pressure determination alone in 185 patients (Palmer-Test-No, PTN).

RESULTS

Intergroup homogeneity was described for the basic characteristics of both population samples, except for mean age and percentage of previous laparotomy. A total of 19 complications were recorded, 10 in PTY and 9 in PTN, with no significant differences (P = 0.814). No differences were found in the analysis of these complications, except for the rate of conversion to laparotomy, which occurred four times in the PTY group and none in PTN (P = 0.044). Furthermore, no differences were found once fixed for the history of previous laparotomy (P = 514.), nor for the percentage of successful access after the first attempt between both groups (P = 0.753).

CONCLUSION

Palmer's test, when used in addition to intraabdominal pressure determination, has not shown to be effective in preventing failed access to abdominal cavity or reducing complications associated with access maneuvers with the Veress needle. Hence, its systematic use is not justified, since it could generate a sense of false security.

Preperitoneal insufflation pressure of the abdominal wall in a porcine model

BACKGROUND

Most complications and adverse events during laparoscopic surgery occur during initial entry into the peritoneal cavity. Among them, preperitoneal insufflation occurs when the insufflation needle is incorrectly placed, and the abdominal wall is insufflated. The objective of this study was to find a range for static pressure which is low enough to allow placement of a Veress needle into the peritoneal space without causing preperitoneal insufflation, yet high enough to separate abdominal viscera from the parietal peritoneum.

METHODS

A pressure test was performed on twelve fresh porcine carcasses to determine the minimum preperitoneal insufflation pressure and the minimum initial peritoneal cavity insufflation pressure. Each porcine model had five needle placement categories. One category tested the initial peritoneal cavity insufflation pressure beneath the umbilicus. The four remaining categories tested the preperitoneal insufflation pressure at four different anatomical locations on the abdomen that can be used for initial entry. The minimum initial insufflation pressures from each carcass were then compared to the preperitoneal insufflation pressures to obtain an optimal range for initial insufflation.

RESULTS

Increasing the insufflation pressure increased the probability of preperitoneal insufflation. Also, there was a statistically significant difference (p < 0.05) between the initial peritoneal cavity insufflation pressures (8.83 ± 4.19 mmHg) and the lowest preperitoneal pressures (32.54 ± 7.84 mmHg) (mean ± SD).

CONCLUSION

Pressures greater than 10 mmHg resulted in initial cavity insufflation and pressures greater than 20 mmHg resulted in preperitoneal insufflation in porcine models. By knowing the minimum pressure required to separate the layers of the abdominal wall, the risk of preperitoneal insufflation can be mitigated while obtaining safe and efficient entry into the peritoneal cavity. The findings in this research are not a guideline for trocar or Veress needle placement, but instead reveal preliminary data which may lead to more studies, technology, etc.

The fibers of the circular junction of the linea alba in normal adult anatomy

The linea alba (LA) is known to be useful to surgeons for making surgical incisions. Laparoscopic entry into the peritoneal cavity using the open technique may involve identification of a point just above or below the umbilicus where the peritoneum is fused to the LA. This anatomical site is found through superficial dissection to expose the junction between the umbilical stalk (US) and the LA, where distinct fibers seem to form a unique ligament-like structure in normal adult anatomy. This point, in fact, is part of a circular fibrous structure that exists almost like a ring around the remnant US. It is formed by the fusion of oblique and transverse fibers of the LA with circular fibers from proliferation of an encircling band of compact mesoderm to close a patent umbilical ring. We describe and name this anatomical landmark as junctio circularis alba or the "circular junction of the LA" as encountered in normal adult human anatomy. We believe this is crucial for describing key surgical procedures at this site to aid effective surgical training and reduce iatrogenic complications from laparoscopic port site entries.

Robotics in Pediatric Urology: Evolution and the Future

Almost 30 years have passed since the inception of minimally invasive surgery in urology and specifically in pediatric urology. Laparoscopy has now become an essential tool in the pediatric urologic armamentarium. The application of robot-assisted surgery in pediatrics has allowed for widespread utilization for common reconstructive procedures such as pyeloplasty and ureteral reimplantation. Understanding the implementation, technical considerations, and outcomes are critical for continued success and adoption. This has allowed for increased use in more complex urologic procedures such as redo pyeloplasty, dismembered ureteral reimplantation, catheterizable channel creation, and bladder augmentation.

Single access laparoscopic total colectomy for severe refractory ulcerative colitis

BACKGROUND

Single port laparoscopic surgery allows total colectomy and end ileostomy for medically uncontrolled ulcerative colitis solely via the stoma site incision. While intuitively appealing, there is sparse evidence for its use beyond feasibility.

AIM

To examine the usefulness of single access laparoscopy (SAL) in a general series experience of patients sick with ulcerative colitis.

METHODS

All patients presenting electively, urgently or emergently over a three-year period under a colorectal specialist team were studied. SAL was performed via the stoma site on a near-consecutive basis by one surgical team using a “surgical glove port” allowing group-comparative and case-control analysis with a contemporary cohort undergoing conventional multiport surgery. Standard, straight rigid laparoscopic instrumentation were used without additional resource.

RESULTS

Of 46 consecutive patients requiring surgery, 39 (85%) had their procedure begun laparoscopically. 27 (69%) of these were commenced by single port access with an 89% completion rate thereafter (three were concluded by multi-trocar laparoscopy). SAL proved effective in comparison to multiport access regardless of disease severity providing significantly reduced operative access costs (> 100€case) and postoperative hospital stay (median 5 d vs 7.5 d, P = 0.045) without increasing operative time. It proved especially efficient in those with preoperative albumin > 30 g/dL (n = 20). Its comparative advantages were further confirmed in ten pairs case-matched for gender, body mass index and preoperative albumin. SAL outcomes proved durable in the intermediate term (median follow-up = 20 mo).

CONCLUSION

Single port total colectomy proved useful in planned and acute settings for patients with medically refractory colitis. Assumptions regarding duration and cost should not be barriers to its implementation.

Specificity of the lactate dehydrogenase isoenzyme index as a preoperative screen for uterine sarcoma before myomectomy

OBJECTIVE

To evaluate the applicability of the Uterine mass Magna Graecia (UMG) risk index (elevation defined by a lactate dehydrogenase isoenzyme index >29) in women undergoing surgery for benign fibroids and to determine whether other factors were associated with an elevated index. An elevated UMG index has been reported to be associated with an increased risk of uterine sarcoma in Italian women.

DESIGN

Retrospective cohort study.

SETTING

University fibroid center.

PATIENTS

All women presenting from July 1, 2013, through June 30, 2019, with fibroids who had lactate dehydrogenase isoenzymes collected and surgery performed.

INTERVENTIONS

Calculation of UMG index.

MAIN OUTCOME MEASURE

Applicability of UMG index.

RESULTS

Of 272 patients initially identified, 179 met inclusion criteria, 163 with UMG index ≤29 and 16 with UMG index >29. There were no cases of uterine sarcoma. Race, age, and presence of endometriosis, adenomyosis, or degenerating fibroids were not predictors of elevated UMG index. Body mass index (BMI) was positively associated with elevated UMG index. Specificity of UMG index to exclude uterine sarcoma was 91.1% (163/179) and higher in non-obese (BMI<30; 95.1%) than obese women (85.5%).

CONCLUSION

A previously reported UMG index cutoff of 29 had a specificity of 91.1% (higher with normal BMI and lower when obese) in our patient population. Although lower than previously reported, the index could be a useful initial method of preoperative screening of women with symptomatic fibroids. Higher BMI appears to be associated with elevated UMG indices, increasing the false-positive rate in obese women.

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.

Successful laparoscope-assisted orchiectomy in three cryptorchid sheep

Three adult Corriedale cryptorchid sheep were subjected to laparoscope-assisted orchiectomy of the retained testicles. One (n = 2) or both (n = 1) the testicles were missing in their scrotal sac and inguinal regions. Ultrasonography was used to locate the retained testicles and their distance from the abdominal surface. The animals were restrained in dorsal recumbency and Trendlenburg posture under lumbosacral epidural anaesthesia using 2% lignocaine hydrochloride. Two laparoscopic ports were created in the caudal abdomen adjacent to the retained testicles. They were identified by their ovoid shape, white glistening surface (Tunica albuginea) and typical vasculature. Laparoscope-assisted exteriorization of the testicles after enlarging the ports, ligation of their blood supply and resection of the spermatic cord was performed successfully. The scrotal testes in two rams were then subjected to routine Burdizzoo castration. The laparoscopic port sites healed without complications and all the animals continued to do well subsequently. From this case report, it is concluded that in sheep the laparoscopy; a minimally invasive procedure can confirm abdominal retention of testicle/s and may also be used for their retrieval in a single sitting. Although total laparoscopic procedure is expected to reduce the incision size further but requires advanced laparoscopic instruments and expertise.

Urethral Catheterization Is Not Necessary During Nononcological Laparoscopic Pelvic Surgery

OBJECTIVES

Expert opinion remains divided regarding whether routine urethral catheterization is required before nononcological laparoscopic pelvic surgery. Catheterization is thought to reduce the incidence of bladder injury when inserting a suprapubic laparoscopic port and prevent obstruction of the view of the pelvis because of bladder filling. However, catheterization comes with a risk of nosocomial infection and harbors financial cost. Moreover, indwelling catheters inhibit early mobilization and increase postoperative discomfort.

METHODS

A systematic review was undertaken using the Meta-Analysis of Observational Studies guidelines to identify eligible publications. End points included bladder injury, positive postoperative urinary microbiology, and postoperative urinary symptoms.

RESULTS

The reported incidence rates of laparoscopic bladder injury in included publications ranges from 0% to 1.3%. Importantly, bladder injury has occurred during both catheterized and noncatheterized operations. Our meta-analysis also shows that patients who are catheterized have a 2.33 times relative risk of developing postoperative positive microbiology in their urine (P = 0.01) and a 2.41 times relative risk of postoperative urinary symptoms (P = 0.005), when compared with noncatheterized patients.

CONCLUSIONS

This meta-analysis indicates that omitting a catheter in emergency and elective nononcological laparoscopic pelvic surgery may be a safe option. Catheterization does not remove the risk of bladder injury but results in more urinary tract infections and symptoms. It may be reasonable to ask a patient to void immediately before anesthesia, after which an on-table bladder scan should be performed. If there is minimal residual volume, a urinary catheter may not be necessary, unless operative time is estimated to be greater than 90 minutes.

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

STUDY OBJECTIVE

To analyze the complications experienced and describe laparoscopic surgery using a gasless optical trocar.

DESIGN

A retrospective study.

SETTING

A department of obstetrics and gynecology in a tertiary center in Italy.

PATIENTS

Seven thousand four hundred thirty-one surgical procedures were performed.

INTERVENTIONS

From the hospital database, data were evaluated regarding major complications of laparoscopy with the ENDOPATH XCEL Bladeless Trocar (Ethicon, Johnson & Johnson, Somerville, NJ) performed between 2000 and 2017 by different laparoscopic surgeons.

MEASUREMENTS AND MAIN RESULTS

The mean age of the patients was 40.66 ± 12.06 years (range, 13-91 years). The mean body mass index was 22.12 ± 3.64 kg/m² (range, 15.74-41.51 kg/m²). The overall complication rate was 0.31% (23/7431 cases). Major complications included stomach perforation in 1 procedure (0.014%), ileal perforation in 2 procedures (0.028%), and blood vessel perforation in 1 procedure (0.014%). Twelve procedures were completed with initial access through the omentum and 2 through an ovarian cyst. In 5 procedures (0.067%), conversion to laparotomy was required because the optical trocar failed to reach the abdominal cavity. With regard to complications requiring further intervention (n = 9), the rate of complications was 0.12%.

CONCLUSIONS

The optical gasless trocar is a feasible laparoscopic entry technique. The complication rate is lower than those reported previously.

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.

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.

A Modified Open Primary Laparoscopic Surgery Port Placement through Umbilical Tube

Background:

A safe, reliable technique for primary trocar introduction is important for laparoscopic surgery. In resource-constrained settings where there is paucity of needed equipment and cost is prohibitive, a method utilizing fewer instruments will be useful.

Aim:

This study aims to describe a method of primary trocar introduction that utilizes any available port.

Methods:

A supra- or infra-umbilical incision is made into an everted tubular umbilicus. The linear alba is incised and the resultant opening bluntly developed, after which any available port is inserted using the trocar as a guide. The trocar is withdrawn while the sleeve is pushed in.

Results:

One hundred and three successful insertions were affected in 107 patients with age range of 1–75 years, with no significant gas leaks.

Conclusion:

This modified open approach is a simple and reliable way of primary port insertion. Access is gained easily in different age groups and umbilicus types.

Laparoscopic Access: Direct Trocar Insertion Versus Open Technique

INTRODUCTION

Creation of pneumoperitoneum and laparoscopic entry into the abdominal cavity are crucial initial steps of laparoscopic surgery and associated with bowel and major vessel injuries. Various methods have been described in literature such as Veress needle, open access technique (OAT), direct trocar insertion (DTI), and optical port. There is no consensus on the safest method of gaining access to the peritoneal cavity to create a pneumoperitoneum. DTI technique appears to be not well accepted by many due to the fear of causing injuries as it is a blind procedure.

OBJECTIVE

To compare the outcome of DTI in terms of feasibility and complications with a well-established and widely practiced OAT for a laparoscopic procedure.

MATERIALS AND METHODS

Nine hundred fifty-five participants were randomized to be in either of the two groups, that is, Group "A" for DTI and Group "B" for OAT. The primary endpoint was major complications (bowel, major vessel, and solid organ injury) and the secondary endpoint was port access time and minor complications directly related to access. Patients were assessed on the first postoperative day, at the time of discharge, 3 months, 6 months, and a year after discharge, for complications.

RESULTS

There was no statistical difference in major complications between DTI and OAT groups, however, DTI was found to be superior to OAT in terms of port access time (P = .01), umbilical port-site hernia, port-site infection, and port-site pain (P = .01).

CONCLUSION

This study further strengthens the literature on DTI being a good and safe technique of laparoscopic access. The technique of DTI is still underutilized and needs to be adopted by surgeons without fear.

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.

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.

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.

Tuberculous peritonitis diagnosed using laparoscopy with assistance of a central venous catheter

Laparoscopy with peritoneal biopsy is a tool for rapid and accurate diagnosis of tuberculous peritonitis (TBP). However, laparoscopic procedures are not risk-free; complications include injuries to the gastrointestinal tract and major blood vessels. The purpose of the present study was to introduce a novel method for safe and straightforward laparoscopic diagnosis of TBP. A case series of 12 patients with TBP diagnosed between October 2012 and November 2013 at our hospital is presented. The patients underwent a novel method of laparoscopy involving the use of a central venous catheter (CVC). The diagnosis was confirmed by biopsy and histology. The efficacy of the method for TBP diagnosis was evaluated by the time taken for the procedure and the rate of successful completion. The safety of the method was evaluated by recording all intra- and post-operative adverse events encountered. The mean age of the patients was 41 years and 33% were male. The mean operation time was 50.6 min and the median duration of hospital stay was 7 days. In all cases, diagnostic laparoscopy was successfully performed. Targeted biopsies were taken from all of the patients and revealed caseous granulomatous inflammation. All patients tolerated the procedure without significant bleeding or digestive tract perforation. In conclusion, the present case series demonstrated a novel method of diagnostic laparoscopy with CVC that is a feasible and straightforward procedure for TBP diagnosis.

Comparison of two methods of laparoscopic trocar insertion (Hasson and Visiport) in terms of speed and complication in urologic surgery

BACKGROUND

Nowadays, diverse approaches have been existed for laparoscopic procedures. The most common laparoscopic entry methods included close and direct entry laparoscopy and open (Hasson) laparoscopy. There is no evidence regarding the superiority in safety and initial speed for the use of open and optical laparoscopic entry. Therefore, the sight of current study was to evaluate comparative survey of two methods of laparoscopic trocar insertion (Hasson and VisiportTM) in terms of speed and complications in urologic surgery.

METHODS

This expertized base clinical trial study was conducted on 100 patients who underwent urological laparoscopy in Alzahra Hospital, Isfahan, Iran. These patients were randomly divided to two groups (n = 50). One group underwent open laparoscopy and another group Visiport optical trocar. Speed and Complications of urologic surgery was extracted from medical records. Independent T test was used for doing of analysis.

RESULTS

The mean age of patients in Hasson and Visiport laparoscopic group was 41.4 ± 11.2 and 41.6 ± 15 years old, respectively (p = 0.91). The mean time for initial trocar placement in patients who underwent Visiport trocar system and Hasson laparoscopic technique was 37.7 ± 15.59 and 95.4 ± 31.75 seconds. There was gratifying difference between two techniques of laparoscopic trocar insertion (Hasson and Visiport) in terms of speed (p = 0.000). In addition, complications were observed in 8% of patients who underwent Visiport trocar system. However, no complications were observed in Hasson laparoscopy group.

CONCLUSION

Visiport optical trocar technique is faster for initial trocar placement than open laparoscopy. However it is associated with complications compared to open laparoscopy. Therefore, there is evidence of benefit in terms of speed for initial trocar placement and harm based on complications in Visiport trocar system.