Initial Trocar Placement Research Articles

Comparison of two methods of laparoscopic trocar insertion (Hasson and Visiport) in terms of speed and complication in urologic surgery.

Background: Nowadays, diverse approaches have been existed for laparoscopic procedures. The most common laparoscopic entry methods included close and direct entry laparoscopy and open (Hasson) laparoscopy. There is no evidence regarding the superiority in safety and initial speed for the use of open and optical laparoscopic entry. Therefore, the sight of current study was to evaluate comparative survey of two methods of laparoscopic trocar insertion (Hasson and VisiportTM) in terms of speed and complications in urologic surgery.Methods: This expertized base clinical trial study was conducted on 100 patients who underwent urological laparoscopy in Alzahra Hospital, Isfahan, Iran. These patients were randomly divided to two groups (n = 50). One group underwent open laparoscopy and another group Visiport optical trocar. Speed and Complications of urologic surgery was extracted from medical records. Independent T test was used for doing of analysis.Results: The mean age of patients in Hasson and Visiport laparoscopic group was 41.4 ± 11.2 and 41.6 ± 15 years old, respectively (p = 0.91). The mean time for initial trocar placement in patients who underwent Visiport trocar system and Hasson laparoscopic technique was 37.7 ± 15.59 and 95.4 ± 31.75 seconds. There was gratifying difference between two techniques of laparoscopic trocar insertion (Hasson and Visiport) in terms of speed (p = 0.000). In addition, complications were observed in 8% of patients who underwent Visiport trocar system. However, no complications were observed in Hasson laparoscopy group.Conclusion: Visiport optical trocar technique is faster for initial trocar placement than open laparoscopy. However it is associated with complications compared to open laparoscopy. Therefore, there is evidence of benefit in terms of speed for initial trocar placement and harm based on complications in Visiport trocar system.

Direct Trocar Insertion with Elevation of the Rectus Sheath in Bariatric Surgery: A Novel Technique.

Initial trocar entry, the first step in laparoscopic surgery, is associated with several complications. In morbidly obese patients, initial trocar placement is associated with a greater number of complications compared to non-obese patients. Materials and Surgical Technique. In this study, we describe our use of an initial trocar entry technique which is direct trocar insertion with elevation of the rectus sheath by a single Backhaus towel clamp and we would like to evaluate the sa fety and efficacy of its administration in bariatric surgery. Our results indicate that gaining initial trocar entry using our technique leads to successful laparoscopic bariatric surgery. Our technique is a safe, effective, and reliable first step in successful laparoscopic surgery for almost all patients, and is only contraindicated in patients with severe hepatomegaly.

Survival and Operative Outcome Analysis of Robotic Assisted Versus Laparoscopic Surgical Staging for Endometrial Cancer

and a blade that is driven by a micrometer cuts trigger, watching all the planes to reach the abdominal cavity as the going through., for what can prevent intra-abdominal injury elements. Being an abdominal approach system safe, reliable, reproducible and easy to perform, allowing effective and rapid initial trocar placement and reducing the complications of closed approach, how to prevent subcutaneous emphysema, among others.

腹腔鏡下手術トロッカー挿入法に関するバーチャルリアリティ・シミュレーション訓練システム

In this paper, we show development of virtual reality training system of the optical access in initial trocar placement for laparoscopic surgery. We measured the trocar inserting motion data including trocar position, vertical force, and rotational torque in the actual operations. and then we designed force feedback device which combined with image display system.

Robotic partial nephrectomy in the setting of prior abdominal surgery

• To evaluate our experience with robotic partial nephrectomy in patients with previous abdominal surgery and evaluate the effect of previous abdominal surgery on perioperative outcomes. We also describe a technique for intraperitoneal access for patients with prior abdominal surgery utilizing the 8 mm robotic camera for direct-vision trocar placement. • From a prospective cohort of 197 consecutive patients who underwent robotic renal surgery at a single academic institution, a total of 95 patients underwent transperitoneal robotic partial nephrectomy (RPN). • Patients with and without previous abdominal surgery were compared. Patients with prior abdominal surgery were subcategorized into two groups: upper midline or ipsilateral upper quadrant scar or lower abdominal, contralateral, or minimally-invasive scar. • Demographic and perioperative variables were compared between the surgery and no surgery groups. Access was obtained using a Veress needle or Hassan technique. • We utilized a technique of direct vision placement of the initial trocar on our 10 most recent cases, using an 8 mm robotic camera placed through the obturator of 12 mm clear-tipped trocar. • Lysis of adhesions was performed as needed to allow for placement of additional robotic ports. • A total of 95 patients underwent transperitoneal RPN, of which 41 (43%) had a history of prior abdominal surgery and six had upper midline or ipsilateral upper quadrant scars. • There were no statistically significant differences between patients with previous abdominal surgery and patients with no previous abdominal surgery in BMI (30.4 vs 29.4 kg/m(2) ), median tumor size (2.5 cm vs 2.3), median total operative time (246 vs 250 min), median warm ischemia time (21 vs 16 min), median EBL (150 vs100 ml), clinical stage, transfusion rate, or complications. • A total of six patients underwent 7 previous upper midline or ipsilateral upper quadrant surgeries, including open cholecystectomy-2 patients (33%), open partial gastrectomy-2 patients (33%) and exploratory laparotomy-1 patient (17%). • Complications in this group were an enterotomy during lysis of adhesions that was repaired robotically without sequelae and a mesenteric hematoma during Veress needle placement. A total of 35 patients underwent 16 other prior abdominal surgeries, including abdominal hysterectomy-10 patients (29%), umbilical/inguinal hernia repair-9 patients (26%) and appendectomy-7 patients (20%). There were no access related injuries in the 10 cases in which the robotic 8 mm camera was used for initial trocar placement. • Transperitoneal robotic partial nephrectomy is feasible in the setting of prior abdominal surgery. The majority of these patients can have their procedure performed safely without an increase in complications. • Direct-vision intraperitoneal placement of initial trocar may be achieved by using an 8 mm robotic camera, without the need to switch between conventional and robotic cameras.

Design of a mechanical clutch-based needle-insertion device

Insertion of trocars, needles, and catheters into unintended tissues or tissue compartments results in hundreds of thousands of complications annually. Current methods for blood vessel cannulation or epidural, chest tube, and initial trocar placement often involve the blind pass of a needle through several layers of tissue and generally rely on distinguishable anatomic landmarks and a high degree of clinical skill. To address this simply and without the use of electronics, a purely mechanical clutch system was developed for use in medical devices that access tissue and tissue compartments. This clutch utilizes the surface contact of a buckled filament inside an S-shaped tube to transmit force from the filament (catheter/guide wire) to the tube (needle). Upon encountering sufficient resistance at the tip, such as dense tissue, the catheter buckles and locks within the tube, causing the filament and needle to advance as one. When the needle reaches the target tissue or fluid-filled cavity, the filament unlocks and slides freely into the target region while the needle remains stationary. A similar locking phenomenon has long been observed in drill strings inside drill shafts used by the oil-drilling industry, and oil industry models were adapted to describe the motion of this clutch system. A predictive analytical model was generated and validated with empirical data and used to develop prototypes of a complete device then tested in vitro on muscle tissue and in vivo on a porcine laparoscopic model with promising results.

Creation of Pneumoperitoneum Using a Bladed Optical Trocar in Morbidly Obese Patients: Technique and Results

It is advised by the manufacturer that the bladed optical trocar is to be applied only after CO(2) insufflation. However, after a long experience with bladed optical trocars after CO(2) insufflation in bariatric patients, we found that it is possible to enter the abdomen with this trocar prior to insufflation. This investigation was performed to test the hypothesis that this bladed technique under direct visualization before abdominal insufflation is a safe and effective method for initial trocar placement for laparoscopic bariatric procedures. Data on a series of 200 consecutive laparoscopic bariatric procedures with bladed optical access trocar were reviewed. The entry time for the optical trocar was measured in 70 patients. All the operative reports were reviewed for the following data: (1) successful initial trocar placement, (2) vascular injury during initial trocar placement, and (3) hollow viscus injury accessing the peritoneal cavity with bladed trocar. The trocar placement time was defined as the time to place the trocar into the peritoneal cavity after skin incision and was recorded in the last 70 cases. There was no evidence of any vascular injury during initial trocar placement. There was no evidence of hollow viscus or organ injury during initial trocar placement. The insertion of the initial trocar was successful in all the patients. The average trocar insertion time was 20 s (range 10-50), and BMI did not affect the time of insertion. We think that our technique of entering the abdominal cavity via a bladed optical trocar without prior abdominal insufflation can be performed safely in morbidly obese patients. More studies and larger series are needed to validate this method.

Initial Trocar Placement and Abdominal Insufflation in Laparoscopic Bariatric Surgery

Initial trocar placement and abdominal insufflation in laparoscopic bariatric surgery can be challenging for the novice. One technique is the use of an optical viewing trocar without prior abdominal insufflation. This investigation tests the hypothesis that this technique can be taught to novice surgeons with good results. Patients undergoing laparoscopic bariatric surgery were included. Novice surgeons (residents/fellows) with 0-50 initial trocar placements placed the initial trocar and insufflated the abdomen in the presence of an expert surgeon (>300 initial trocar placements in morbidly obese patients). Trocar placement time was defined as the time to place the trocar into the peritoneal cavity (including infiltration of local anesthesia and incision). Insufflation time was defined as the time to insufflate the abdomen to a pressure of 10 to 15 mm Hg (including time to place tubing on trocar). Novice times were compared with expert times. There were 81 patients (56 by expert and 25 by novice) in this study. No bowel or vessel injury during initial trocar placement was noted. No correlation was seen between times and BMI or waist/hip circumference (P = NS). Mean expert trocar placement time was shorter than the mean novice time (25 +/- 9 versus 54 +/- 27 s; P < 0.0001); although there was no difference in mean insufflation time (expert versus novice: 16 +/- 5 versus 19 +/- 10; P = NS). The mean total time to place the initial trocar and insufflate the abdomen for the novices was 72 +/- 26 s. Initial trocar placement can be taught safely to novices. The technique using an optical viewing trocar without prior abdominal insufflation is effective and efficient in morbidly obese patients.

P-182A A new technique of laparoscopic initial trocar placement through a center of the umbilicus(Laparoscopic surgery, the 44th Annual Meeting of Japanese Society of Pediatric Surgeons)

P-182A A new technique of laparoscopic initial trocar placement through a center of the umbilicus(Laparoscopic surgery, the 44th Annual Meeting of Japanese Society of Pediatric Surgeons)

Robotic-assisted laparoscopic prostatectomy in obese patients: The Columbia University experience

14619 Background: In addition to being more likely to be found with more aggressive prostate cancer (PCa), obese patients (OPs) face challenges with treatment options for localized PCa. Several studies have shown that open radical retropubic prostatectomy, pure laparoscopic, and robotic-assisted laparoscopic prostatectomy (RALP) may be associated with increased operative times, blood loss, and even a higher rate of capsular incision. We examined our own experience with the surgical and pathologic outcomes of OPs undergoing transperitoneal RALP at our institution. Methods: We queried the Columbia University IRB approved database for transperitoneal RALPs performed by a single fellowship trained laparoscopic oncologist (DS) for which body mass index (BMI) data was available. We identified patients who met the CDC definition of obese (BMI &gt; or = 30 kg/m2) at the time of surgery. We compared surgical and pathologic outcomes between these OPs and NOPs. Of note, operative time was defined as the time from initial trocar placement to skin closure, and does not include robotic set-up time. Results: BMI data was available for 78% of RALP patients in the database. We identified 22 OPs (mean BMI 32.7 (30.1 to 46.7)) and 112 NOPs (mean BMI 25.6). One patient in each group was converted to open. There were no statistically significant differences in the surgical outcomes of mean blood loss, operative time or length of stay for the OPs vs. NOPs (179cc v. 191cc, 213min v. 221min, and 1.4d vs. 1.7d, respectively). There was no significant difference in preoperative PSA, pre-treatment MSKCC 5yr progression-free probability, pre or post-operative Gleason sum, margin status, or perioperative complications. There was a trend towards increased prostatic volume in OPs vs NOPs (51cc vs 44cc, p = 0.10). Conclusions: Unlike a prior robotic, pure laparoscopic and ORRP series, OPs who received transperitoneal RALP at our institution had no statistically significant increases in blood loss, operative time or perioperative complications when compared to their non-obese cohorts. We believe RALPs may be safely recommended to OPs as an option for treatment of localized prostate cancer. No significant financial relationships to disclose.

Safety and Efficacy of Initial Trocar Placement in Morbidly Obese Patients

The use of a nonbladed trocar with an optical view is a safe and effective method for initial trocar placement for laparoscopic bariatric surgery. Retrospective review of consecutive patients. University-associated hospital. All patients who underwent laparoscopic bariatric surgery from December 2002 to November 2003. Initial trocar placement. Injury and bleeding during initial trocar placement, trocar placement time, and insufflation time. Trocar placement time was defined as the time to place the trocar into the peritoneal cavity (including infiltration of local anesthesia and incision). Insufflation time was defined as time to insufflate the abdomen to a pressure of 10 to 15 mm Hg (including time to place tubing on trocar). There were 228 patients who had no evidence of any bowel or vessel injury during initial trocar placement. In the last 50 patients, average body mass index (calculated as weight in kilograms divided by the square of height in meters) was 47 (range, 35-63). Average trocar placement time was 25 seconds (range, 10-60 seconds), and average insufflation time was 16 seconds (range, 5-25 seconds). In almost all cases, appropriate pneumoperitoneum was established in less than a minute. No correlation was seen between times and body mass index (trocar, P = .56; insufflation, P = .95) or waist-hip circumference (trocar, P = .74; insufflation, P=.48). Initial trocar placement using a nonbladed trocar with an optical view without prior abdominal insufflation is safe and effective in morbidly obese patients. This method can be applied even in the super obese.

Optical Access Trocar Injuries in Urological Laparoscopic Surgery

Inadvertent injuries during trocar and Veress needle placement are a rare but potentially serious complication of laparoscopic surgery. An access alternative is an optical trocar under direct vision. Limited data are available regarding the safety of this technique. We reviewed complications related to optical access trocars during standard transperitoneal urological laparoscopic procedures performed at a single institution. From 1995 to 2001 the optical access trocar was used as the initial trocar in 1,283 urological laparoscopic procedures. The procedures included simple and radical nephrectomy in 309 cases, donor nephrectomy in 386, partial nephrectomy in 79, pyeloplasty in 173 and various other procedures in 336. Intra-abdominal complications caused by optical access trocar were assessed. The optical trocar was inserted at the umbilicus in 88 patients (7.4%), in the right upper quadrant in 445 (34.7%) and in the left upper quadrant in 750 (58.5%). There were 4 injuries (0.31%) associated with the optical access trocar. Complications occurred on the left side in 3 cases and on the right side in 1, including 1 injury to bowel, 1 mesenteric injury resulting in a retroperitoneal hematoma and 2 injuries to epigastric vessels. Three cases were recognized and repaired immediately but in a case of epigastric vessel injury the expanding abdominal wall hematoma required postoperative repair. Optical access trocars provide a safe and rapid technique for initial trocar placement. Results of this large series support the finding that few trocar related complications are associated with the optical access trocar.

Use of the optical access trocar for safe and rapid entry in various laparoscopic procedures.

The use of the Veress needle in laparoscopy to create the pneumoperitoneum has inherent risks; it may cause vascular and visceral injuries. The open technique is compromised by the leakage of carbon dioxide and can also be time consuming. One alternative is to enter the abdomen using an optical trocar under direct view. Our aim was to determine whether the optical access trocar can be used to effect a safe and rapid entry in various laparoscopic procedures. Over a 4-year period, the Optiview trocar was used for initial entry in 650 laparoscopic procedures. The procedures included cholecystectomy (n = 282), transabdominal inguinal hernia repair (n = 76), radiofrequency ablation of liver tumors (n = 73), adrenalectomy (n = 54), appendectomy (n = 41), colorectal surgery (n = 39), and various other procedures (n = 85). The following parameters were analyzed: presence of previous abdominal operations, site and duration of entry, and complications. Of the 650 patients, 156 (24%) had had previous abdominal operations. In 25 cases, previous trocar sites were reused for optical access. The optical trocar was inserted at the umbilicus in 495 patients (76%), in the right upper quadrant in 77 (12%), in the left upper quadrant in 26 (4%), in the upper midline in eight (1%), in the right lower quadrant in six (0.9%), and in the left lower quadrant in three (0.5%). In 35 patients undergoing posterior adrenalectomy, optical trocars were used to enter Gerota's space. Mean (SD) entry times were 92 (45) sec at the umbilical site, 114 (30) sec at the back, and 77 (35) sec at the remaining sites. Complications (0.3%) included one injury to the bowel and one injury to the gallbladder; however, they were recognized and repaired immediately. To our knowledge, this report comprises the largest series in which the optical access trocar was used for laparoscopic surgery. This device provides the basis for a safe and fast technique for initial trocar placement: it also has the potential to reduce costs. Thanks to our favorable experience, the optical trocar method has become the standard technique for abdominal access in our laparoscopic practice since 1995.

The spinal needle test for estimating the thickness of the umbilicus at laparoscopy

Purpose: Originally described by Semm in 1987, the spinal needle test can be used to estimate the thickness of the umbilicus following insufflation and before initial trocar placement at laparoscopy. The purpose of this study was to correlate umbilical thickness with body mass index (BMI) and weight. Methods: Patients enrolled presented for diagnostic and operative laparoscopy. The spinal needle test was performed following carbon dioxide insufflation by inserting a spinal needle attached to a saline-filled syringe perpendicular to the skin and advancing the needle until the gas pocket was identified. The umbilical thickness was then measured and recorded on three occasions. Data were compared using Pearson correlation and Student t test. Results: Of the 85 women in the study group, 50 (59%) were nulliparous, 33 (39%) had undergone previous laparoscopy, and 19 (22%) had undergone previous laparotomy. The mean age of the total group was 37.5 years (range 15 to 61), with a mean body weight of 157 lb (94 to 360) and an umbilical thickness of 2.0 cm (0.5 to 6.3). The average BMI was 26.6 (17.5 to 60) with 17 (20%) considered clinically obese as defined by a BMI of 30 or more. A significant correlation was noted between umbilical thickness and weight ( R = 0.73, P <0.01) as well as umbilical thickness and BMI ( R = 0.69, P <0.01). The mean umbilical thickness significantly differed between obese (3.1 + 0.3 cm) and nonobese (1.7 + 0.1 cm) groups ( P = 0.001). Conclusion: Not surprisingly, the thickness of the umbilicus correlates well with weight and BMI. However, even in obese patients the mean umbilical thickness was only 3 cm, and in nonobese patients it was 1.7 cm.

Transumbilical direct trocar entry for operative videolaparoscopy

Objectives: Complications associated with initial abdominal entry are a prime concern for laparoscopic surgeons. We describe our technique of transumbilical direct trocar entry and evaluate the effectiveness and safety of this approach to primary trocar entry based on over 5 years’ experience.Study design: Complications were reviewed by retrospective consecutive review of charts of patients who underwent operative laparoscopy.Methods: Between September 1993 and January 1999, 1,027 patients underwent 2,251 operative laparoscopic procedures at Stanford University Medical Center, a tertiary care facility. Nine-hundred-eighteen patients underwent transumbilical direct trocar entry. One hundred and nine patients considered to be at high risk for intraabdominal adhesions underwent initial pneumoperitoneum using Veress needle prior to initial trocar placement. Laser treatment of endometriosis, adhesiolysis, and myomectomy (laparoscopic and laparoscopic-assisted) represented 1,543 (68.5%) of the procedures performed.Results: Complication rates associated with primary trocar placement were evaluated. No major complications were observed. Two of 918 patients who underwent transumbilical direct trocar placement experienced umbilical infections.Conclusion: Transumbilical direct trocar placement is a safe and effective method of primary trocar entry.

Transumbilical direct trocar entry for operative videolaparoscopy

Abstract Objectives: Complications associated with initial abdominal entry are a prime concern for laparoscopic surgeons. We describe our technique of transumbilical direct trocar entry and evaluate the effectiveness and safety of this approach to primary trocar entry based on over 5 years’ experience. Study design: Complications were reviewed by retrospective consecutive review of charts of patients who underwent operative laparoscopy. Methods: Between September 1993 and January 1999, 1,027 patients underwent 2,251 operative laparoscopic procedures at Stanford University Medical Center, a tertiary care facility. Nine-hundred-eighteen patients underwent transumbilical direct trocar entry. One hundred and nine patients considered to be at high risk for intraabdominal adhesions underwent initial pneumoperitoneum using Veress needle prior to initial trocar placement. Laser treatment of endometriosis, adhesiolysis, and myomectomy (laparoscopic and laparoscopic-assisted) represented 1,543 (68.5%) of the procedures performed. Results: Complication rates associated with primary trocar placement were evaluated. No major complications were observed. Two of 918 patients who underwent transumbilical direct trocar placement experienced umbilical infections. Conclusion: Transumbilical direct trocar placement is a safe and effective method of primary trocar entry.