Direct Trocar Insertion Technique Research Articles

Comparison of three umbilical entry sites for intraperitoneal access by the direct trocar insertion technique: a randomized pilot study.

The most effective methods and entry sites for laparoscopic surgery remain a subject of ongoing investigation and discussion. The purpose of the study was to analyze and compare three umbilical entry sites for intraperitoneal access using the direct trocar insertion technique. A randomized pilot study was conducted between March 2021 and January 2023, involving women eligible for laparoscopic gynecological surgery. The women were allocated to one of three equally sized groups based on trocar entry points: subumbilical, supraumbilical, or umbilical. Success and failure rates of trocar entry, factors influencing success or failure, and early and late complications were systematically evaluated and compared across groups. A total of 243 patients, with a mean age of 32.93±8.33 years, were included in three groups of 81 each. Trocar entry success rates were 97.5%, 89.2%, and 89.5% in the supraumbilical, umbilical, and subumbilical groups, respectively (p>0.05). Failed trocar entry was significantly associated with age, gravidity, body mass index (BMI), waist circumference, hip circumference, and abdominal subcutaneous fat thickness (p<0.001). Regression analysis revealed that, in the subumbilical group, higher gravidity [odds ratios (OR): 0.390, 95% confidence interval (CI): 0.174-0.872, p=0.022) and greater abdominal subcutaneous fat thickness (OR: 0.090, 95% CI: 0.019-0.431, p=0.03) were associated with lower odds of successful trocar entry. In contrast, in the umbilical group, a higher waist circumference was associated with lower odds of successful trocar entry (OR: 0.673, 95% CI: 0.494-0.918, p=0.012). None of the covariates were significant in the supraumbilical group. The study highlighted the importance of selecting the appropriate trocar entry site in laparoscopic gynecological surgery. Surgeons should consider factors such as age, gravidity, BMI, waist circumference, hip circumference, and abdominal subcutaneous fat thickness, as these factors significantly influence the success of trocar entry.

Comparison between direct trocar versus Veress needle for laparoscopic access: a randomized controlled study

Background: The existence of numerous techniques for creation of pneumoperitoneum at laparoscopy indicates that none has been proven totally efficacious or complication free. There is dearth of study in India comparing these techniques. The aim of present study was to compare the safety and duration for creating pneumoperitoneum between direct trocar (DT) and Veress needle (VN) technique.Methods: One hundred-fourteen patients aged between 18 and 70 years were included in this single-blind randomized controlled study. Group DT and group VN patients underwent laparoscopic surgery after trocar placement by direct trocar insertion technique and Veress needle technique respectively. The primary outcome measure was the incidence of complications whereas secondary outcome measures were number of items required and time needed to introduce the laparoscope. Intergroup comparison of categorical and continuous variables was done using the Chi-square test/Fisher’s exact test and unpaired t-test respectively.Results: The number of attempts for trocar placement, and complications were comparable between direct trocar and Veress needle group. The mean duration of trocar placement at the first attempt was 102.6 and 142.3 seconds in direct trocar and Veress needle group respectively (p value =0.001).Conclusions: Veress needle is a safe, efficient, and rapid alternative technique as compared to direct trocar.

A comparative study between direct safety trocar insertion versus veress needle technique for creating pneumoperitoneum in laparoscopic surgeries

Background: There are two methods of trocar insertion in laparoscopic surgeries one is direct insertion and second is Veress needle insertion. In this study we compared these two methods.Methods: In this study we divided 50 patients equally into two group group A for in group A patients, direct trocar insertion technique was used for creation of pneumoperitoneum whereas amongst patients of group B, pneumoperitoneum was created using Veress needle insertion technique.Results: The incidence of visceral injuries, vascular injuries and other post-operative complications were similar in both the groups. The present study observed no significant difference in failure rates between two methods.Conclusions: Both the techniques i.e.; Direct trocar insertion (DTI) and Veress needle technique are equally effective, safe and feasible for creation of pneumoperitoneum during laparoscopic procedure.

2917 A Novel Twist on Direct Trocar Insertion

Video Objective To describe a novel direct trocar insertion (DTI) technique for minimally invasive surgery that requires minimal force and provides excellent visualization Setting Tertiary health care facility. Patients who underwent minimally invasive gynecologic surgery for benign and malignant indications between 2014 -2016 were reviewed Interventions Minimally invasive gynecologic surgery by two senior Gynecologic Oncology faculty members. 780 patients underwent minimally invasive gynecologic surgeries for benign and malignant indications. A Left upper quadrant (LUQ) approach was used in all the patients. With a level operating room table, we made a 5 mm incision. With the laparoscope inside the 5 mm Optiview trocar, we applied gentle pressure while rotating or twisting the trocar. Abdominal wall layers were distinctly identified without tenting the abdominal wall. Atraumatic entry was achieved in all cases. BMI and prior pelvic surgery did not impact the use of this technique; however, we routinely used LUQ approach in patients with prior abdominal surgeries. Creation of pneumoperitoneum with this DTI technique was feasible in all patients. No major complications were associated with the technique. Conclusion This study demonstrates the feasibility of direct trocar insertion under visualization. Our application of light pressure and twisting while visualizing abdominal layer without having to tent up the abdominal wall allows excellent control and visualization of abdominal wall layers and prevents inadvertent popping of the trocar. It also helps avoid trocar skiving keeping the appropriate distance from targeted anatomy.

Laparoscopic Access: Direct Trocar Insertion Versus Open Technique.

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

Direct Laparoscopic Trocar Insertion: Lessons Learned from Nine Litigated Cases

Study ObjectiveTo report circumstances and clinical and medicolegal outcomes of 9 litigated cases associated with direct trocar insertion (DTI) injuries to the bowel (7 cases) and major vessel (2 cases) during primary laparoscopic access. DesignA case series from 1990 through 2015 (Canadian Task Force Classification II-2). PatientsNine litigated cases. InterventionsA retrospective review of medical and legal records of litigated cases in Canada reviewed by the primary author (G.A.V.). Measurements and Main ResultsThe average and range of age and body mass index of the women were 31 years (range, 14–65 years) and 25 kg/m2 (range, 20–35 kg/m2), respectively. Indications for laparoscopy included diagnostic (4), laparoscopically assisted vaginal hysterectomy (3), pelvic mass (1), and laparoscopic cholecystectomy (1). DTI was performed with 10-mm trocars (5 shielded, 1 reusable, and 3 unknown). Two complications were experienced by patients of the same male surgeon (cases 2 and 9). Injuries included the small bowel (4 cases), colon (3 cases), and major vessel (2 cases). Vascular injuries resulted in permanent brain damage in 1 and near loss of limb in the other; litigation was favorable to the plaintiff in both cases. All bowel injuries presented with signs and symptoms of peritonitis within 3 postoperative days (PODs) (5 patients on POD 1, 1 patient on POD 2, and 1 patient on POD 3); however, only 2 cases were acted upon and remedied with favorable clinical and medicolegal outcomes. A delayed exploratory laparotomy resulted in significant adverse clinical outcomes (ileostomy/colostomy in 4 patients, multiple surgeries in 7 patients, and 1 death), and in all delayed actions, the medicolegal outcomes were favorable to the plaintiff. ConclusionDuring laparoscopic primary peritoneal access using the DTI technique, inadvertent intra-abdominal injury may be significant when major vessels are involved and when intervention is delayed in bowel injuries. These result in significant adverse clinical complications and may provoke higher litigation with more favorable outcomes for the plaintiff.

Comparison of Direct Trocar Entry and Veress Needle Entry in Laparoscopic Bariatric Surgery: Randomized Controlled Trial.

We aimed to compare the direct trocar insertion (DTI) and Veress needle insertion (VNI) techniques in laparoscopic bariatric surgery. Eighty-one patients scheduled for bariatric surgery at Inonu University, Malatya, Turkey, were included in this study. In 39 patients, a bladed retractable nonoptical trocar was used for DTI, and VNI was performed in 42 patients. Intraoperative access-related parameters were compared. Data were analyzed with Student's t and chi-squared tests. A P value of <.05 was considered significant. Both groups had comparable demographic profiles. Laparoscopic entry time was shorter in the DTI group (79.6 ± 94.6 versus 217.6 ± 111.0 seconds; P < .0001). Successful entry rates in the first attempt, CO2 consumptions, failed attempt rates, and overall intraoperative complication rates were similar. However, in the DTI group, 2 patients had mesenteric injuries, and 1 of them required conversion to open surgery due to the mesenteric hemorrhage. DTI in obese patients significantly shortens the entry time, but there can be severe complications with DTI when a nonoptical bladed trocar is used blindly. Actually, neither method can be recommended for entry into the abdomen in this population based on our results. If the surgeon has to choose a nonoptical trocar in bariatric surgery, preference for the VNI technique instead of the DTI technique is safer.

English

Purpose of this study is to access the safety and efficacy of direct trocar insertion (DTI) for accessing the abdominal cavity for operative laparoscopy without prior pneumoperitoneum. DTI is one of the safe and effective alternative to veress needle insertion, open access (Hassan's technique) and visual entry systems (disposable optic trocars and endotip visual cannula) in laparoscopic surgery. METHODS: The study included 2480 patients who has undergone laparoscopic procedures at civil hospital, Jalandhar from Nov. 2003 to Sept. 2012 and at Punjab Institute of Medical Sciences (PIMS) Jalandhar from Sept. 2012 to June 2014. Procedures include 2310 laparoscopic cholecystectomies, 148 laparoscopic appendectomies, 10 cases of TAPP Groin hernia repairs and 12 cases of simple ovarian cysts. For DTI, abdominal wall was lifted and trocar was pushed through the fascia and muscle layer. The surgeon felt click when the trocar had pierced the peritoneum and entered the abdominal cavity. RESULTS: Direct trocar insertion was feasible in 100% of patients. There was no evidence of intestinal or vascular injury during trocar placement. Peritoneal access and creation of laparoscopic workspace were attained faster and more efficiently by the DTI technique. CONCLUSIONS: DTI is a fast, safe and reliable alternative to traditional

Comparison Between Direct Trocar and Veress Needle Insertion in Laparoscopic Cholecystectomy

Although the Veress needle (VN) is widely used for insufflation of the peritoneum, direct trocar (DT) insertion is going to be more popular. A lot of complications have been reported because of the use of VN. We designed a prospective, nonrandomized study for the comparison of VN and DT insertion techniques. A pneumoperitoneum was created using the VN in 135 patients and using DT insertion technique in 148 patients during a 3-year period. Although no major complication was seen in the DT group, three major complications were seen in the VN group, but there was no statistically significant difference between both groups. More frequent minor complications were seen in the VN group, but it was statistically insignificant. Surgical skill and experience of the surgeon with the entry technique who is using it is an important factor for the selection of the abdominal insufflation technique.

Direct Trocar Insertion: A Safe Laparoscopic Access

Background: The most important and potentially dangerous first step in laparoscopy is safe and successful insertion of a primary port. Techniques for the creation of pneumoperitoneum at laparoscopy include the standard technique of insufflation after insertion of the Veress needle (VN) via the umbilicus, open laparoscopy, optical trocar insertion and direct trocar insertion (DTI) as well as variations on these techniques. The DTI technique without pre-insufflation is an alternative to VN insertion and open laparoscopy for accessing the abdominal cavity for operative laparoscopy. It recommends elevation of anterior abdominal wall with the non-dominant hand while inserting the sharp primary trocar directly and blindly towards the peritoneal cavity with the other. Conclusion: After reviewing the methods available and surveying the existing data concerning the rates of failure and complications, we conclude that, DTI at laparoscopy is a safe alternative to the VN technique and is associated with fewer minor complications.

Insufflation Techniques in Gynecologic Laparoscopy

Our objectives were to assess the safety and efficacy of different insufflation methods in women undergoing laparoscopy and to develop a model for selection of the appropriate insufflation technique based on the patient's characteristics and surgeon's experience. We performed a retrospective analysis of laparoscopic procedures on 3086 women over a 13-year period at the University of Louisville Hospital, Louisville, KY. All laparoscopic procedures were performed on an outpatient basis by residents under faculty supervision. Five different insufflation techniques were evaluated: standard transumbilical insufflation, open laparoscopy, transuterine insufflation, subcostal insufflation, and direct trocar insertion technique. Body mass index and previous abdominal surgeries were identified as the most important factors in the selection of the most successful insufflation method based on the surgeon's experience, using data mining techniques. During the first insufflation attempt, we were successful at achieving a pneumoperitoneum 94.7% of the time. This number increased to 98.1% when we switched to a second alternative insufflation method. In all, there were 5 complications out of 3086 patients (0.16%) after all insufflation techniques.

The use of veress needle and 10-mm trocar (VN) versus direct trocar insertion (DTI) in the beginning of laparoscopy

Seven hundred fifty-six women were randomly divided into two groups. Group 1 (378 cases) were operated on via laparoscopy with VN and group 2 (378 cases) with DTI technique. Complications were compared between the two groups. No major complications occurred. Minor complications were: a problem with insufflation of CO2 (19 VN, 2 DTI, P<0.001); more than one insertion of the instrument (18 VN, 13 DTI, NS); need to alter the technique (6 VN, 10 DTI, NS); and penetration of the fascia but not the peritoneum by trocar sleeve (2 VN, 19 DTI, P<0.001). The significant differences found presented no serious problems, and we concluded that both methods were satisfactory.