Laparoscopic entry: a review of Canadian general surgical practice

Enhancing Veress Needle Entry with Proximal Vibroacoustic Sensing for Automatic Identification of Peritoneum Puncture

Laparoscopic access, a critical yet challenging step in surgical procedures, often leads to complications. Existing systems, such as improved Veress needles and optical trocars, offer limited safety benefits but come with elevated costs. In this study, a prototype of a novel technology for guiding needle interventions based on vibroacoustic signals is evaluated in porcine cadavers. The prototype consistently detected successful abdominal cavity entry in 100% of cases during 193 insertions across eight porcine cadavers. The high signal quality allowed for the precise identification of all Veress needle insertion phases, including peritoneum puncture. The findings suggest that this vibroacoustic-based guidance technology could enhance surgeons' situational awareness and provide valuable support during laparoscopic access. Unlike existing solutions, this technology does not require sensing elements in the instrument's tip and remains compatible with medical instruments from various manufacturers.

Intraoperative and Postoperative Outcomes of Modified Bidirectional Intra-Umbilical Incision versus Infra-Umbilical Incision for Direct Trocar Insertion in Gynaecological Laparoscopy: A randomised controlled trial

Objectives

This study aimed to describe a modified, curved, deep, bidirectional, intra-umbilical, vertical incision for primary trocar insertion and prospectively compare its intraoperative and postoperative outcomes with an infra-umbilical incision in gynaecologic laparoscopy.

Methods

Between August 2019 and March 2021, 110 patients subjected to the direct trocar insertion technique for laparoscopic intervention were classified into two groups. Group A comprised 55 cases of infra-umbilical incision, whereas group B comprised 55 cases of a modified, curved, longitudinal, deep, bidirectional, intra-umbilical incision. Afterwards, intraoperative and postoperative assessments were performed.

Results

The increase in the numbers of parity, gravidity and previous caesarean sections was found to be statistically significant; a smaller number of infertility complaints were observed in group B. Similarly, group B expressed a statistically significant less peri-trocar CO2 leakage (46 [83.6%] patients versus 28 [50.9%] patients) and more tightness of the primary portal entry (45 [81.8%] patients versus 30 [54.5%] patients) when compared to group A throughout the whole operation. After a one-month follow-up, a statistically significant (P = 0.029) decrease in the Observer Scar Assessment Scale and Patient Scar Assessment Scale scores in group B (10.4 ± 4.2 and 11.8 ± 4.3, respectively), demonstrating better cosmoses when compared to group A (13.3 ± 5.7 and 16.0 ± 6.8, respectively).

Conclusion

Performing a modified, curved, deep, bidirectional, intra-umbilical, vertical incision for the insertion of a primary laparoscopic trocar (i.e. Darwish laparoscopic entry) is a simple and fast step that results in the elimination of intraoperative gas leakage and trocar slippage without the need for any additional sutures. Aesthetically, it results in a better scar with satisfactory cosmoses when compared to an infra-umbilical incision.

The relevance of reducing Veress needle overshooting

Safe insertion of the Veress needle during laparoscopy relies on the surgeons' technical skills in order to stop needle insertion just in time to prevent overshooting in the underlying organs. To reduce this risk, a wide variety of Veress needle systems were developed with safety mechanisms that limit the insertion speed, insertion depth or decouple the driving force generated by the surgeon's hand on the needle. The aim of this study is to evaluate current surgeons' perceptions related to the use of Veress needles and to investigate the relevance of preventing overshooting of Veress needles among members of the European Association of Endoscopic Surgery (EAES). An online survey was distributed by the EAES Executive Office to all active members. The survey consisted of demographic data and 14 questions regarding the use of the Veress needle, the training conducted prior to usage, and the need for any improvement. A total of 365 members residing in 58 different countries responded the survey. Of the responding surgeons, 36% prefer the open method for patients with normal body mass index (BMI), and 22% for patients with high BMI. Of the surgeons using Veress needle, 68% indicated that the reduction of overshoot is beneficial in normal BMI patients, whereas 78% indicated that this is beneficial in high BMI patients. On average, the members using the Veress needle had used it for 1448 (SD 3031) times and felt comfortable on using it after 22,9 (SD 78,9) times. The average years of experience was 17,6 (SD 11,1) and the surgeons think that a maximum overshoot of 9.4 (SD 5.5) mm is acceptable before they can safely use the Veress needle. This survey indicates that despite the risks, Veress needles are still being used by the majority of the laparoscopic surgeons who responded. In addition, the surgeons responded that they were interested in using a Veress needle with an extra safety mechanism if it limits the risk of overshooting into the underlying structures.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

Major and minor complications in Veress needle (VN) and direct trocar insertion (DTI) for laparoscopic closed-entry techniques: an updated systematic review and meta-analysis

OBJECTIVE

Direct insertion of the trocar is an alternative method to Veress needle insertion for the creation of pneumoperitoneum. We conducted a systematic review and meta-analysis to compare these two entry closed techniques.

DATA SOURCE

A systematic review of the literature was done on PubMed, MEDLINE, Embase, Scopus, and EBSCO.

METHODS

The literature search was constructed until May 01, 2022, around search terms for "Veress," "direct trocar," "needle," "insertion," and "laparoscopic ways of entry." This systematic review was reported according to the PRISMA Statement 2020.

RESULTS

Sixteen controlled trials (RCTs) and 5 observational studies were included in the systematic review. We found no significant differences in the risk of major complication during the access manoeuvres between DTI and VN: bowel injuries (OR = 0.76, 95% CI: 0.24-2.36, P = 0.63), major vascular injuries (OR = 1.74, 95% CI 0.56-5.38, P = 0.34), port site hernia (OR = 2.41, 95% CI: 0.28-20.71, P = 0.42). DTI has a lower risk of minor complications such as subcutaneous emphysema (OR = 5.19 95% CI: 2.27-11.87, P < 0.0001), extraperitoneal insufflation (OR = 5.93 95% CI: 1.69-20.87, P = 0.006), omental emphysema (OR = 18.41, 95% CI: 7. 01-48.34, P < 0.00001), omental bleeding (OR = 2.32, 95% CI: 1.18-4.55, P = 0.01), and lower number of unsuccessful entry or insufflation attempts (OR = 2.25, 95% CI: 1.05-4.81, P = 0.04). No significant differences were found between the two groups in terms of time required to achieve complete insufflation (MD =  - 15.53, 95% CI: - 91.32 to 60.27, P = 0.69), trocar site bleeding (OR = 0.66, 95% CI, 0.25-1.79, P = 0.42), and trocar site infection (OR = 1.19, 95% CI, 0.34-4.20, P = 0.78).

CONCLUSION

There were no statistically significant differences in the risk of major complications during the access manoeuvres between DTI and VN. A lower number of minor complications were observed in DTI compared with those in Veress access.

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.

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.

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 Comparison of Times Taken for the Placement of the First Portal and Complication Rates between the Veress Needle Technique and the Modified Hasson Technique in Canine Ovariectomy Laparoscopic Surgery

Minimally invasive surgery is increasingly being used in veterinary medicine. Laparoscopic procedures have several advantages compared with open surgery. These include the magnification of the field of surgery, reduced post-surgical pain and associated stress, reduced post-operative infection rates, and decreased hospitalization time. The establishment of a pneumoperitoneum is a critical step; however, this procedure can prolong the operation time, and most of the complications associated with laparoscopic surgery have been attributed to the insertion of devices into the abdominal cavity. Two main techniques have been employed to create pneumoperitoneum: the closed-entry method using the Veress needle and the open Hasson technique. The first portal is necessary to start insufflation and, subsequently, to realize the operative channel to insert the laparoscopic instruments into the abdomen. Many authors have compared the time necessary to create the first portal using different techniques in human medicine, but studies on this topic in veterinary medicine are lacking. In the veterinary medicine literature, complications associated with the creation of a pneumoperitoneum and the placement of ports include spleen, bowel, or bladder injuries; pneumothorax; and subcutaneous emphysema. The aim of the present study was to compare the times required for the placement of the first portal and the creation of pneumoperitoneum, and the rates of intraoperative complications using the Veress needle technique (VNT) and the open modified Hasson technique (MHT). The sample population comprised 30 female dogs who underwent laparoscopic ovariectomies. The dogs were randomly organized into two groups and two different entry techniques were used: Veress needle (VNT = group A) and the modified Hasson technique (MHT = group B). Complications related to abdominal entry were classified as major, in cases of organ perforation, and minor, in cases of subcutaneous emphysema and gas leakage. The VNT and MHT required 374.0 s and 242.9 s, respectively, for the placement of the first portal and for establishing pneumoperitoneum (p < 0.05). Their major complications rates were 20% and 0%, respectively (p < 0.05). Their minor complications rates were 20% and 35%, respectively (p < 0.05). No surgical procedures required laparotomy. The MHT was associated with a lower major complication rate and required less time to create the first portal, compared with the Veress needle technique.

A novel Veress needle mechanism that reduces overshooting after puncturing the abdominal wall

BACKGROUND

Complications that occur in laparoscopic surgery are often associated with the initial entry into the peritoneal cavity. The literature reported incidences of Veress needle (VN) injuries of e.g. 0.31% and 0.23%. In a 2010 national survey of laparoscopic entry techniques in the Canadian General Surgical practice, 57.3% of respondents had either experienced or witnessed a serious laparoscopic entry complication like bowel perforation and vascular injury. As those complications are potentially life threatening and should be avoided at all costs, improving safety of this initial action is paramount.

METHODS

Based on a bare minimum design approach with focus on function expansion of existing components, a new Safety mechanism was developed for the VN that decreases the risks of VN overshooting. The mechanism works by preventing the puncturing acceleration of the tip of the VN by decoupling the surgeon's hand from the VN immediately after entering the abdomen.

RESULTS

Based on a set of requirements, a first prototype of the VN+ with force decoupling safety mechanism is presented and evaluated on an ex vivo porcine abdominal wall tissue model in a custom setup. The experiments conducted by two novices and one experienced surgeon indicated a significant difference between the attempts with a standard, conventional working VN (41.4 mm [37.5-45 mm]) and VN+ with decoupling mechanism (20.8 mm [17.5-22.5 mm]) of p < 0.001.

CONCLUSION

A new decoupling safety mechanism was integrated successfully in a standard VN resulting in a VN+ . The results from the pilot study indicate that this new VN+ reduces overshooting with a minimum of 50% in a standardised ex vivo setting on fresh porcine abdominal wall specimens.

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.

First in-human experience with a novel robotic platform and Magnetic Surgery System

BACKGROUND

Magnetic technologies have been introduced to reduce invasiveness of surgical procedures. This study was aimed to analyse the performance of a novel combined magnetic-robotic controller as an enhanced accessory to the Magnetic Surgical System in laparoscopic cholecystectomy (LC).

METHODS

This was a prospective study of 10 consecutive patients undergoing LC with this novel surgical system.

RESULTS

Ten patients were included, nine were female. The mean age was 30.3 ± 9 years. All patients had chronic cholecystitis. Procedures were completed successfully. The median operative time was 50 ± 11 min. The system performed effectively in all cases with no need of additional interventions. There were no device-related complications or side effects. All patients were discharged the same day. Recovery was uneventful during follow-up.

CONCLUSIONS

This study demonstrates the first in-human successful performance of surgeries utilizing a novel combination of magnetic and robotic technologies in one integrated system.

Surgical Approaches for Common Gynecologic and Obstetrics Surgeries

Common obstetrics and gynecology operations have different approaches and techniques and variations in the procedure. We aimed to discuss different approaches and variations in the techniques of the procedures as cystectomy, myomectomy, laparoscopy entry technique, sacrospinous ligament fixation, uretherocele, and rupture uterus.

Transumbilical versus periumbilical incision for laparoscopic surgery: A meta-analysis

BACKGROUND

Whether a transumbilical or periumbilical incision is beneficial for the initial peritoneal access in laparoscopic abdominal surgery has been debated. Our aim is to determine whether a transumbilical or periumbilical incision is a better route for the initial umbilical trocar.

METHODS

PubMed, Embase, and Cochrane Library databases were searched for articles published before March 2020. The meta-analysis calculated the pooled effect size by using a random effects model.

RESULTS

Five trials involving 783 patients were reviewed. The transumbilical group significantly reduced operation time (mean difference: -7.73; 95% confidence interval: -13.10 to -2.35) when compared to the periumbilical group. The length of hospital stay, mean pain scores on operation day and postoperation day 1 did not differ significantly between the two groups. Moreover, the incidence of surgical site infection, cosmetic satisfaction, and complication rate did not differ significantly between groups.

CONCLUSION

A transumbilical incision is better than a periumbilical incision for laparoscopic surgery as it saves operation time. Hence, we suggest transumbilical incisions for the initial peritoneal access in laparoscopic abdominal surgery.

Direct trocar insertion without previous pneumoperitoneum versus insertion after insufflation with Veress needle in laparoscopic gynecological surgery: a prospective cohort study

The aim of this study was to determine whether direct trocar entry without prior pneumoperitoneum at umbilical level (DTI) can be a safe alternative to access the abdominal cavity in gynaecological laparoscopic surgery. We present a prospective observational analytical study of cohorts, comparing DTI with umbilical entry with trocar after previous insufflation with a Veress needle at umbilical level (V). The study period was performed from June 2013 to April 2016; data was collected on 600 patients who underwent gynaecological laparoscopic surgery. There were no significant differences in the risk of suffering a complication during the access manoeuvres between DTI (6.49%) and V (7.39%), OR 0.89 (95% CI: 0.42-1.81). The duration of the access manoeuvres was 69 s in DTI and 193 s in V (p < .001). The percentage of patients in whom two or more access attempts were performed was lower in DTI (7.8%) than in V (12.3%) (p > .05). We concluded that DTI is at least as safe as V, regarding the risk of suffering complications arising from access into the abdominal cavity. DTI has advantages with regard to V, such as: the shorter duration of access manoeuvres or the lesser number of unsuccessful entry or insufflation attempts. Impact statement What is already known on this subject? There are few international publications comparing DTI and V. When we conducted a search in PubMed for the terms 'Veress needle and direct trocar insertion', 51 publications were obtained. When we increased the restriction and added the terms 'laparoscopic entry and laparoscopy complications', 27 publications were obtained; thus, the uniqueness of our study. What do the results of this study add? We present a 3-year observational prospective study of cohorts that included 600 patients. The aim of this study was to determine that in laparoscopic gynaecological surgery, DTI is an access method to the abdominal cavity at least as safe as V, with respect to the risk of complications. On the other hand, DTI has some advantages such as the shorter duration of access manoeuvres or the lower number of failed entry attempts. What are the implications of these findings for clinical practice and/or further research? Given the limited number of publications that compared both techniques, our study indicates that DTI can be a safe alternative for access to abdominal cavity in gynaecological surgery, compared to the traditional V.

Cosmetic outcomes of infraumbilical, supraumbilical, and transumbilical entry routes in laparoscopic surgery

OBJECTIVE

The aim of the present study was to determine which of the umbilical entry routes for intraperitoneal access has a better cosmetic result.

MATERIAL AND METHODS

This was a prospective study (Canadian Task Force classification II-1). In total, 105 patients who underwent laparoscopic surgery were included. A vertical or transverse umbilical incision is appropriately made for the trocar to be inserted, and an infraumbilical, supraumbilical, or transumbilical route was preferred for initial intraperitoneal access. Demographic data of patients, body mass indices, entry point of the trocars (infraumbilical-transumbilical-supraumbilical), type of incision (vertical-transverse), duration of the operation, and scar properties at postoperative week 12 were prospectively collected and analyzed. The Vancouver scar scale was used to evaluate the cosmetic results.

RESULTS

Cosmetic results did not differ statistically between the transumbilical-infraumbilical-supraumbilical groups. The variables, such as vascularity, height, and total score, of the Vancouver scar scale were significantly higher in patients who had transverse incisions. There was no statistically significant effect of using a Veress needle with the cosmetic results. There was no statistically significant correlation between age, gravida, body mass indices, skin thickness, time of entry, duration of the operation, and cosmetic results in terms of vascularity, height, and total score.

CONCLUSION

During laparoscopic surgery, each patient should be assessed individually for the satisfaction of the patient and, thereby, of the surgeon in terms of cosmetic outcomes. Vertical incision offers superior cosmetic effects than transverse incision. Further research is required to define long-term scar-related outcomes of the laparoscopic intraperitoneal access techniques.

Periumbilical vs transumbilical laparoscopic incision: A patients' satisfaction-centered randomised trial

BACKGROUND

While studies suggested that transumbilical incisions (TUI) incur better postoperative cosmetic satisfaction scores (CSS) and shorter operative time (OT) than periumbilical incisions (PUI) during general surgery laparoscopic interventions, others did not. Concerns have been raised toward the potential negative impact of TUI on the incidence of surgical site infection (SSI) but this issue is under documented.

METHODS

A controlled trial was conducted between August 2014 and August 2015 in our hospital. Individuals aged 18-70 undergoing a laparoscopic rectopexy, cholecystectomy, appendectomy or proctocolectomy were considered. Patients were randomized in two groups (PUI or TUI) following a 1:1 allocation ratio. Participants with a body mass index >40, with a history of abdominal surgery, undergoing co-operations, requesting a specific incision or converted to open surgery were excluded.

RESULTS

Among the 56 randomized patients, 50 (27 PUI vs 23 PUI) produced analyzable data. There were no significant difference between the characteristics of both groups. CSS evolution (pre-op vs 1 month post-op), SSI incidence and OT were also comparable. Only 28% of participants valued the appearance of their umbilicus prior to intervention. Those who did had a significantly worst CSS evolution (OR -1.7; IC95-2.6/-0.72, p = 0.001). Higher preoperative CSS was also a predictor of postoperative CSS decline (OR -0.4; IC95-0.6/-0.2, p = 0.001).

CONCLUSIONS

SUI and TUI were similar for all tested outcomes. Among the participants, the minority of patients who valued the appearance of their umbilicus and those with a high preoperative CSS were particularly prone to postoperative CSS decline.

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

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

Laparoscopic access overview: Is there a safest entry method?

BACKGROUND

Laparoscopy is a minimally invasive technique to access the abdominal cavity, for diagnostic or therapeutic applications. Optimizing the access technique is an important step for laparoscopic procedures. The aim of this study is to assess the outcomes of different laparoscopic access techniques and to identify the safest one.

METHODS

Laparoscopic access questionnaire was forwarded via e-mail to the 60 centers who are partners in working group for laparoscopic and robotic surgery of the Italian Urological Society (SIU) and their American and European reference centers.

RESULTS

The response rate was 68.33%. The total number of procedures considered was 65.636. 61.5% of surgeons use Veress needle to create pneumoperitoneum. Blind trocar technique is the most commonly used, but has the greatest number of complications. Optical trocar technique seems to be the safest, but it's the less commonly used. The 28,2% of surgeons adopt open Hasson's technique. Total intra-operative complications rate was 3.3%. Open conversion rate was 0.33%, transfusion rate was 1.13%, and total post-operative complication rate was 2.53%.

CONCLUSION

Laparoscopic access is a safe technique with low complication rate. Most of complications can be managed conservatively or laparoscopically. The choice of access technique can affect the rate and type of complications and should be planned according to surgeon experience, safety of each technique and patient characteristics. All access types have perioperative complications. According with our study, optical trocar technique seems to be the safest.

Implementation of a Cross-specialty Training Program in Basic Laparoscopy

Background and Objectives:

Several surgical specialties use laparoscopy and share many of the same techniques and challenges, such as entry approaches, equipment, and complications. However, most basic training programs focus on a single specialty. The objective of this study was to describe the implementation of a regional cross-specialty training program for basic laparoscopy, to increase the flexibility of educational courses, and to provide a more efficient use of simulation equipment.

Methods:

Using a regional training program in basic laparoscopy for gynecology as a model, we developed a cross-specialty training program for residents in surgery, gynecology, urology, and thoracic surgery. We reviewed data on training for the first year of the program and evaluated the program by using a scoring system for quality criteria for laparoscopic curricula and skills.

Results:

We held 6 full-day theoretical courses involving 67 residents between September 1, 2013, and August 31, 2014. In the weeks following each course, residents practiced in a self-directed, distributed, and proficiency-based manner at a simulation center and in local hospital departments. A total of 57 residents completed the self-practice and a subsequent practical animal laboratory–based course. The structure of the training program was evaluated according to identified quality criteria for a skills laboratory, and the program scored 38 of a maximum 62 points.

Discussion:

Implementation of a regional cross-specialty training program in basic laparoscopy is feasible. There are several logistic benefits of using a cross-specialty approach; however, it is important that local departments include specialty-specific components, together with clinical departmental follow-up.

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.

The integration of minimally invasive surgery in surgical practice in a Canadian setting: results from 2 consecutive province-wide practice surveys of general surgeons over a 5-year period

BACKGROUND

Although minimally invasive surgery (MIS) has been quickly embraced, the introduction of advanced procedures appears more complex. We assessed the evolution of MIS in the province of Quebec over a 5-year period to identify areas for improvement in the modern surgical era.

METHODS

We developed, test-piloted and conducted a self-administered questionnaire among Quebec general surgeons in 2007 and 2012 to examine stated MIS practice, MIS training and barriers and facilitators to the use of MIS.

RESULTS

Response rates were 51.3% (251 of 489) in 2007 and 31.3% (153 of 491) in 2012. A significant increase was observed for performance of most advanced MIS procedures, especially for colectomy for benign (66.0% v. 84.3%, p < 0,001) and malignant diseases (43.3% v. 77.8%, p < 0,001) and for rectal surgery for malignancy (21.0% v. 54.6%, p < 0.001). More surgeons practised 3 or more advanced MIS procedures in 2012 than in 2007 (82.3% v. 64.3%, p < 0,001). At multivariate analysis, the 2007 survey administration was associated with fewer surgeons practising advanced MIS (odds ratio 0.13, 95% confidence interval 0.06-0.29). In 2012, more respondents stated they gained their skills during residency (p = 0.028).

CONCLUSION

From 2007 to 2012 there was a significant increase in advanced MIS procedures practised by general surgeons in Québec. This technique appears well established in current surgical practice. The growing place of MIS in residency training seems to be a paramount part of this development. Results from this study could be used as a baseline for studies focusing on ways to further improve the MIS practice.

The future

Practical relevance:

Laparoscopic surgery minimizes tissue trauma and speeds recovery, but its uptake into veterinary clinical practice has been slow.

Clinical challenges:

Laparoscopy is distinctly different from traditional open surgery and a reduced working area and loss of depth perception are among the challenges that the surgeon must get to grips with. Indeed, it is often lack of the necessary skills, rather than the cost of equipment, that presents the greatest obstacle.

Audience:

This article is aimed at practitioners keen to embrace minimally invasive surgery and advises on how to develop excellence in laparoscopic skills. It makes the case for simulation training and outlines methods that can be instituted in practice at low cost and with comparatively little time expenditure. It also describes technological advances that have already increased the success of veterinary ‘keyhole’ surgery, as well as those that look promising for the future.

Evidence base:

Simulation training has been an intense area of research and publication within the past 15 years. This article draws on that evidence base and the experience gained by the author and her research team, which is at the forefront of efforts to develop laparoscopic training for veterinarians.

The safety and feasibility of reoperation for the treatment of hepatolithiasis by laparoscopic approach

BACKGROUND

Hepatolithiasis removal is associated with high rates of postoperative residual and recurrence, which in some cases may require multiple surgeries. The progress and development of laparoscopic techniques introduced a new way of treating hepatolithiasis. However, the selection criteria for laparoscopic hepatolithiasis surgery, particularly among patients with a history of biliary surgery, remain undetermined. This study aimed to evaluate the safety, feasibility, and efficacy of reoperation for the treatment of hepatolithiasis via a laparoscopic approach.

METHODS

A retrospective analysis of the perioperative course and outcomes was performed on 90 patients who underwent laparoscopic procedures for hepatolithiasis between January 1, 2008, and December 31, 2012. Thirty-eight patients had previous biliary tract operative procedures (PB group) and 52 patients had no previous biliary tract procedures (NPB).

RESULTS

There was no significant difference in operative time (342.3 ± 101.0 vs. 334.1 ± 102.7 min), intraoperative blood loss (561.2 ± 458.8 vs. 546.3 ± 570.5 ml), intraoperative transfusion (15.8 vs. 19.2 %), postoperative hospitalization (12.6 ± 4.2 vs. 13.4 % ± 6.3 days), postoperative complications (18.4 vs. 23.1 %), conversion to open laparotomy (10.5 vs. 9.6 %), or intraoperative stone clearance rate (94.7 vs. 90.4 %). There was also no significant difference in stone recurrence (7.9 vs. 11.5 %) and recurrent cholangitis (5.3 vs. 13.5 %) at a mean of 19 months of follow-up (range, 3-51 months) for PB patients compared to NPB patients. The final stone clearance rate was 100 % in both groups.

CONCLUSIONS

Reoperation for hepatolithiasis by laparoscopic approach is safe and feasible for selected patients who have undergone previous biliary operations.

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.

Multiple-, but not single-, dose of parecoxib reduces shoulder pain after gynecologic laparoscopy

BACKGROUND

The aim of this study was to investigate effect of single- and multiple-dose of parecoxib on shoulder pain after gynecologic laparoscopy.

METHODS

126 patients requiring elective gynecologic laparoscopy were randomly allocated to three groups. Group M (multiple-dose): receiving parecoxib 40mg at 30min before the end of surgery, at 8 and 20hr after surgery, respectively; Group S (single-dose): receiving parecoxib 40mg at 30min before the end of surgery and normal saline at the corresponding time points; Group C (control): receiving normal saline at the same three time points. The shoulder pain was evaluated, both at rest and with motion, at postoperative 6, 24 and 48hr. The impact of shoulder pain on patients' recovery (activity, mood, walking and sleep) was also evaluated. Meanwhile, rescue analgesics and complications were recorded.

RESULTS

The overall incidence of shoulder pain in group M (37.5%) was lower than that in group C (61.9%) (difference=-24.4%; 95% CI: 3.4~45.4%; P=0.023). Whereas, single-dose regimen (61.0%) showed no significant reduction (difference with control=-0.9%; 95% CI: -21.9~20.0%; P=0.931). Moreover, multiple-dose regimen reduced the maximal intensity of shoulder pain and the impact for activity and mood in comparison to the control. Multiple-dose of parecoxib decreased the consumption of rescue analgesics. The complications were similar among all groups and no severe complications were observed.

CONCLUSIONS

Multiple-, but not single-, dose of parecoxib may attenuate the incidence and intensity of shoulder pain and thereby improve patients' quality of recovery following gynecologic laparoscopy.