Direct Trocar Insertion Research Articles

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

Laparoscopic entry techniques in obese patient: veress needle, direct trocar insertion or open entry technique?

Laparoscopy is a common procedure in bariatric surgery. Serious complications can occur during laparoscopic entry as reported by Ahmad et al. (Cochrane Database Syst Rev 15:2, 2012). Several techniques, instruments, and approaches to minimize the risk of injury (the bowel, bladder, major abdominal vessels, and an anterior abdominal wall vessel) have been introduced. These methods include the standard technique of insufflation after insertion of the Veress needle, the open (Hasson technique), the direct trocar insertion, and optical trocar insertion. Furthermore, it is more difficult to perform in the obese patient, especially if the first trocar is not umbilical. This is because obese patients have a very thick abdominal wall (particularly in women) as well as a thick peritoneum. The aim of this article was to demonstrate the safety of various laparoscopic entry techniques in obese patient.

A comparison of three different entry techniques in gynecological laparoscopic surgery: a randomized prospective trial

ObjectiveLaparoscopic entry techniques vary and still remain debated. We conducted a randomized control trial to compare three entry techniques.Study design: Women aged 18–70 years, nominated for laparoscopic surgery at University of Rome Campus Bio-Medico, were randomized into three different groups: Veress needle (VER), Direct trocar insertion (DIR) and Open technique (OP). For each group, minor complications (extra-peritoneal insufflation, trocar site bleeding, omental injury and surgical site infection), failed entry and time of entry of the main trocar were evaluated. Major complications were also considered. Between-group comparisons were performed using chi-square test. Significance P value was <0.05. ResultsA series of 595 consecutive procedures were included: 193 in the VER group, 187 in the DIR group and 215 in the OP group. Minor complications occurred in 36 cases: extraperitoneal insufflation (n=6) in the VER group only, site bleeding (n=2 in the VER group, n=2 in the DIR group and n=1 in the OP group), site infection (n=5 in the VER and n=6 in OP group), and omental injury (n=6 in the VER group and n=3 in the DIR group). Failed entry occurred in 4 cases of the VER group and 1 case of the DIR group. Mean time of entry was 212.4, 71.4 and 161.7s for the VER, DIR and OP groups respectively. Among major complications, one bowel injury resulted following the Veress technique. ConclusionsIn our series, DIR and OP entry presented a lower risk of minor complications compared with VER. In addition, time of entry was shorter in DIR than with OP entry.

The Safety of Direct Trocar Versus Veress Needle for Laparoscopic Entry: A Meta-Analysis of Randomized Clinical Trials

This study assessed the safety of direct trocar insertion (DTI) versus Veress needle followed by primary trocar insertion (VN). Ovid MEDLINE(®), Cochrane Library, Google Scholar, Scopus, and the reference lists of published articles were searched up to September 2011 to identify randomized clinical trials comparing DTI with VN. This meta-analysis was restricted to randomized studies comparing the safety of these two laparoscopic entry techniques. Seven randomized studies consisting of 2940 women (VN, n=1525; DTI, n=1415) were identified. The data on the safety of two entry techniques were abstracted, integrated, and analyzed with the meta-analysis method and are presented as pooled relative risk (RR) with 95% confidence intervals (CI). There were 4 cases of a major complication in the VN group in contrast to none in the DTI group. Pooled results failed to show a statistically significant difference in the risk of major complications between the two groups. A significantly higher risk of minor complications was detected in the VN group (RR [95% CI]=10.78 [6.27-18.51]). Among minor complications, preperitoneal injuries (46.73 [11.55-189.10]) and omental injuries (4.51 [2.12-9.62]) were the two most common complications in the VN group. There were significantly increased risks of multiple insertions (more than two attempts) (2.99 [2.11-4.23]) and failed entry (2.21[1.07-4.56]) in the VN group. This meta-analysis suggests that the commonly used VN entry technique carries a significantly increased risk of minor complications. In addition, the likelihood of multiple insertions and failed entry are significantly higher in the VN group.

Laparoscopic Management of Large Ovarian Cysts

The aim of this study was to describe a new technique for laparoscopic removal of large ovarian cystic masses. The authors performed a retrospective study during the period January 2008 to December 2009 in the Second Department of Obstetrics and Gynecology of Aretaieion University Hospital; 19 women with large ovarian cysts were included in the study. During the study period, 53 women underwent laparoscopic excision of ovarian cysts. Among them, 19 had very large complex ovarian cysts with a mean diameter of 8.4 cm. The mean age of the patients was 32.1 years. Ultrasound examination revealed findings suggestive of benign disease in all patients. In 8 out of 19 patients CA-125 levels were elevated, ranging from 40.5 to 194.7 IU/mL. A 5-mm suprapubic trocar was directly inserted into the cyst and fluid contents aspirated, so the decompressed cyst could fit in a 5-cm laparoscopic bag. The cyst wall was carefully detached from the healthy ovarian tissue and placed in the bag without any spillage. The remaining cyst wall was removed from the peritoneal cavity with the laparoscopic bag. The mean operative time was 45 minutes. No operative or postoperative complications were noted. There was no conversion to laparotomy. Mean hospital stay was 1 day. Pathology revealed 7 endometriomas, 3 mucinous cystadenomas, 3 serous cystadenomas, 3 serous cysts, and 3 teratomas. Direct trocar insertion within the ovarian cyst followed by aspiration of the fluid contents is a safe and feasible method for the laparoscopic management of large ovarian cysts.

Direct trocar insertion for laparoscopy.

The Veress needle (VN) technique for establishing pneumoperitoneum in laparoscopic surgery is widely used and yet is associated with slow insufflation rates and potentially life-threatening complications. Although these complications have been rarely reported, they represent a major source of morbidity and mortality from laparoscopic procedures and a major reason for conversion to open surgery. The open laparoscopy (OL) is an alternative to the VN technique, being relatively safer, even if considered cumbersome by many authors. Recently, the direct trocar insertion (DTI) technique of establishing pneumoperitoneum has been reported as an alternative to both techniques, but it is largely confined to gynecologic procedures. We report a case-series study where we evaluate the patients who underwent a DTI entry for laparoscopy during a recent 5-year period, focusing attention on feasibility, safety, and the benefits of DTI. This is a case series of 2175 different laparoscopic procedures (1456 [66.9%] scheduled cases and 719 [33%] emergencies). In 2091 (96.1%) of them (1425 [68.1%] scheduled cases and 666 [31.8%] emergencies), pneumoperitoneum was established with DTI, either in the umbilicus or in Palmer's point. There were no injuries, either minor or major. Peritoneal access and the creation of a laparoscopic workplace were obtained quickly and efficiently by DTI. Our results suggest that DTI is a fast, safe, and reliable alternative to traditional techniques for pneumoperitoneum establishment and should be regarded as a part of the surgical armamentarium of a trained laparoscopic surgeon.

Single-Port Access Total Laparoscopic Hysterectomy (SPA-TLH) with Standard Instrumentations

Current techniques of single-port access hysterectomy have many advantages, but also disadvantages. These disadvantages act as barriers disturbing its popularization. To overcome these, many instruments have been developed. However, these are not satisfactory, furthermore very expensive. All my SPA surgeries have been performed only with straight instrumentations. And also I've tried to improve current techniques: such as 1) modified direct trocar insertion under periumbilical incision, which is more convenient and gives faster decision making whether to convert to multi-port surgery or laparotomy than Haesson technique, 2) anchoring sutures for faster, easier closure of the large single-port, 3) modified homemade port including better smoke drainage and less trocar heads' fighting, 4) easier removal of Allexis inner ring with vein retractor, 5) percutaneous sling suture saving additional port in total laparoscopic hysterectomy, myomectomy, ovarian cystectomy, 6) laparoscopic morcellation with morcellating knife, and, 7) better laparoscopic vault closure technique using vaginal tube.

Use of a No. 11 Blade Scalpel and Reusable Blunt Trocar To Establish Pneumoperitoneum: Description of a Safe and Inexpensive Technique

First access is crucial in laparoscopic surgery because of its potentially life-threatening complications. A number of procedures using a variety of instruments have been previously described; however, the safest approach remains uncertain. Herein, we describe a simple and inexpensive method for direct trocar insertion using reusable instruments that was developed over 10 years in a series of 4721 consecutive gynecologic laparoscopic procedures. Observed data revealed that the technique is feasible, rapidly performed, and safe, with a likely cost savings, using a small set of reusable instruments. This procedure should be compared with other access methods in randomized studies to confirm the observed advantages.

Direct Trocar Insertion Technique for Initial Access in Morbid Obesity Surgery: Technique and Results

Obtaining access to the peritoneal cavity in laparoscopic surgery is more difficult in morbidly obese patients. There is no clear consensus as to the optimal method of entry into the peritoneal cavity. This study assesses the safety and feasibility of the direct trocar insertion technique without pre-existing pneumoperitoneum in patients undergoing laparoscopic bariatric surgery. From February 2006 to July 2009, 155 morbidly obese patients underwent laparoscopic adjustable gastric band surgery. There were 128 women (82.6%) and 27 men (17.4%). The mean age was 41 and ranged between 18 and 59 years. All patients met the National Institutes of Health criteria for bariatric surgery. The mean body mass index was 45 kg/m (range 35 to 61). There was no evidence of intestinal or vascular injury during trocar placement. Immediate minor complications were extraperitoneal insufflations in 5 patients, gastric serosal laceration in 1 patient, and left liver lobe laceration in 1 patient. No major complications were associated with this technique. All complications related to the direct trocar insertion technique were minor and these complications did not affect the success of surgery. We concluded that the direct trocar technique for initial access in laparoscopic bariatric surgery provides safe and quick entry into the peritoneal cavity.

A multi-center study of a modified open trocar first-puncture approach in 17 350 patients for laparoscopic entry

Background Laparoscopic entry is of primary importance in laparoscopic surgery because of its potential association with serious complications such as visceral and vascular injuries. There are several approaches now available for laparoscopic entry. The present study reported a modified open trocar first-puncture approach (Yan's open technique) and validated its safety and practicability in a multi-center research. Methods The study was performed in seven gynecological endoscopy centers for 8 successive years from September 1998 to March 2006 involving 17 350 patients, who received the modified open trocar first-puncture approach developed by Dr. LIU Yan as the study group (MOT group). The “Yan's open technique” is the umbilical incision with a scalpel and then a 10-mm trocar entry into the abdominal cavity through direct trocar puncture or insertion of the cannula sheath via the opened umbilicus under no resistance. Another 4570 patients received the traditional Veress needle puncture as the control (VN group). The first puncture procedures of both groups were performed by 28 experienced gynecologic laparoscopists and 170 learners. Results In MOT group, the successful achievement rate (AR) of first puncture was 99.99% (17 348/17 350), including smooth manipulation in 17 326 cases and unsmooth manipulation in 22 cases. The remaining two cases failed. First-puncture associated complications occurred in two cases (0.01%). In VN group, the successful AR of first puncture was 99.89% (4565/4570), including smooth manipulation in 4542 cases and unsmooth manipulation in 23 cases. The remaining five cases failed. First-puncture associated complications occurred in four cases (0.09%). There was no significant difference in the successful AR between the experienced gynecologic laparoscopists of the two groups (100% vs 100%, P &gt;0.05), but the difference was significant between the learners of the two groups (99.98% vs 99.81%, P &lt;0.05). The complication rate of VN group was significantly higher than that of MOT group (0.09% vs 0.01%, P &lt;0.05). Conclusions Compared with the traditional Veress needle puncture, the modified open trocar first-puncture is easier to follow, especially for learners. In addition, it can avoid possible Veress needle-associated injuries. Opening the umbilical hole for the sake of minimizing or zeroing puncture resistance is a safer and more practicable maneuver for laparoscopic entry.

Direct Trocar Versus Veress Needle Insertion for Laparoscopy: A Randomized Clinical Trial

Study Objective: To compare between direct trocar (DTI) and Veress needle (VN) insertion for creation of pneumoperitoneum at laparoscopy as regards the duration of the procedure, volume of gas consumption, ease of performance and frequency of complications.

Entry complications in laparoscopic surgery

To review the complications associated with laparoscopic surgery and provide clinical direction regarding the best practice based on the best available evidence. The laparoscopic entry techniques and technologies reviewed include the classic pneumoperitoneum (Veress/trocar), the open (Hasson), the direct trocar insertion, the use of disposable shielded trocars, radially expanding trocars and visual entry systems. Medline, Pubmed and Cochrane Databases were searched for English language articles published before December 2008. It is an evidence based fact that minimal access surgery is superior to conventional open surgery since this is beneficial to the women, community and the healthcare system.Over the past 50 years, many techniques, technologies and guidelines have been introduced to eliminate the risks associated with laparoscopic entry. No single technique or instrument has been proved to eliminate laparoscopic entry associated injury. Proper evaluation of the women, supported by surgical skills and good knowledge of the technology and instrumentation is the keystone to safe access and prevention of complications during laparoscopic surgery.

Is Pneumoperitoneum Really Required before Primary Trocar Insertion in Laparoscopy?

ABSTRACT Objectives Traditionally a Veress needle is used to create a pneumoperitoneum before entering the primary trocar/cannula for laparoscopy. Insufflation of gas into the peritoneal cavity with the Veress needle is not without its problems. To do away with these problems the technique of direct trocar access was started. Materials and methods Between 01 Jan 2003 and 31 Dec 2008— 2958 laparoscopic procedures were carried out in a Government hospital. 345 patients out of these had undergone previous laparotomies. In all cases direct trocar insertion without pneumoperitoneum was done. Result In this series there were no complications except in one case there was mesenteric injury with bleeding which required a laparotomy. There were no failed laparoscopies. Conclusion We have found that direct trocar insertion before creating pneumoperitoneum is a safe and effective method for laparoscopic access and offers advantages over the conventional access modality of using a Veress needle for pneumoperitoneum.

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.

Minimal access approach to the management of large ovarian cysts

We read with interest the novel approach of Goh et al. [1] to laparoscopically assisted extracorporeal cystectomy for very large ovarian cysts without spillage of cyst contents. We commend their efforts. However, certain issues need to be clarified. The authors used open laparoscopy to access the abdominal cavity. We suggest the use of direct trocar insertion through Palmer s point, except when the ovarian cyst is large enough to fill the abdominal cavity, because adhesions are rare at this site [2]. The authors described a technique using a Cook aspiration needle and suction cannula to prevent the spillage of cyst contents. We suggest the use of a 5.5-mm trocar and cannula to puncture the cyst and aspirate the contents of the cyst with a suction tip, which can be placed through the same cannula after removal of trocar. In this manner, even multilocular cysts can be managed because the suction cannula is long enough to get across other cysts. We hope further discussion and suggestion will contribute to the advancement and popularity of this novel technique.

Laparoscopic Entry: A Review of Techniques, Technologies, and Complications

ObjectiveTo provide clinical direction, based on the best evidence available, on laparoscopic entry techniques and technologies and their associated complications. OptionsThe laparoscopic entry techniques and technologies reviewed in formulating this guideline include the classic pneumoperitoneum (Veress/trocar), the open (Hasson), the direct trocar insertion, the use of disposable shielded trocars, radially expanding trocars, and visual entry systems. OutcomesImplementation of this guideline should optimize the decision-making process in choosing a particular technique to enter the abdomen during laparoscopy. EvidenceEnglish-language articles from Medline, PubMed, and the Cochrane Database published before the end of September 2005 were searched, using the key words laparoscopic entry, laparoscopy access, pneumoperitoneum, Veress needle, open (Hasson), direct trocar, visual entry, shielded trocars, radially expanded trocars, and laparoscopic complications. ValuesThe quality of evidence was rated using the criteria described in the Report of the Canadian Task Force on the Periodic Health Examination. Recommandations et déclaration sommaire1.Left upper quadrant (LUQ, Palmer’s) laparoscopic entry should beconsidered in patients with suspected or known periumbilicaladhesions or history or presence of umbilical hernia, or after threefailed insufflation attempts at the umbilicus. (II-2 A) Other sites ofinsertion, such as transuterine Veress CO2 insufflation, may beconsidered if the umbilical and LUQ insertions have failed or havebeen considered and are not an option. (I-A)2.The various Veress needle safety tests or checks provide very littleuseful information on the placement of the Veress needle. It istherefore not necessary to perform various safety checks oninserting the Veress needle; however, waggling of the Veressneedle from side to side must be avoided, as this can enlarge a1.6 mm puncture injury to an injury of up to 1 cm in viscera orblood vessels. (II-1 A)3.The Veress intraperitoneal (VIP-pressure ≤ 10 mm Hg) is a reliableindicator of correct intraperitoneal placement of the Veress needle;therefore, it is appropriate to attach the CO2 source to the Veressneedle on entry. (II-1 A)4.Elevation of the anterior abdominal wall at the time of Veress orprimary trocar insertion is not routinely recommended, as it doesnot avoid visceral or vessel injury. (II-2 B)5.The angle of the Veress needle insertion should vary according tothe BMI of the patient, from 45˚ in non-obese women to 90˚ inobese women. (II-2 B)6.The volume of CO2 inserted with the Veress needle shoulddepend on the intra-abdominal pressure. Adequatepneumoperitoneum should be determined by a pressure of 20 to30 mm Hg and not by predetermined CO2 volume. (II-1 A)7.In the Veress needle method of entry, the abdominal pressure maybe increased immediately prior to insertion of the first trocar. Thehigh intraperitoneal (HIP-pressure) laparoscopic entry techniquedoes not adversely affect cardiopulmonary function in healthywomen. (II-1 A)8.The open entry technique may be utilized as an alternative to the Veress needle technique, although the majority of gynaecologists prefer the Veress entry. There is no evidence that the open entry technique is superior to or inferior to the other entry techniquescurrently available. (II-2 C)9.Direct insertion of the trocar without prior pneumoperitoneum maybe considered as a safe alternative to Veress needle technique. (II-2)10.Direct insertion of the trocar is associated with less insufflation-related complications such as gas embolism, and it is a faster technique than the Veress needle technique. (I)11.Shielded trocars may be used in an effort to decrease entryinjuries. There is no evidence that they result in fewer visceral andvascular injuries during laparoscopic access. (II-B)12.Radially expanding trocars are not recommended as beingsuperior to the traditional trocars. They do have blunt tips that mayprovide some protection from injuries, but the force required forentry is significantly greater than with disposable trocars. (I-A)13.The visual entry cannula system may represent an advantage overtraditional trocars, as it allows a clear optical entry, but thisadvantage has not been fully explored. The visual entry cannulatrocars have the advantage of minimizing the size of the entrywound and reducing the force necessary for insertion. Visual entrytrocars are non-superior to other trocars since they do not avoidvisceral and vascular injury. (2B)

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.

Direct Trocar Insertion without Pneumoperitoneum and the Veress Needle in Laparoscopic Cholecystectomy: a Comparative Study

Purpose: The purpose of this study is to compare the safety and complications of direct trocar insertion without pneumoperitoneum (DTI) with Veress needle (VN) in laparoscopic cholecystectomy (LC). Methods: We studied 84 patients admitted to our hospital for LC, in a random simple blind design, 42 patients were assigned to DTI and 42 to VN. The variables analysed were: procedure complications, laparoscope insertion time and duration of surgery.Results: Complication percentages between the groups were significantly different (DTI 2.3% versus VN 23.8%, p = 0.009). The duration of surgery between the two groups was also significantly different (DTI 56 ±31 versus VN 71 ± 28 minutes, p < 0.02). Finally, laparoscope insertion time between the two techniques was significantly different (DTI 1.5 ± 0.5 versus VN 3.0 ± 0.4 minutes p < 0.001).Conclusions: Our results show DTI to be a safe, efficient, rapid and easily-learned alternative technique, reducing the number of procedure-related complications.

The Safety and Efficacy of Direct Trocar Insertion With Elevation of the Rectus Sheath Instead of the Skin for Pneumoperitoneum

No AccessJournal of UrologyUrological Survey: Urolithiasis/Endourology: Urolithiasis, Endourology and Laparoscopy1 Nov 2005The Safety and Efficacy of Direct Trocar Insertion With Elevation of the Rectus Sheath Instead of the Skin for Pneumoperitoneum Ralph V. ClaymanM.D. Ralph V. ClaymanRalph V. Clayman More articles by this author View All Author Informationhttps://doi.org/10.1016/S0022-5347(01)68807-4AboutFull TextPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail "The Safety and Efficacy of Direct Trocar Insertion With Elevation of the Rectus Sheath Instead of the Skin for Pneumoperitoneum." The Journal of Urology, 174(5), pp. 1847–1848 © 2005 by American Urological Association, Inc.FiguresReferencesRelatedDetails Volume 174Issue 5November 2005Page: 1847-1848 Advertisement Copyright & Permissions© 2005 by American Urological Association, Inc.MetricsAuthor Information Ralph V. Clayman More articles by this author Expand All Advertisement Loading ...