Secondary Trocars Research Articles

Investigating the effects of drainage by hemovac drain on shoulder pain after female laparoscopic surgery and comparison with deep breathing technique: a randomized clinical trial study.

The incidence of shoulder pain following laparoscopic surgery has been reported to be high. This study was designed to investigate the effect of Hemovac drain on postoperative pain of women after laparoscopic surgery, dose of postoperative drug, duration of hospitalization as well as comparison with deep breathing technique. In this clinical trial, one hundred and fourteen female patients treated by laparoscopy were randomly assigned to three groups of 38 patients. In our study group, the Hemovac drain was implemented from the secondary trocar site with a closed system. In the deep breathing group, the patient was asked to breathe slowly and deeply three time per hour at full vigilance after surgery. In the non-drain group, laparoscopic surgery was done routinely. The severity of abdominal and shoulder pain was measured with a visual scale of pain at 3, 6, 12, and 24h after surgery. There were no significant differences in age, type of surgery, duration of hospitalization, postoperative nausea and vomiting between the groups after surgery. The severity of shoulder pain was significant between groups 3, 6, 12, and 24h after surgery (p < 0.001). Consumption of diclofenac after operation was higher in the control group (p < 0.001). The pain level of laparoscopic surgery was not different between the three groups within the first 24h after surgery (p = 0.841). The use of Hemovac drain in female laparoscopic surgery is beneficial for reducing the subsequent shoulder pain. Further studies are recommended to investigate the effects of deep breathing as a non-pharmacological and safe method in other laparoscopic areas.

Using the internal inguinal ring as a landmark for the safe placement of secondary trocars at laparoscopy

Aim Avoidance of injury to the epigastric vessels is an important safety consideration in siting secondary ports at laparoscopy. We evaluated trans-illumination, direct visualization of vessels and using the internal inguinal ring, which has a constant relationship with the inferior epigastric vessels as an anatomical landmark to locate these vessels. Methods Ninety consecutive women undergoing laparoscopy were recruited for the study. The Ability to trans-illuminate the superficial and inferior epigastric vessels, to visualize inferior epigastric vessels and to locate the round ligament entering the internal inguinal ring were documented. The body mass index (BMI) was noted. The association of the body mass index (BMI) with these variables was calculated by simple regression analysis. Results Ability to visualize the internal inguinal ring was significantly higher than that of locating the superficial or inferior epigastric vessels by trans -illumination or by directvisualization. p Ability to visualize and to trans -lluminatethe inferior epigastric vessels decreased with increasing BMI (p Conclusion Locating the deep inguinal ring and using it as an anatomical landmark and placing the lateral trocars lateral to a saggital line originating from the internal ring is a reliable and useful method in preventing unintended injury to anterior abdominal wall vessels during secondary trocar placement

Evaluación de tres diferentes posiciones de los puertos de entrada para la funduplicatura de Nissen laparoscópica en conejos

Introduction: Paediatric laparoscopic surgery provides new challenges for surgeons; therefore there is a need for adequate training before performing procedures directly on patients. Several different models were designed for training, including both virtual simulators and live animals. However, training with animal models is the most appropriate method for surgical instruction, as it reproduces similar surgical conditions. The objective of this study was to establish the best localization of surgical ports for Nissen fundoplication in rabbit cadavers for both experimental and teaching purposes. Method: The research was conducted using six New Zealand white rabbit cadavers. The location of the trocars was established by two veterinary and one paediatric with experience in laparoscopy surgery. The model was evaluated by four paediatric surgeons. A 5 mm trocar was used, and a laparoscope of 5 mm and 30° attached to a microcamera was inserted. The abdomen was insufflated (to a pressure of 6-8 mm Hg). The placement of secondary trocars was conducted with direct visualization. Diverse factors were considered to establish the location of the trocars such the anatomy of the rabbit stomach and esophagus, laparoscopic Nissen fundoplication performed in rabbits with conventional laparoscopic instruments, and the length of paediatric laparoscopic instruments. Three approaches were repeated in order to locate a satisfactory view of the surgical area. Every position of the ports received a score: one point was scored when the instrumentation was crossed, one point when the organs were too far away to manipulate, and one point when the organs were too close to manipulate. The position was considered ideal when a zero value was obtained. Fleiss Kappa coefficient for 4 raters was used to estimate the level of concordance between observers. Results: It was possible to obtain a value of zero in the latter approach. The position of the trocars was established in the following way: the telescope port positioned at midline 1.6 cm caudal to the umbilical scar (2.0 cm with insufflation), and with the secondary ports placed slightly lateral to the third mammary glands. To establish the exact location of these trocars a point was established at 1.5 cm caudal to the telescope trocar. After forming an angle of 90°, 3.3 cm were measured on each side. These last measures were taken with the abdomen insufflated. Discussion or Conclusion: In this research was established the appropriate positions of the working ports, without causing fatigue of the operator’s wrist joint and with adequate space for comfortable movement. In addition, this would also reduce the use of live rabbits for the establishment of the ports in future research, accepting the concept of the three Rs for animal experimentation. With these models was obtained an excellent view of the surgical field without interference between the instruments and telescope.

On-table urethral catheterisation during laparoscopic appendicectomy: Is it necessary?

Laparoscopic appendicectomy (LA) is the most commonly performed surgical emergency procedure. The aim of this study was to highlight a series of iatrogenic bladder injuries during LA and suggest a simple method of prevention. A retrospective review was carried out of all LA performed in a university teaching hospital over a two year period 2012-2013. Iatrogenic visceral injuries were identified and operative notes examined. During the study period 1124 appendicectomies were performed. Four iatrogenic bladder injuries occurred related to secondary trocar insertion. No patient was catheterised preoperatively. One of the injuries was identified intra-operatively, another in the early postoperative period where as two re-presented acutely unwell post-discharge from hospital. Three were repaired by laparotomy and one laparoscopically. Iatrogenic secondary trocar induced bladder injuries are a rare but preventable and potentially serious complication of LA. Urethral catheterisation during LA is a safe and simple method which can prevent this complication.

Extrapolating Veress needle for directional precision of secondary laparoscopic ports — A handy technique

In today’s era of advanced laparoscopy, it is still not uncommon to encounter potentially lethal port site bleeding during placement of secondary trocars on the perietes. This is usually due to the inadvertent transaction of a subcutaneous/ rectus sheath vessel/s by “blind” insertion of secondary trocar/s. In this regard, we describe a simple and rapid technique of siting a trouble-free port track using a Veress needle.

Femoral Nerve Injury After Gynecologic Laparoscopy

Femoral nerve injury after gynecologic laparoscopy is reported very rarely, and usually only as a consequence of lithotomy position. A 36-year-old woman underwent left partial laparoscopic ovariectomy. A primary Hasson trocar was inserted through infraumbilical incision; 2 secondary trocars were placed in right hypocondrium and left iliac fossa, just cranially to the inguinal fold. After operation, the patient showed irreversible femoral neuropathy, with left thigh weakness and allodynic paresthesias, from the site of the left trocar insertion to the anteromedial aspect of the thigh and medial aspect of the leg and foot. To our knowledge, this is the first report of femoral nerve injury caused by trocar insertion. Peritoneal adhesions and inadequate pneumoperitoneum may have increased the risk of nerve injury. Physicians should be aware of the possibility of this complication, and should avoid too caudal a trocar insertion in iliac fossa.

Laparoscopic Entry Technique???A Survey of Practices of Consultant Gynaecologists

ABSTRACT This study was conducted to identify the method of laparoscopic entry used by practicing gynecologists and learn whether they are following new recommendations for improvement of the safety of laparoscopic gynecologic surgery. Several international societies of endoscopy have endorsed new guidelines for safe laparoscopic entry techniques. Physicians are advised to place the primary incision in the base of the umbilicus when performing closed laparoscopy. If adhesions are suspected, the incision can be made in Palmer’s point. Intraabdominal pressure should be 25 mm Hg for trocar insertion. In open laparoscopy, the incision should be made at the lower border of the umbilicus and care taken to elevate the deep fascia to separate the abdominal wall from its contents. Secondary trocars should be inserted under direct laparoscopic guidance. The authors mailed an anonymous questionnaire about laparoscopic techniques to all gynecologists in the United Kingdom and Ireland (n = 1190). They received 764 (64%) responses. A large majority (90%) of responders used a closed entry technique with a Veress needle, 8% preferred a direct entry technique without a pneumoperitoneum, and 1% each used Hasson’s method or a combination of open and closed laparoscopy. The patient positions used in performing laparoscopy were lithotomy with Trendelenburg tilt (61%), the flat position (29%), or a combination of positions (10%). Over half of respondents (54%) used a subumbilical entry point, 44% preferred an intraumbilical entry point, 2% used a suprapubic entry, and 2% used a combination of sites. Only 44% indicated that they performed a check test to assure correct positioning of the Veress needle; when used, Palmer’s aspiration technique was used most often (90%). Sixty-two percent of responders used volume (range, less than 2.0–3.5) and 38% used the intraabdominal pressure technique (range, 15–25 mm Hg) to establish a satisfactory pneumoperitoneum before trocar insertion. Half of the responding gynecologists (53%) said that they would use their preferred techniques for all patients, regardless of a patient’s history. Forty-seven percent would change their techniques for obese patients or those who had prior abdominal surgery. One third (34%) indicated that their techniques had changed in the past 5 years. Thirty-four percent of the responders had attended a laparoscopic or endoscopic surgery course in the past and 66% had not. Those who had attended a course were more likely to follow the new recommendations for safe laparoscopy (69%). Only 26% of responders were aware of the new guidelines, whereas 74% were not aware of these recommendations.

Visualization of the epigastric vessels and bladder before laparoscopic trocar placement

Objective Transillumination and laparoscopic visualization are two techniques recommended to minimize the risks of injury to abdominal wall structures during insertion of secondary trocars. This study was designed to determine the effectiveness of these techniques to locate the epigastric vessels and superior bladder margin. Design Prospective observational. Setting Academic medical centers. Patient(s) One hundred five women undergoing laparoscopy for tubal sterilization, infertility, pelvic masses, or pelvic pain. Intervention(s) None. Main outcome measure(s) The ability to visualize the superficial and inferior epigastric vessels, and bladder margin; body mass index (BMI; in kilograms per meter squared); and skin color. Result(s) Transillumination successfully visualized 64% of superficial epigastric vessels and was less effective both as weight increased (BMI <25 kg/m 2: 86%; BMI = 25–30 kg/m 2: 61%; BMI >30 kg/m 2: 25%) and in dark-skinned women (69%) compared to those with lighter skin (42%). Laparoscopic visualization successfully identified 82% of inferior epigastric vessels and 46% of bladder margins, and was less effective as weight increased. Conclusion(s) Transillumination can successfully locate superficial epigastric vessels, and laparoscopic visualization can locate inferior epigastric vessels and the superior bladder margin in the majority of women undergoing laparoscopy. Transillumination is less effective in dark-skinned women, and both techniques are less effective with increasing body weight.

Visualization of superficial and inferior epigastric vessels and bladder during laparoscopy.

Objective: Both transillumination and laparoscopic visualization are techniques recommended to minimize the risks of injury to abdominal wall structures during placement of secondary trocars. This study was designed to determine how often the epigastric vessels and superior bladder margin can be located using these techniques. Methods: The ability to visualize the superficial and inferior epigastric vessels, and bladder margin was prospectively determined in 102 women undergoing laparoscopy. Patients were divided based on body mass index (BMI = kg/M2; normal weight < 25, overweight 25-30, and obese > 30). Light-skinned patients were compared to dark-skinned patients self-identified as black, asian or hispanic. Groups were compared using Chi square analysis. Results: Transillumination successfully visualized 64% of superficial epigastric vessels. This technique was less effective as weight increased (normal weight 86%, overweight 61%, obese patients 25%) and in dark-skinned women (69%) compared to those with lighter skin (42%). Laparoscopic visualization successfully identified 82% of inferior epigastric vessels, and 46% of bladder margins. This technique was also less effective as weight increased for both vessels (normal weight 89%, overweight 68%, obese patients 25%) and bladder margins (normal weight 68%, overweight 38%, and obese patients 11%), but skin color had no effect. Conclusion: Transillumination is an effective technique for locating the superficial epigastric vessels and laparoscopic visualization for both the inferior epigastric vessels and superior margin of the bladder prior to secondary trocar insertion in the majority of women. Transillumination is less effective in dark-skinned women and both techniques become less effective as body weight increases.

Transcervical or intraperitoneal analgesia for laparoscopic tubal sterilization: a randomized controlled trial

Objective: To test the effectiveness of analgesia administered transcervically through a uterine manipulator compared with direct topical application to the fallopian tubes for relief of postoperative pain after interval laparoscopic tubal sterilization. Methods: Sixty-one women who had laparoscopic sterilization were enrolled in a randomized, double-masked clinical trial comparing analgesia with 75 mg of bupivacaine administered through a uterine manipulator with 75 mg of bupivacaine applied directly to the fallopian tubes through a secondary trocar. Results were evaluated using visual analog scale pain levels, time of administration of analgesics, total analgesics required, and recovery room times. We calculated that a sample size of 60 women would detect a 30% difference in pain levels with a power of 80% at a significance level of .05. Results: In the 59 women who completed the study, there were no differences in the two groups in pain levels, amounts of medications used, or times to administration of postoperative analgesia. Mean recovery room time was shorter in the group given analgesia transcervically, but that difference was not statistically significant. Conclusion: There were no significant differences in postoperative pain relief between transcervical administration and topical application of analgesia for laparoscopic tubal sterilization.

Litigation of Laparoscopic Major Vessel Injuries in Canada

This study is a review of conditions and circumstances associated with 15 injuries to great vessels during laparoscopic surgery. Thirteen cases were litigated in Canada and two occurred in the author's operating room. Body habitus may have been an underlying factor in the injuries. Most injuries were entry related and independent on complexity of surgery. One was caused by the Veress needle and one by a secondary trocar, and three occurred during dissection of adhesions. Ten were primary trocar injuries, 9 after pneumoperitoneum and 1 at direct trocar insertion. Of these, five were caused by reusable and five by disposable trocars with so-called safety shields. In 6 of 15 cases recognition of the injury was delayed; 5 in the recovery room. Eleven women had uncomplicated recovery. Of 13 litigated cases, 8 (62%) resulted in settlement.

Technique for safe placement of reusable trocars during endoscopic extraperitoneal inguinal hernioplasty

Endoscopic extraperitoneal inguinal hernioplasty has become an established technique for the repair of inguinal hernias. To reduce the cost of the procedure, reusable metallic trocars are substituted for disposable trocar ports. However, the use of metallic trocars is often associated with pericannula air leak and uncontrolled sliding movements. The insertion of the primary subumbilical trocar by open dissection technique has been widely accepted but percutaneous placement of secondary trocars with sharp obturators, even under direct endoscopic vision, is still potentially hazardous in the confined extraperitoneal space. We have, therefore, modified our method of placement of secondary trocars with finger dissection and railroad techniques. Making the trocar snug with a purse‐string suture over the fascial opening can substantially reduce peri‐cannula air leak, diminish the sliding movement of the cannula and facilitate closure of the wound. To avoid the risk of visceral and major vascular injuries, all endoscopic instruments are blunt‐tipped. Open dissection combined with finger dissection and railroad techniques enables the safe placement of trocars for endoscopic extraperitoneal inguinal hernioplasty. image image

Perioperative Morbidity of Gynecological Laparoscopy: A Prospective Monocenter Observational Study

Background. To study the morbidity rate of gynecological laparoscopy and to the most influential variables. Methods. We conducted a prospective observational study from January 1st 1992 to December 31st 1998 in a single tertiary care center. It concerned patients who underwent gynecological laparoscopic surgery performed by seniors and residents. We have prospectively recorded patients characteristics, indications for laparoscopy, leading diagnosis, main operative procedures, post-operative course, surgical and anesthetic incidents and accidents. Complications were defined as any event that would modify the usual course of laparoscopy or of the post-operative period. Results. One thousand and thirty-three laparoscopies were included. 80.1% of the procedures were major or advanced laparoscopies. The overall complication rate was 3%, with a laparotomy rate of 1.2%. About half of those complications (54.8%) occurred during the installation of laparoscopy. Veress needle and first trocar insertion accounted for 23.5% of those accidents (0.3% of the procedures) and suprapubic trocar insertion for 76.5%. Hemorrhages constituted almost all of the complications occurring during the operative stage (80%). The risk increased with the level of surgery and decreased with surgeon's experience. Prior abdominal surgery had no significant effect on the overall morbidity rate. Post-operative and anesthetic complications were rare. The overall complication rate as well as the laparotomy rate were stable all along the course of the study. Conclusions. Complication rate of gynecological laparoscopy is not negligible. Efforts should be made to lower the complications induced by the installation of laparoscopy, especially for secondary trocars.

Perioperative morbidity of gynecological laparoscopy. A prospective monocenter observational study.

To study the morbidity rate of gynecological laparoscopy and to the most influential variables. We conducted a prospective observational study from January 1st 1992 to December 31st 1998 in a single tertiary care center. It concerned patients who underwent gynecological laparoscopic surgery performed by seniors and residents. We have prospectively recorded patients characteristics, indications for laparoscopy, leading diagnosis, main operative procedures, post-operative course, surgical and anesthetic incidents and accidents. Complications were defined as any event that would modify the usual course of laparoscopy or of the post-operative period. One thousand and thirty-three laparoscopies were included. 80.1% of the procedures were major or advanced laparoscopies. The overall complication rate was 3%, with a laparotomy rate of 1.2%. About half of those complications (54.8%) occurred during the installation of laparoscopy. Veress needle and first trocar insertion accounted for 23.5% of those accidents (0.3% of the procedures) and suprapubic trocar insertion for 76.5%. Hemorrhages constituted almost all of the complications occurring during the operative stage (80%). The risk increased with the level of surgery and decreased with surgeon's experience. Prior abdominal surgery had no significant effect on the overall morbidity rate. Post-operative and anesthetic complications were rare. The overall complication rate as well as the laparotomy rate were stable all along the course of the study. Complication rate of gynecological laparoscopy is not negligible. Efforts should be made to lower the complications induced by the installation of laparoscopy, especially for secondary trocars.

Microlaparoscopy using an optical Veress needle inserted at Palmer's point

Objective To avoid vascular and visceral injury in a patient undergoing laparoscopic adhesiolysis and known to have extensive intra-abdominal adhesions. Design An optical Veress needle was used to establish pneumoperitoneum under direct vision through Palmer's point. Safe sites were identified for the insertion of the secondary trocars. Result Satisfactory laparoscopic adhesiolysis was performed without any complications. Conclusion Microlaparoscopy using an optical Veress needle inserted through Palmer's point seems to be a safe technique for avoiding laparoscopic injury when extensive adhesions are suspected.

Laparoscopic ilioinguinal nerve injury

ObjectiveTo report a case of laparoscopic ilioinguinal nerve damage due to direct trauma from a secondary trocar placed in the right iliac fossa.DesignCase report and literature review.SettingTertiary referral hospital in an Australian city.ConclusionPatients with ilioinguinal neuralgia present significant diagnostic and management problems. This report highlights the need for gynaecologists to have a knowledge of the anatomical relations of the inguinal nerves in the lower abdominal wall, so that iatrogenic injury can be avoided.

The Laparoscopic Sound: A Simple Instrument for Rapid and Safe Secondary Trocar Insertion in Retroperitoneal Laparoscopy

In retroperitoneal laparoscopic surgery, the insertion of secondary trocars results sometimes in serous complications that may spoil the entire procedure. To obviate this problem we report our initial experience with the use of a new instrument. The instrument has the basic characteristics of a urethral sound but is larger, longer and with more prominent curve. The tip of the laparoscopic sound has been designed to have a slightly smaller diameter than the inner diameter of the 10-mm trocar sheath, so that they can fit together. With proper pull-through manipulations, the trocar sheath is inserted into the retroperitoneal space rapidly and safely. No complications arose due to trocar placement. No gas leak was noticed in any of the patients, nor was any peritoneal tearing, vascular injury or muscular splitting observed. The method represents an important progress in the technique of inserting secondary trocars and creating the retroperitoneal space due to its simplicity, safety, rapidity, low cost and effectiveness.

Retroperitoneal Laparoscopic Nephrectomy and Other Procedures in the Upper Retroperitoneum Using a Balloon Dissection Technique

This article describes a hydraulic balloon dissection technique. The retroperitoneum is developed via a small lumbodorsal incision between the edges of the musculus latissimus dorsi and musculus obliquus externus and then after visualization of its correct position the balloon catheter is filled with 500-1,200 ml of warm normal saline (according to patient size). The device consists of the finger of a surgeon's glove ligated around the end of a rigid bladder catheter. The balloon insufflation is maintained for 5 min to guarantee adequate hemostasis. Recently, we have replaced the balloon catheter by a balloon trocar sheath allowing direct endoscopic control of the hydraulic dissection. After retrieval of the balloon the CO2 insufflator is connected to the first trocar. All secondary trocars are placed under endoscopic control. The hydraulic dissection techniques also enable optimal creation of an effective pneumoperitoneum in children. Until now, we have used this technique for twelve procedures in the upper retroperitoneum including five nephrectomies, two nephroureterectomies, one tumor nephrectomy, one nephropexy, one renal cyst marsupialization and two renal biopsies. Up to now we have encountered no major complications. Three of the nephrectomized patients had undergone multiple previous abdominal surgical interventions. The retroperitoneal approach allows the surgeon to apply similar dissecting techniques as used in respective open procedures. It has become the routine approach for laparoscopic procedures in benign renal disease. This procedure can be performed even in cases with previous abdominal surgery.