Laparoscopy Entry in Patients With Previous Abdominal and Pelvic Surgery

Laparoscopic entry techniques: Which should you prefer?

BACKGROUND

Despite a debate spanning two decades, no consensus has been achieved about the safest laparoscopic entry technique.

OBJECTIVES

To update the evidence about the safety of the main different laparoscopic entry techniques.

SEARCH STRATEGY

Six electronic databases were searched from inception to February 2021.

SELECTION CRITERIA

All randomized controlled trials (RCTs) comparing different laparoscopic entry techniques were included.

DATA COLLECTION AND ANALYSIS

Entry-related complications and total time for entry were compared among the different methods of entry calculating pooled odds ratios (ORs) and mean differences, with 95% confidence intervals (CIs); P < 0.05 was considered significant.

MAIN RESULTS

In total, 25 RCTs (6950 patients) were included. Complications considered were vascular, visceral and omental injury, failed entry, extraperitoneal insufflation, bleeding and infection at the trocar site bleeding, and incisional hernia. Compared to direct trocar, the OR for Veress needle was significantly higher for omental injury (OR 3.65, P < 0.001), for failed entry (OR 4.19, P < 0.001), and for extraperitoneal insufflation (OR 5.29, P < 0.001). Compared to the open method, the OR for Veress needle was significantly higher for omental injury (OR 4.93, P = 0.001), for failed entry (OR 2.99, P < 0.001), for extraperitoneal insufflation (OR 4.77; P = 0.04), and for incisional hernia. Compared to the open method, the OR for direct trocar was significantly lower for visceral injury (OR 0.17, P = 0.002) and for trocar site infection (OR 0.27, P = 0.001).

CONCLUSIONS

The direct trocar method may be preferred over Veress needle and open methods as a laparoscopic entry technique since it appears associated to a lower risk of complications.

Complications in Laparoscopic Access in Standing Horses Using Cannula and Trocar Units Developed for Human Medicine

First cannulation is a critical manoeuvre in equine laparoscopy. This retrospective study aimed at the comparison of the frequency and type of complications detected when using different human laparoscopy devices for laparoscopic access in standing horses, and the influence of body condition in such complications. Forty-four procedures were included, and retrieved data comprised cannula insertion technique, body condition, and type and frequency of complications. Laparoscopic access techniques were classified into five groups: P: pneumoperitoneum created using Veress needle prior to cannulation; T: sharp trocar; D: direct access via surgical incision; V: Visiport optical trocar and H: optical helical cannula (OHC). In groups T, D, V and H, access was achieved without prior induction of pneumoperitoneum. Complications were registered in 13/44 procedures, of which retroperitoneal insufflation was the most common (6/13). Statistically significant association was found between the complication incidence and the type of access, with group D showing the highest complication frequency (80%) and group H the lowest frequency (0%). The majority of complications (9/13) were observed in overweight horses. We conclude that devices designed for human patients can be used for laparoscopic access in standing horses, with the use of OHC minimizing the appearance of complications, especially in overweight horses with OW.

Evidence-based surgery for laparoscopic appendectomy: A stepwise systematic review

Introduction

Appendectomy is a common emergency surgery performed globally. Despite the frequency of laparoscopic appendectomy, consensus does not exist on the best way to perform each procedural step. We identified literature on key intraoperative steps to inform best technical practice during laparoscopic appendectomy.

Methods

Research questions were framed using the population, indication, comparison, outcome (PICO) format for 6 key operative steps of laparoscopic appendectomy: abdominal entry, placement of laparoscopic ports, division of mesoappendix, division of appendix, removal of appendix, and fascial closure. These questions were used to build literature queries in PubMed, EMBASE, and the Cochrane Library databases. Evidence quality and certainty was assessed using Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) definitions.

Results

Recommendations were rendered for 6 PICO questions based on 28 full length articles. Low quality evidence favors direct trocar insertion for abdominal entry and establishment of pneumoperitoneum. Single port appendectomy results in improved cosmesis with unclear clinical implications. There was insufficient data to determine the optimal method of appendiceal stump closure, but use of a specimen extraction bag reduces rates of superficial surgical site infection and intra-abdominal abscess. Port sites made with radially dilating trocars are less likely to necessitate closure and are less likely to result in port site hernia. When port sites are closed, a closure device should be used.

Conclusion

Key operative steps of laparoscopic appendectomy have sufficient data to encourage standardized practice.

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.

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.

Does previous abdominal surgery affect the course and outcomes of laparoscopic bariatric surgery?

BACKGROUND

Global experiences in general surgery suggest that previous abdominal surgery may negatively influence different aspects of perioperative care. As the incidence of bariatric procedures has recently increased, it is essential to assess such correlations in bariatric surgery.

OBJECTIVES

To assess whether previous abdominal surgery influences the course and outcomes of laparoscopic bariatric surgery.

SETTING

Seven referral bariatric centers in Poland.

METHODS

We conducted a retrospective analysis of 2413 patients; 1706 patients who underwent laparoscopic sleeve gastrectomy (SG) or Roux-en-Y gastric bypass (RYGB) matched the inclusion criteria. Patients with no history of abdominal surgery were included as group 1, while those who had undergone at least 1 abdominal surgery were included as group 2.

RESULTS

Group 2 had a significantly prolonged median operation time for RYGB (P = .012), and the longest operation time was observed in patients who had previously undergone surgeries in both the upper and lower abdomen (P = .002). Such a correlation was not found in SG cases (P = .396). Groups 1 and 2 had similar rates of intraoperative adverse events and postoperative complications (P = .562 and P = .466, respectively). Group 2 had a longer median duration of hospitalization than group 1 (P = .034), while the readmission rate was similar between groups (P = .079). There was no significant difference between groups regarding the influence of the long-term effects of bariatric treatment on weight loss (percentage of follow-up was 55%).

CONCLUSIONS

Previous abdominal surgery prolongs the operative time of RYGB and the duration of postoperative hospitalization, but does not affect the long-term outcomes of bariatric treatment.

International guidelines for groin hernia management

INTRODUCTION

Worldwide, more than 20 million patients undergo groin hernia repair annually. The many different approaches, treatment indications and a significant array of techniques for groin hernia repair warrant guidelines to standardize care, minimize complications, and improve results. The main goal of these guidelines is to improve patient outcomes, specifically to decrease recurrence rates and reduce chronic pain, the most frequent problems following groin hernia repair. They have been endorsed by all five continental hernia societies, the International Endo Hernia Society and the European Association for Endoscopic Surgery.

METHODS

An expert group of international surgeons (the HerniaSurge Group) and one anesthesiologist pain expert was formed. The group consisted of members from all continents with specific experience in hernia-related research. Care was taken to include surgeons who perform different types of repair and had preferably performed research on groin hernia surgery. During the Group's first meeting, evidence-based medicine (EBM) training occurred and 166 key questions (KQ) were formulated. EBM rules were followed in complete literature searches (including a complete search by The Dutch Cochrane database) to January 1, 2015 and to July 1, 2015 for level 1 publications. The articles were scored by teams of two or three according to Oxford, SIGN and Grade methodologies. During five 2-day meetings, results were discussed with the working group members leading to 136 statements and 88 recommendations. Recommendations were graded as "strong" (recommendations) or "weak" (suggestions) and by consensus in some cases upgraded. In the Results and summary section below, the term "should" refers to a recommendation. The AGREE II instrument was used to validate the guidelines. An external review was performed by three international experts. They recommended the guidelines with high scores. The risk factors for inguinal hernia (IH) include: family history, previous contra-lateral hernia, male gender, age, abnormal collagen metabolism, prostatectomy, and low body mass index. Peri-operative risk factors for recurrence include poor surgical techniques, low surgical volumes, surgical inexperience and local anesthesia. These should be considered when treating IH patients. IH diagnosis can be confirmed by physical examination alone in the vast majority of patients with appropriate signs and symptoms. Rarely, ultrasound is necessary. Less commonly still, a dynamic MRI or CT scan or herniography may be needed. The EHS classification system is suggested to stratify IH patients for tailored treatment, research and audit. Symptomatic groin hernias should be treated surgically. Asymptomatic or minimally symptomatic male IH patients may be managed with "watchful waiting" since their risk of hernia-related emergencies is low. The majority of these individuals will eventually require surgery; therefore, surgical risks and the watchful waiting strategy should be discussed with patients. Surgical treatment should be tailored to the surgeon's expertise, patient- and hernia-related characteristics and local/national resources. Furthermore, patient health-related, life style and social factors should all influence the shared decision-making process leading up to hernia management. Mesh repair is recommended as first choice, either by an open procedure or a laparo-endoscopic repair technique. One standard repair technique for all groin hernias does not exist. It is recommended that surgeons/surgical services provide both anterior and posterior approach options. Lichtenstein and laparo-endoscopic repair are best evaluated. Many other techniques need further evaluation. Provided that resources and expertise are available, laparo-endoscopic techniques have faster recovery times, lower chronic pain risk and are cost effective. There is discussion concerning laparo-endoscopic management of potential bilateral hernias (occult hernia issue). After patient consent, during TAPP, the contra-lateral side should be inspected. This is not suggested during unilateral TEP repair. After appropriate discussions with patients concerning results tissue repair (first choice is the Shouldice technique) can be offered. Day surgery is recommended for the majority of groin hernia repair provided aftercare is organized. Surgeons should be aware of the intrinsic characteristics of the meshes they use. Use of so-called low-weight mesh may have slight short-term benefits like reduced postoperative pain and shorter convalescence, but are not associated with better longer-term outcomes like recurrence and chronic pain. Mesh selection on weight alone is not recommended. The incidence of erosion seems higher with plug versus flat mesh. It is suggested not to use plug repair techniques. The use of other implants to replace the standard flat mesh in the Lichtenstein technique is currently not recommended. In almost all cases, mesh fixation in TEP is unnecessary. In both TEP and TAPP it is recommended to fix mesh in M3 hernias (large medial) to reduce recurrence risk. Antibiotic prophylaxis in average-risk patients in low-risk environments is not recommended in open surgery. In laparo-endoscopic repair it is never recommended. Local anesthesia in open repair has many advantages, and its use is recommended provided the surgeon is experienced in this technique. General anesthesia is suggested over regional in patients aged 65 and older as it might be associated with fewer complications like myocardial infarction, pneumonia and thromboembolism. Perioperative field blocks and/or subfascial/subcutaneous infiltrations are recommended in all cases of open repair. Patients are recommended to resume normal activities without restrictions as soon as they feel comfortable. Provided expertise is available, it is suggested that women with groin hernias undergo laparo-endoscopic repair in order to decrease the risk of chronic pain and avoid missing a femoral hernia. Watchful waiting is suggested in pregnant women as groin swelling most often consists of self-limited round ligament varicosities. Timely mesh repair by a laparo-endoscopic approach is suggested for femoral hernias provided expertise is available. All complications of groin hernia management are discussed in an extensive chapter on the topic. Overall, the incidence of clinically significant chronic pain is in the 10-12% range, decreasing over time. Debilitating chronic pain affecting normal daily activities or work ranges from 0.5 to 6%. Chronic postoperative inguinal pain (CPIP) is defined as bothersome moderate pain impacting daily activities lasting at least 3 months postoperatively and decreasing over time. CPIP risk factors include: young age, female gender, high preoperative pain, early high postoperative pain, recurrent hernia and open repair. For CPIP the focus should be on nerve recognition in open surgery and, in selected cases, prophylactic pragmatic nerve resection (planned resection is not suggested). It is suggested that CPIP management be performed by multi-disciplinary teams. It is also suggested that CPIP be managed by a combination of pharmacological and interventional measures and, if this is unsuccessful, followed by, in selected cases (triple) neurectomy and (in selected cases) mesh removal. For recurrent hernia after anterior repair, posterior repair is recommended. If recurrence occurs after a posterior repair, an anterior repair is recommended. After a failed anterior and posterior approach, management by a specialist hernia surgeon is recommended. Risk factors for hernia incarceration/strangulation include: female gender, femoral hernia and a history of hospitalization related to groin hernia. It is suggested that treatment of emergencies be tailored according to patient- and hernia-related factors, local expertise and resources. Learning curves vary between different techniques. Probably about 100 supervised laparo-endoscopic repairs are needed to achieve the same results as open mesh surgery like Lichtenstein. It is suggested that case load per surgeon is more important than center volume. It is recommended that minimum requirements be developed to certify individuals as expert hernia surgeon. The same is true for the designation "Hernia Center". From a cost-effectiveness perspective, day-case laparoscopic IH repair with minimal use of disposables is recommended. The development and implementation of national groin hernia registries in every country (or region, in the case of small country populations) is suggested. They should include patient follow-up data and account for local healthcare structures. A dissemination and implementation plan of the guidelines will be developed by global (HerniaSurge), regional (international societies) and local (national chapters) initiatives through internet websites, social media and smartphone apps. An overarching plan to improve access to safe IH surgery in low-resource settings (LRSs) is needed. It is suggested that this plan contains simple guidelines and a sustainability strategy, independent of international aid. It is suggested that in LRSs the focus be on performing high-volume Lichtenstein repair under local anesthesia using low-cost mesh. Three chapters discuss future research, guidelines for general practitioners and guidelines for patients.

CONCLUSIONS

The HerniaSurge Group has developed these extensive and inclusive guidelines for the management of adult groin hernia patients. It is hoped that they will lead to better outcomes for groin hernia patients wherever they live. More knowledge, better training, national audit and specialization in groin hernia management will standardize care for these patients, lead to more effective and efficient healthcare and provide direction for future research.

Open Versus Closed Laparoscopy: Yet an Unresolved Controversy

INTRODUCTION

Safe placement of the Verres needle or the primary trocar for establishment of pneumoperitoneum is the most critical step in laparoscopic procedure as it is associated with bowel, bladder and life threatening vascular injuries and embolism. In the last few decades many techniques and guidelines have been introduced to eliminate complications in creation of pneumoperitoneum. Classical closed technique (Verres needle) and the open classic technique (Hasson) are the most commonly used techniques for creation of pneumoperitoneum.

AIM

To compare the rate of occurrence and nature of complications in open and closed laparoscopy during establishment of pneumoperitoneum in different surgical and gynaecological procedures.

MATERIALS AND METHODS

This was a comparative study conducted at three hospitals in Dibrugarh district, Assam, India from January 2012 to December 2014. Total 3000 cases were included in the study with 1500 cases of open laparoscopy and 1500 cases of closed laparoscopy. Complications occurring in both the groups were compared by using Fisher's-exact test.

RESULTS

In closed laparoscopy group minor complications occurred in 80 (5.33%) and major complications in 20 (1.33%) cases. In open laparoscopy group minor complications were observed in 60 (4%) and major complications in 2 (0.13%). The p-value of the difference between the two groups for minor complications was 0.0834 and for major complications was 0.0001(significant).

CONCLUSION

Open laparoscopy was seen to be better than closed laparoscopy in terms of not only the rate of occurrence of complications but also the nature and severity of the complications. This study is clinically relevant as there is no consensus for a particular method of safe entry in to the peritoneal cavity warranting the need for more research. Open technique can be performed in all cases irrespective of previous operative scar, suspected intra peritoneal adhesions or obesity. Favourable outcome may be achieved in closed technique in cases of normal BMI, absence of postoperative scar in the abdomen, absence of abdominal and genital tuberculosis and pelvic inflammatory disease.

Laparoscopic entry techniques

BACKGROUND

Laparoscopy is a common procedure in many surgical specialities. Complications arising from laparoscopy are often related to initial entry into the abdomen. Life-threatening complications include injury to viscera e.g. the bowel or bladder, or to vasculature e.g. major abdominal and anterior abdominal wall vessels. Minor complications can also occur, such as postoperative wound infection, subcutaneous emphysema, and extraperitoneal insufflation. There is no clear consensus 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

This updated review has drawn on the search strategy developed by the Cochrane Menstrual Disorders and Subfertility Group. In addition, MEDLINE, EMBASE, CENTRAL and PsycINFO were searched through to September 2014.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) in which one laparoscopic entry technique was compared with another.

DATA COLLECTION AND ANALYSIS

Two 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 46 RCTs including three multi-arm trials (7389 participants) and evaluated 13 laparoscopic entry techniques. Overall there was no evidence of advantage using any single technique for preventing major vascular or visceral complications. The evidence was generally of very low quality; the main limitations were imprecision and poor reporting of study methods. Open-entry versus closed-entry There was no evidence of a difference between the groups for vascular (Peto OR 0.14, 95% CI 0.00 to 6.82, three RCTs, n = 795, I(2) = n/a; very low quality evidence) or visceral injury (Peto OR 0.61, 95% CI 0.06 to 6.08, three RCTs, n = 795, I(2) = 0%; very low quality evidence). There was a lower risk of failed entry in the open-entry group (Peto OR 0.16, 95% CI 0.04 to 0.63, n = 665, two RCTs, I(2) = 0%; very low quality evidence). This suggests that for every 1000 patients operated on, 31 patients in the closed-entry group will have failed entry compared to between 1 to 20 patients in the open-entry group. No events were reported in any of the studies for mortality, gas embolism or solid organ injury. Direct trocar versus Veress needle entry There was a lower risk of vascular injury in the direct trocar group (Peto OR 0.13, 95% CI 0.03 to 0.66, five RCTs, n = 1522, I(2) = 0%; low quality evidence) and failed entry (Peto OR 0.21, 95% CI 0.14 to 0.30, seven RCTs, n = 3104; I ²= 0%; moderate quality evidence). This suggests that for every 1000 patients operated on, 8 patients in the Veress needle group will experience vascular injury compared to between 0 to 5 patients in the direct trocar group; and that 64 patients in the Veress needle group will experience failed entry compared to between 10 to 20 patients in the direct trocar group. The vascular injury significance is sensitive to choice of statistical analysis and may be unreliable. There was no evidence of a difference between the groups for visceral (Peto OR 1.02, 95% CI 0.06 to 16.24, four RCTs, n = 1438, I(2) = 49%; very low quality evidence) or solid organ injury (Peto OR 0.16, 95% Cl 0.01 to 2.53, two RCTs, n = 998, I(2) = n/a; very low quality evidence). No events were recorded for mortality or gas embolism. Direct vision entry versus Veress needle entry There was no evidence of a difference between the groups in the rates of visceral injury (Peto OR 0.15, 95% CI 0.01 to 2.34, one RCT, n = 194; very low quality evidence). Other primary outcomes were not reported. Direct vision entry versus open-entry There was no evidence of a difference between the groups in the rates of visceral injury (Peto OR 0.13, 95% CI 0.00 to 6.50, two RCTs, n = 392; low quality evidence), solid organ injury (Peto OR 6.16, 95% CI 0.12 to 316.67, one RCT, n = 60, I(2) = n/a; very low quality evidence), or failed entry (Peto OR 0.40, 95% CI 0.04 to 4.09, one RCT, n = 60; low quality evidence). Vascular injury was reported, however no events occurred. Our other primary outcomes were not reported. Radially expanding (STEP) trocars versus non-expanding trocars There was no evidence of a difference between the groups for vascular injury (Peto OR 0.24, 95% Cl 0.05 to 1.21, two RCTs, n = 331, I(2) = 0%; low quality evidence), visceral injury (Peto OR 0.13, 95% CI 0.00 to 6.37, two RCTs, n = 331, I(2) = n/a; low quality evidence), or solid organ injury (Peto OR 1.05, 95% CI 0.07 to 16.91, one RCT, n = 244; very low quality evidence). Other primary outcomes were not reported. Comparisons of other laparoscopic entry techniquesThere was a higher risk of failed entry in the group in which the abdominal wall was lifted before Veress needle insertion than in the not-lifted group (Peto OR 4.44, 95% CI 2.16 to 9.13, one RCT, n = 150; very low quality evidence). There was no evidence of a difference between the groups in rates of visceral injury or extraperitoneal insufflation. The studies had small numbers and excluded many patients with previous abdominal surgery, and women with a raised body mass index. These patients may have unusually high complication rates.

AUTHORS' CONCLUSIONS

Overall, there is insufficient evidence to recommend one laparoscopic entry technique over another.An open-entry technique is associated with a reduction in failed entry when compared to a closed-entry technique, with no evidence of a difference in the incidence of visceral or vascular injury.An advantage of direct trocar entry over Veress needle entry was noted for failed entry and vascular injury. The evidence was generally of very low quality with small numbers of participants in most studies; our findings should be interpreted with caution.

Laparoscopy in trauma: An overview of complications and related topics

The introduction of laparoscopy has provided trauma surgeons with a valuable diagnostic and, at times, therapeutic option. The minimally invasive nature of laparoscopic surgery, combined with potentially quicker postoperative recovery, simplified wound care, as well as a growing number of viable intraoperative therapeutic modalities, presents an attractive alternative for many traumatologists when managing hemodynamically stable patients with selected penetrating and blunt traumatic abdominal injuries. At the same time, laparoscopy has its own unique complication profile. This article provides an overview of potential complications associated with diagnostic and therapeutic laparoscopy in trauma, focusing on practical aspects of identification and management of laparoscopy-related adverse events.

Bladeless direct optical trocar insertion in laparoscopic procedures on the obese patient

Results of the study suggest that direct optical entry technique reduced entry time and blood loss with trends to slightly decrease the occurrence of minor vascular and bowel injuries in obese women.

Background:

Recently, we have shown advantages of a direct optical entry (DOE) using a bladeless trocar in comparison with the open Hasson technique (OHT) in older reproductive-age women with previous operations, as well as in comparison with Veress needle entry in reproductive-age and postmenopausal women.

Objectives:

A prospective multicenter randomized study to determine whether the DOE is feasible for establishing safe and rapid entry into the abdomen in comparison with those of the OHT in reproductive-age obese women.

Methods:

Two types of surgical techniques were blindly applied in 224 obese reproductive-age women with benign neoplastic diseases of ovary and uterus. Namely, laparoscopic entry into the abdomen in 108 patients was performed by DOE and in 116 women by OHT. Following parameters (entry time in seconds needed to establish the intra-abdominal vision after pneumoperitoneum, blood loss, occurrence of vascular and/or bowel injuries) were compared during surgery as main outcomes.

Results:

Main baseline characteristics of patients, including age (36.1 ± 4.5 vs 35.7 ± 5.8), body mass index (34.9 ± 5.1 vs 35.1 ± 4.9 kg/m²), and parity (2.1 ± 0.4 vs 1.9 ± 0.9), were not significantly different between the DOE and OHT groups (P > .05). While intraoperative parameters such as the entry time (71.9 ± 3.7 vs 215.1 ± 6.2 seconds) and blood loss value (9.7 ± 6.1 vs 12.2 ± 2.9 mL) were significantly reduced in the DOE group in comparison with those of OHT group (respectively, P < .0001 and < .01), there were also trends to slight decrease of the occurrence of the minor injuries, manifested as omental small vessels rupture (0 of 108 vs 4 of 116) and punctures and pinches of jejunal serosa (0 of 108 vs 3 of 116) in patients of the DOE group in comparison with those of OHT group (respectively, P = .0515 and = .0925).

Conclusions:

DOE reduced entry time and blood loss with trends to slightly decrease of the occurrence of the minor vascular and bowel injuries, thus enabling a possible alternative to OHT in obese women; however, further larger trials need to confirm the possible additional benefits of a DOE.

Safe introduction of ancillary trocars

The problem of laparoscopic entry is currently still unsolved, and despite the various techniques adopted by the surgical community, it has not yet been determined which is the correct access in all patients. Add to this the problem of safe ancillary port introduction; all surgeons must avoid vascular and visceral damage. The 2 most common problems with second port trocars are inferior and superior epigastric artery damage, and bowel loops and adhesions. Over the years, we have developed 2 steps that are very useful to avoid iatrogenic injuries to vessels and viscera. In this brief report, we explain the following 2 simple steps, called by the authors "yellow island" port entry and second trocar "tip entry guided" by a suction cannula. In our practice of more than 3400 conventional laparoscopies, with data from patients with different characteristics, surgeons who have introduced laparoscopic surgery into their daily practice might teach these steps to young fellows and trainees.

The effect of postoperative hyperbaric oxygen treatment on intra-abdominal adhesions in rats

Abdominal adhesions, whether caused by peritoneal trauma, radiation, infection, or a congenital condition, are associated with a wide range of complications. These complications include chronic abdominal or pelvic pain, infertility, and adhesive small bowel obstruction. Such adhesions render re-operation difficult, with attendant risks of inadvertent enterostomy and increased operation time. The purpose of this study was to investigate the potential of hyperbaric oxygen (HBO) therapy in the prevention of abdominal adhesions in an experimental animal study. A laparotomy was performed on Wistar rats to induce the formation of adhesions on the cecum and the intra-abdominal area (1 × 2 cm). A superficial layer of the underlying muscle from the right abdominal wall was also shaved and prepared for aseptic surgery. The rats were divided into four groups according to the duration of HBO therapy; five additional groups were designated according to the conditions of HBO therapy. When the rats were evaluated according to adhesion area and grade, a statistically significant difference was observed between the control and HBO treatment groups (p < 0.005). Results from this study suggest that HBO treatment could reduce adhesion formation; and further suggest that HBO therapy may have therapeutic potential in the treatment of postoperative peritoneal adhesion.

Comparison of two entry methods for laparoscopic port entry: technical point of view

Laparoscopic entry is a blind procedure and it often represents a problem for all the related complications. In the last three decades, rapid advances in laparoscopic surgery have made it an invaluable part of general surgery, but there remains no clear consensus on an optimal method of entry into the peritoneal cavity. The aim of this paper is to focus on the evolution of two used methods of entry into the peritoneal cavity in laparoscopic surgery.

Laparoscopy and natural orifice surgery: first entry safety surveillance step

Results of this study suggest that surveillance of the first entrance port in laparoscopic and natural orifice transvaginal endoscopic procedures may assist in recognizing complications that might otherwise be missed.

Background and Objective:

We are sharing information regarding the surveillance of the first entrance port in laparoscopic and natural orifice transvaginal endoscopy surgeries. However, we are not analyzing techniques or other surgical findings.

Method:

In this study, 160 women with previous abdominal pelvic surgeries underwent laparoscopic surgery, 145 patients underwent transvaginal Minilaparoscopy Assisted Natural Orifice Surgery (hybrid), and 3 patients underwent pure natural orifice transvaginal endoscopic surgery (pure). For those patients who had laparoscopy and hybrid procedures, the surveillance was from a laparoscope or gastroscope placed in a secondary port. Surveillance in pure cases was done using a gastroscopic retro view to see the pouch of Douglas.

Results:

The laparoscopic procedures were gynecological procedures. The hybrid procedures included gynecological procedures as well as appendectomies and cholecystectomies; the pure procedures were cholecystectomies. There were a few minor vascular and bowel injuries in the laparoscopy group. There were no injuries in the transvaginal hybrid or pure procedures groups.

Conclusion:

The surveillance of the first entrance port can be an effective precautionary step. The cumulative experience suggests that using such surveillance in cases involving patients with prior surgery may assist in recognizing complications that might otherwise be missed.