Epigastric Trocar Research Articles

P-072 INCIDENCE OF TROCAR SITE HERNIA AFTER LAPAROSCOPIC BARIATRIC SURGERY, A LONG TERM FOLLOW UP

Abstract Aim Given the increased use of laparoscopic surgery, the possible complications associated with it must be considered. Trocar site hernias (TSH) are one of them, being more frequent in obese patients. With this study we want to know the importance of the problem and evaluate our own results. Methods We made an observational, descriptive, longitudinal and retrospective study in patients undergoing laparoscopic bariatric surgery with 12mm bladeless trocars without fascial closure between January 2015 and July 2016. They were interrogated about symptoms and postoperative infection in the ports, and an abdominal wall ultrasound were performed by an expert radiologist in December 2022. Results 45 patients were included. The average age was 49.9 years-old (77.8% women) with a mean initial BMI of 45.5kg/m2 and actual BMI of 30.2 kg/m2. Among risk factors we found 31.1% of smokers, 46.7% of diabetes and 64.4% of respiratory pathology. The main surgery was gastric bypass (88.9%). 7 patients presented TSH (15.6%) and 6 patients presented symptomatology in any trocar site (13.3%), although only 2 (4.4%) showed hernia ecographically at the symptomatic port. We studied 189 ports and detected a 3.7% TSH in the control echography 6–7 years after surgery, all of them in the epigastric trocar. Conclusions The incidence of TSH after bariatric surgery with 12mm bladeless trocars is low considering patient´s characteristics. All the THS were in the midline port, which raises the possibility of systematic closure, change its position or contemplate this low incidence as acceptable considering its difficulty of closing.

Retaining the epigastric trocar, until rest all ports closed decreases post-operative shoulder pain in laparoscopic cholecystectomy patients

Background: Laparoscopic cholecystectomy has become the mainstay of treatment for gallstone disease cases due to its lower morbidity and pain compared to open techniques. Unfortunately, the use of carbon dioxide to insufflate the abdomen is the main contributor to post-operative shoulder pain. Aims and Objectives: The aim of the study was to evaluate the effectiveness of retaining the epigastric port trocar in position until rest all ports closed after completion of lap cholecystectomy in decreasing the post-operative shoulder pain. Materials and Methods: A prospective, randomized, and clinical trial was done in AIIMS hospital, Bhubaneswar, on 102 patients who have undergone laparoscopic cholecystectomy. The patients were alternatively selected, one in the study group (52) and the other in the control group (50). For those patients in the study group, after the completion of the surgery, the epigastric port trocar is retained in position until the rest of all ports were closed. In the control group, all trocars were removed and port closure was done. The patients were evaluated for the next 24 h for post-operative shoulder pain. A numerical rating scale (NRS) was used to assess shoulder pain on patient arrival to the ward, at 4, 6, 12, and 24 h postoperatively. One hundred and two patients were included in the final data analysis. Results: NRS pain scores were significantly lower in the study group at 6, 12, and 24 h post-laparoscopic cholecystectomy compared to the control group with no additional requirement of IV analgesics. Conclusion: Retaining the epigastric trocar in position is an easy way that is beneficial in reducing post-operative shoulder pain post laparoscopic cholecystectomy surgery.

Impact of Routine 12mm Epigastric Trocar Site Closure on Incisional Hernia After Sleeve Gastrectomy: a Prospective Before/After Study.

Recent studies have reported trocar site hernia (TSH) rates after bariatric surgery ranging from 0 to 45.2% based on imaging assessment. The objective of this study was to evaluate the TSH rate after sleeve gastrectomy (SG) comprising routine 12mm epigastric trocar site closure (TSC). Prospective observational study with retrospective control cohort of a group of patients undergoing primary SG with routine 12mm epigastric TSC. The "before" group (control group) was a previously published group of patients without 12mm epigastric TSC and the "after" group (closure group) concerned patients with routine 12mm epigastric TSC. Primary endpoint was the TSH rate after routine epigastric TSC. Secondary endpoints were comparison of the TSH rate, TSC feasibility and causes of failure, TSC-related morbidity, evaluation of TSC time and its course, and identification of risk factors for TSH. One hundred twenty-three patients were analyzed during the study period. Feasibility of epigastric TSC was 97.3% without related morbidity. Mean epigastric TSC time was 44.2s (18-150). Epigastric TSC time was always less than 60s after 10-15 procedures. At 1year, 10 patients presented TSH (8.1%): epigastric in 6.5% (n = 8) cases and after open laparoscopy in 1.6% (n = 2) cases. Comparison of the two groups revealed a lower TSH rate in the closure group (8.1% vs. 17.0%; p = 0.02), due to a lower epigastric TSH rate (6.5% vs. 14.8%; p = 0.02). Routine epigastric TSC was a protective factor for TSH (p = 0.03; relative risk of 0.43). Routine epigastric TSC during SG is rapid and provides effective prevention of TSH.

Trocar site hernia after laparoscopic sleeve gastrectomy using a specific open laparoscopy technique

BackgroundObesity is recognized as a risk factor for trocar site hernia (TSH) after laparoscopic surgery. Some recent studies have reported a TSH rate after bariatric surgery ranging from 0% to 1.6% using clinical evaluation and may underestimate the TSH rate. The objective of this study was to evaluate the TSH rate after sleeve gastrectomy (SG) by abdominal computed tomography (CT) scan. MethodsA retrospective review of all patients who underwent first-line SG and abdominal CT scan between March 2004 and February 2014 was performed. The primary endpoint was the incidence of TSH. Secondary endpoints were the site of TSH, the TSH rate with open laparoscopy using the authors’ technique, and risk factors for TSH after SG. ResultsDuring the period study, 1108 patients underwent first-line SG, including 10 cases of conversion to laparotomy (excluded from the present analysis). Of the remaining patients, 228 had abdominal CT scan (20.7%), with a mean age of 45.1 years (18–68 yr) and a mean BMI of 47.6 kg/m2 (33–75.4 kg/m2). The median time interval between SG and CT scan was 27 months (3–92 mo). CT scan revealed 44 TSH in 43 patients (18.8%). The site of the TSH was epigastric (16.6%), open laparoscopy (1.7%), right subcostal margin (0.8%), with no TSH in the left subcostal margin. In patients with>1 year of follow-up, the TSH rate was 19.7%. ConclusionThe TSH rate after bariatric surgery is underestimated. The authors’ open laparoscopy technique is a reliable technique with a low TSH rate. In the light of these results, the epigastric trocar site is systematically closed at the end of SG.

Blend mode reduces unintended thermal injury by laparoscopic monopolar instruments: a randomized controlled trial

The purpose of this study was to compare histologic evidence of thermal injury at the epigastric and umbilical incisions after elective laparoscopic cholecystectomy performed using the monopolar "Bovie" instrument set on the higher voltage coag mode versus the lower voltage blend mode. We hypothesized that the higher voltage coag mode would create more unintended thermal tissue injury at the epigastric trocar's incision. A prospective blinded randomized controlled trial of patients undergoing elective laparoscopic cholecystectomy was performed. Patients were randomized to have their operation performed with the monopolar instrument set at 30 W on either the coag mode or the blend mode. Immediately at the end of the operation, a biopsy sample of skin was obtained from the lower edge of the epigastric incision (through which the monopolar instrument was inserted) and the umbilical incision (through which the camera/telescope was inserted). The outcomes measured were histologic evidence of thermal injury at the epigastric and umbilical incisions (determined by a blinded pathologist). Forty patients were randomized (20 per group). Baseline demographics in the two groups were similar for age, gender, body mass index, preoperative diagnosis, operative time, and blood loss. Unintentional thermal injury was found at 20 % of epigastric incisions and 35 % of umbilical incisions in the total group. The incidence of thermal injury was higher after operations using the coag mode compared to the blend mode at both the epigastric (35 vs. 5 %; p = 0.044) and umbilical (55 vs. 15 %; p = 0.019) trocar incisions. Radiofrequency energy from the monopolar Bovie instrument causes unintentional thermal injury to skin adjacent to the epigastric and umbilical trocar incisions. The incidence of thermal injury was reduced by using the lower voltage blend mode compared to the coag mode at both the epigastric and umbilical trocar incisions. NCT016648060 ( www.clinicaltrials.gov ).

Differences Between Attendings’ and Residents’ Operative Notes for Laparoscopic Cholecystectomy

Operative notes are the gold standard for detecting adverse events and near misses and form the basis for scientific research. In order to guarantee safe patient care, operative notes must be objective, complete, and accurate. This study explores the current routine of note writing for laparoscopic cholecystectomy (LC) and the differences between the notes of attendings and residents. Attendings and residents were sent a DVD with footage of three LCs and were asked to "write" the corresponding notes and to complete a questionnaire. Dictation tapes were transcribed and items in the notes were analyzed for each procedure ("item described" or "item not described"). Fisher's exact tests were performed using SPSS 16.0 for Mac. Thirteen sets of typewritten notes and 10 dictation tapes were returned. The results of the questionnaire showed that 16 of the 23 sets of notes were dictated. Eight participants found the current system for generating notes inadequate. 14 items (31 %) were included more often in the attendings' notes and 25 items (56 %) were included more often in the residents' notes. Overall, residents significantly more often described the location of the epigastric trocar (P = 0.018), the size of both working trocars (P = 0.019), the opening of the peritoneal envelope (P = 0.002), Critical View of Safety reached (P = 0.002), and the location for removing the gallbladder (P = 0.019). With the exception of "gallbladder perforation" (20 of 21 notes), complications were underreported. In this study residents described more items than attendings. All notes lacked information concerning complications in the procedure, which makes the notes subjective and incomplete. A procedure-specific template or black-box-based operative notes based on established guidelines could improve the quality of the notes of both attendings and residents.

Intraabdominal Laparoscopy-Assisted “Open” Vessel Ligation of Testicular Vessels: A Potential Treatment for Varicocele

We tested our laparoscopy-assisted "open" ligation (LOL) technique on testicular vessels. We ligated the left testicular artery and vein (TAV) in 8-week-old male Wister rats using LOL (LOL group; n=10) or laparotomy (open group; n=10). In LOL, a 0-degree laparoscope was introduced through a 5-mm epigastric trocar. A 3-mm grasper was used to expose the left TAV. A lapa-her-closure (LHC) needle loaded with 3-0 SurgiPro was directly inserted into the left lower quadrant where the left TAV should be and advanced under the vessels, and the suture material was released leaving one end outside. The LHC was then withdrawn a little and advanced again over the vessels to grasp the end of the suture material just released to bring it outside. This was proximally repeated. The two ends of both sutures were conventionally tied outside, and the knot was passed through the insertion site and tightened around the vessels. In the open group, the left TAV were ligated using two 3-0 SurgiPro ties. In both groups, the right side was left intact. All rats were sacrificed 2 weeks postoperatively, and both testes were examined with hematoxylin and eosin. Treatment time was 5-7 minutes for LOL and 7-8 minutes for the open group. Postoperative recovery was uneventful. No adhesions were present between the ligated vessels and bowel in any rat. Histopathology of all left testes showed coagulative necrosis of germinal cells and seminiferous tubules; all right testes were normal. LOL appears to be as effective as open ligation and may find application for treating varicocele.

Laparoscopic appendectomy at 34 weeks of gestation

ABSTRACTObjective To present a case of laproscopic appendectomy in a pregnant woman at 34 weeks of gestation. Using an open Hasson technique for the epigastric trocar, combined with low‐pressure pneumoperitoneum and two trocars in the right and left upper quadrants as the working channels, appendectomy was performed safely and effectively. The procedure was well tolerated with favourable maternal and perinatal outcomes.Conclusion The open laparoscopy technique seems to be a safe option for accessing the abdominal cavity to perform an appendectomy late in pregnancy.

7107 Clinical significance of hepatocyte growth factor and portal blood flow as a parameter of hepatic function following cO2pneumoperitoneum in cirrhotic patients.

Background: Laparoscopic surgery under carbon dioxide (CO2) pneumoperitoneum has many benefits. However, little is known concerning the risks of CO2pneumoperitoneum for the patients with liver cirrhosis. Influence of CO2pneumoperitoneum for the cirrhotic patients was investigated by assessing hemodynamics of portal vein and change of cytokine. Material & Methods: Participants were cholelithiasis patients divided into two groups: Group I (with liver cirrhosis: LC, n=12), and Group II (without liver cirrhosis: Control, n=12). The cross section area of the portal vein trunk (S) and the velocity of the portal blood (V) were measured using a laparoscopic pulsed Doppler ultrasonic probe (Aloka Ind., Ltd., Tokyo, Japan) inserted through the epigastric trocar when the abdomen was insufflated to an intra-abdominal pressure (IAP) of 4mmHg to 15 mm Hg preoperatively. The mean portal blood flow Φ at each IAP was calculated from the measured variables of S and V. In addition, plasma level of hepatocyte growth factor (HGF), interleukin (IL)-6, IL-8, tumor necrosis factor (TNF) were measured during CO2pneumopeitoneum. Total bilirubin (Tbil), AST, ALT were measured at postoperative day 1(1POD). Results: Laparoscopic cholecystectomy was performed successfully without any complications in all cases. With increases in IAP, S and V value were significantly decreased only in the LC group. F value was also significantly decreased with elevation of IAP in the LC group. No significant differences in changes of IL-6, IL-8 and TNF value during the preoperative CO2pneumopeitoneum were found in both group, but only HGF showed significant differences in changes of IAP in LC group. HGF and F value in IAP of 15mmHg showed significant correlations with AST and ALT at 1POD. Conclusions: On the basis of these results, HGF and F value were considered to be a good indicator for evaluation of liver function and CO2pneumopeitoneum during laparoscopic surgery would be a deteriorating factor for the patients with liver cirrhosis.