To the Editor, We read with interest the article by Dauser et al. describing the use of a peripheral venous catheter placed intraperitoneally to evacuate smoke during single-incision laparoscopic surgery (SILS) [1]. The proliferation of SILS has posed new challenges in the steps that surgeons take for granted during multiport laparoscopic surgery, and efficient evacuation of smoke to provide a clear view of the operative field is one of them. Many of the special access ports designed for SILS lack a dedicated smoke extraction channel. The problem becomes even more challenging when performing SILS using the ‘‘single-skin-incision, multi-trocar’’ approach. Most plastic, low-profile trocars used in this approach have a rubber cap with a membrane valve provided to maintain the pneumoperitoneum, but these trocars make evacuation of the smoke rather cumbersome. Even when using some of the low-profile trocars that have a built-in gas port on the side, smoke does not escape easily once a 5-mm instrument is introduced through it. Also, repeated opening of the cap covering the gas port by an assistant to release smoke may hinder the surgeon using an operative instrument through the trocar. We have used two methods for evacuation of smoke during SILS. The most common SILS procedure we undertake is cholecystectomy and it is performed without any special access ports or roticulating instruments. We use two trocars (one metal, 10 mm, and another low-profile, 5 mm) placed through separate fascial incisions along with two traction sutures on the gallbladder [2]. After using plastic low-profile trocars in several initial cases, we have now shifted to a 5-mm, low-profile, rigid metal trocar designed for thoracoscopic surgery (Karl Storz, Tuttlingen, Germany). As this trocar has a cap without a membrane valve, smoke can be evacuated easily by intermittently removing the operative instrument or during exchange of instruments. Moreover, use of this reusable, easy-to-clean, and easy-to-sterilize trocar makes SILS cost-effective. However, a drawback of using this method is the need to interrupt the operation momentarily for evacuation of smoke. Intraperitoneal placement of a Veress needle to vent the pneumoperitoneum that occurs accidentally during a totally extraperitoneal inguinal hernia repair is well described. Based on the same principle, we insert a Veress needle through the fascia alongside the trocars in all SILS procedures (Fig. 1). The camera person or nurse opens the valve on the Veress needle intermittently to release the smoke without interrupting the operation or disturbing the surgeon. We find that using a Veress needle in this manner is advantageous as it is readily available, its long length allows it to be used in patients of all body habitus, and the rigid metal channel does not collapse when gripped by a thick abdominal wall (as is sometimes likely when a peripheral venous catheter is used). As a Veress needle is guarded by a blunt obturator, there is no danger of visceral injury when using this method, even though the tip of the needle is not in constant view of the endocamera.
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