Sharp Trocar Research Articles

Complications in Laparoscopic Access in Standing Horses Using Cannula and Trocar Units Developed for Human Medicine.

First cannulation is a critical manoeuvre in equine laparoscopy. This retrospective study aimed at the comparison of the frequency and type of complications detected when using different human laparoscopy devices for laparoscopic access in standing horses, and the influence of body condition in such complications. Forty-four procedures were included, and retrieved data comprised cannula insertion technique, body condition, and type and frequency of complications. Laparoscopic access techniques were classified into five groups: P: pneumoperitoneum created using Veress needle prior to cannulation; T: sharp trocar; D: direct access via surgical incision; V: Visiport optical trocar and H: optical helical cannula (OHC). In groups T, D, V and H, access was achieved without prior induction of pneumoperitoneum. Complications were registered in 13/44 procedures, of which retroperitoneal insufflation was the most common (6/13). Statistically significant association was found between the complication incidence and the type of access, with group D showing the highest complication frequency (80%) and group H the lowest frequency (0%). The majority of complications (9/13) were observed in overweight horses. We conclude that devices designed for human patients can be used for laparoscopic access in standing horses, with the use of OHC minimizing the appearance of complications, especially in overweight horses with OW.

Bladed and bladeless conical trocars do not differ in terms of caused fascial defect size in a Porcine Model

IntroductionTrocar insertion during laparoscopy may lead to complications such as bleeding, bowel puncture and fascial defects with subsequent trocar site hernias. It is under discussion whether there is a difference in the extent of the trauma and thus in the size of the fascia defect between blunt and sharp trocars. But the level of evidence is low. Hence, we performed a Porcine Model.MethodsA total of five euthanized female pigs were operated on. The average weight of the animals was 37.85 (Standard deviation SD 1.68) kg. All pigs were aged 90 ± 5 days. In alternating order five different conical 12-mm trocars (3 × bladeless, 2 × bladed) on each side 4 cm lateral of the mammary ridge were placed. One surgeon performed the insertions after conducting a pneumoperitoneum with 12 mmHg using a Verres’ needle. The trocars were removed after 60 min. Subsequently, photo imaging took place. Using the GSA Image Analyser (v3.9.6) the respective abdominal wall defect size was measured.ResultsThe mean fascial defect size was 58.3 (SD 20.2) mm2. Bladed and bladeless trocars did not significant differ in terms of caused fascial defect size [bladed, 56.6 (SD 20) mm2 vs. bladeless, 59.5 (SD 20.6) mm2, p = 0.7]. Without significance the insertion of bladeless trocars led to the largest (Kii Fios™ First entry, APPLIEDMEDICAL©, 69.3 mm2) and smallest defect size (VersaOne™ (COVIDIEN©, 54.1 mm2).ConclusionBladed and bladeless conical 12-mm trocars do not differ in terms of caused fascial defect size in the Porcine Model at hand. The occurrence of a trocar site hernia might be largely independent from trocar design.

The G2 research R.I.P. fragmenting bullet-radiographic features of a recently encountered projectile.

Gunshot wounds (GSWs) are an important cause of disability and death in the USA. Although radiography is limited in its ability to detect bullet types, a projectile introduced during the last decade, the R.I.P. bullet by G2 Research, consists of a base slug connected to 6 to 8 sharp trocars designed to diverge within soft tissue following impact, resulting in what we believe to be a unique imaging appearance that can be confusing to those not familiar with this particular projectile. Furthermore, this bullet is 100% copper, which may allow for safe imaging with magnetic resonance imaging if correctly identified prior to scanning.

Laparoscopic Entry via the DE-ALWIS METHOD

Despite the rapid advances in laparoscopic surgery in the past 2 decades the initial entry still accounts for approximately 40% to 50% of laparoscopic complications and should be considered the most dangerous step of a laparoscopic procedure. In this review, the authors share a technique for initial umbilical entry, and provide alternative entry sites in cases where umbilical entry is comtraindicated. Rev Obstet Gynecol. 2009; 2(3):193-198 doi; 10.3909/riog0088. Laparoscopy for diagnostic purposes to a modality for minor and major surgical procedures, had been advancing rapidly over the last 3 decades. The initial entry still accounts for about 40-50% of laparoscopic complications and is the most dangerous step of this surgical procedure [1, 2]. Laparoscopic entry using a veres needle followed by a blind insertion of a sharp trocar is the common method used by gynaecologists [3-5]. There is no concensious as to which laparascopic entry is superior and the common recommendation is use the entry methods with which the surgeons feel comfortable [6]. Umbilical entry is not suitable in certain instances, such as previous midline abdominal incision, previous umbilical hernia surgery, previous pelvic peritonitis and so forth, due to the presence of pelvic adhesions. An open surgery does not guarantee against a visceral injury [7].

Should we use visual entry techniques in patients with previous laparotomies?

Laparoscopic surgery has become the method of choice for treating an ever increasing number of gynaecological disorders that require surgery. However, primary port insertion is a potentially dangerous step especially in patients with previous laparotomies. The aim of this study is to identify whether visual entry technique has any advantage over the closed one in patients with previous laparotomies. This is a retrospective observational case control study of 2541 patients with previous laparotomies who underwent laparoscopic surgery from January 1992 to September 2003 at Vijaya Hospital, Kochi and from October 2003 to October 2015 at Department of Endoscopy, Paul’s Hospital, Kochi, India. The control group comprised of 1261 patients, operated between January 1992 and September 2003 at Vijaya Hospital, Kochi, in whom closed technique of abdominal access for primary port creation was used. The study group comprised of 1280 patients, operated between October 2003 and October 2015 at Department of Endoscopy, Paul’s Hospital, Kochi, in whom visual entry (EndoTIP) was used for primary port creation. Procedures included in both groups were total laparoscopic hysterectomy, laparoscopic myomectomy, laparoscopic ovarian cystectomy, laparoscopic conservative surgery, laparoscopic tubal reanastomosis, laparoscopic sacrocolpopexy, laparoscopic sacrocervicopexy, laparoscopic adhesiolysis and laparoscopic sterilisation. There was no evidence of intestinal or vascular injury during visual entry using a blunt EndoTIP cannula. There were three cases of bowel injury with the closed, blind entry technique using a sharp linear trocar in the control group. The p value (Chi-square test) is 0.04, which is statistically significant. Visual entry, as an approach to abdominal access in patients with previous laparotomies, wherein chances of encountering peritoneal and bowel adhesions are very high, is safer than the closed blind entry technique in preventing bowel injuries.

Suprapubic catheter insertion using an ultrasound‐guided technique and literature review

What's known on the subject? and What does the study add? The conventional 'blind' technique for suprapubic catheter (SPC) insertion relies on adequate filling of the bladder to displace bowel away from the site of needle puncture. However, in a small percentage of patients this fails to happen, which can occasionally lead to life-threatening bowel injury. Recently published British Association of Urological Surgeons (BAUS) guidelines have recommended that ultrasonography (US) may be helpful to identify bowel loops and recommends its usage whenever possible. This paper describes the technique of US-guided needle puncture and SPC insertion to reduce the likelihood of bowel injury. The paper addresses training, equipment and logistical issues associated with this advice. We have reviewed the available publications on the outcomes from this technique and also present our experience. Suprapubic catheter (SPC) insertion is a common method of bladder drainage in contemporary urological practice. The procedure involves insertion of a sharp trocar into the bladder percutaneously, usually by palpation, percussion or cystoscopy for guidance. Although generally considered a safe procedure, the risk of bowel injury is estimated at up to 2.4% with a mortality rate of 1.8%. Recently published British Association of Urological Surgeons (BAUS) guidelines have recommended that ultrasonography (US) may be helpful to identify bowel loops and recommends its usage whenever possible. The present paper describes the use of US for SPC insertion and discusses the implications of this advice. This paper is designed to support and supplement practical techniques learnt on a course and in clinical practice.

Safety and Efficacy of Single Incision Laparoscopic Surgery for Total Extraperitoneal Inguinal Hernia Repair

Almost 20 years after the first laparoscopic inguinal hernia repair was performed, single incision laparoscopic surgery (SILS™) is set to revolutionize minimally invasive surgery. However, the loss of triangulation must be overcome before the technique can be popularized. This study reports the first 100 laparoscopic total extraperitoneal hernia repairs using a single incision. The study cohort comprised 68 patients with a mean age of 44 (range, 18 to 83): 36 unilateral and 32 bilateral hernias. Twelve patients also underwent umbilical hernia repair with the Ventralex patch requiring no additional incisions. A 2.5-cm to 3-cm crescentic incision within the confines of the umbilicus was performed. Standard dissecting instruments and 52-cm/5.5-mm/30(0) laparoscope were used. Operation times were 50 minutes for unilateral and 80 minutes for bilateral. There was one conversion to conventional 3-port laparoscopic repair and none to open surgery. Outpatient surgery was achieved in all (except one). Analgesic requirements were minimal: 8 Dextropropoxyphene tablets (range, 0 to 20). There were no intraoperative or postoperative complications with a high patient satisfaction score. Single-incision laparoscopic hernia repair is safe and efficient simply by modifying dissection techniques (so-called "inline" and "vertical"). Comparable success can be obtained while negating the risks of bowel and vascular injuries from sharp trocars and achieving improved cosmetic results.

418: The impact of fetoscopic access diameter after fetoscopic laser coagulation

Several entry techniques are used at laser coagulation for twin-to-twin-transfusion syndrome (TTTS). Theoretically percutaneous entry with a sharp trocar loaded into a cannula rather than the fetoscopic sheath, reduces friction between instruments and the fetal membranes. Little is known about how access diameter may affect outcome. We assessed the effect of access diameter on the rate of preterm rupture of the membranes (PPROM <32) and preterm birth before 32 weeks (PTB <32).

Successful Treatment of Invasive Pulmonary Aspergillosis in a Neonatal Foal

Successful Treatment of Invasive Pulmonary Aspergillosis in a Neonatal Foal

Transumbilical Access for Pneumoperitoneum (Modified Hasson Procedure) in Laparoscopy in Children and Adolescents

Two principal methods are used to introduce the pneumoperitoneum in laparoscopic procedures. The first and most common technique is blind insertion of the Veress needle, followed by blind puncture of the abdominal wall with a sharp trocar. The second is the open method first described in 1971 by Hasson. Either method produces a scar at least 3 to 4 cm long in the umbilical region. We present a study of 191 consecutive cases (age range, 1.6–29 years; median, 12 years) in which a longitudinal transumbilical access through the lower umbilicus was achieved for insertion of a blunt trocar. The technique is compared with the periumbilical transverse incision and the gridiron incision. Our technique renders a much better cosmetic result and better stability, while maintaining the safety of the Hasson method.

Umbilical Richter's hernia: unusual early complication of gynaecological laparoscopic surgery

Case A 39-year-old lady undergoing her fourth laparoscopy developed a 5-cm Richter's hernia of the small bowel through the umbilical port site. Its diagnosis was difficult and this resulted in delay in treatment. Conclusions Post-laparoscopy incisional hernias are uncommon, occurring mostly with ports of 10 mm and above, and at the umbilical site. Their occurrence is not influenced by the surgeon's experience. Predisposing factors include previous laparoscopies, extensive manipulation during surgery, increased intra-abdominal pressure, obesity, use of sharp cutting-tip trocars, rapid abdominal deflation at the end of surgery, poor port removal techniques and defective closure of the abdominal fascia. The diagnosis is often delayed because most cases present late, and treatment might be instituted along other lines. Computed tomography scans are helpful in its diagnosis and will facilitate prompt treatment to avoid the grave consequence of bowel gangrene.

Pseudoaneurysms of the superficial temporal artery secondary to placement of external ventricular drainage catheters

BACKGROUND Pseudoaneurysms of the superficial temporal artery have been described following trauma and various surgical procedures. There are no reports in the literature of these lesions following the placement of external ventricular drainage catheters. This article describes two patients and their successful treatment, and reviews diagnostic and treatment strategies. CASE DESCRIPTION Two patients developed tender, nonpulsatile masses in the scalp along the former subcutaneous tract of an EVD catheter. Both lesions were successfully excised in the operating room and found to be thrombosed pseudoaneurysms of the superficial temporal artery. CONCLUSION Pseudoaneurysms of the parietal branch of the STA may occur secondary to incision of the skin for twist drill hole placement or the use of a sharp trocar for subcutaneous tunneling of catheters. Use of a blunt-tipped trocar may reduce the risk of developing pseudoaneurysms secondary to EVD placement. Knowledge of the possibility of developing these lesions from catheter placement may aid the neurosurgeon in proper diagnosis and treatment.

Commentary

BACKGROUNDPseudoaneurysms of the superficial temporal artery have been described following trauma and various surgical procedures. There are no reports in the literature of these lesions following the placement of external ventricular drainage catheters. This article describes two patients and their successful treatment, and reviews diagnostic and treatment strategies.CASE DESCRIPTIONTwo patients developed tender, nonpulsatile masses in the scalp along the former subcutaneous tract of an EVD catheter. Both lesions were successfully excised in the operating room and found to be thrombosed pseudoaneurysms of the superficial temporal artery.CONCLUSIONPseudoaneurysms of the parietal branch of the STA may occur secondary to incision of the skin for twist drill hole placement or the use of a sharp trocar for subcutaneous tunneling of catheters. Use of a blunt-tipped trocar may reduce the risk of developing pseudoaneurysms secondary to EVD placement. Knowledge of the possibility of developing these lesions from catheter placement may aid the neurosurgeon in proper diagnosis and treatment.

Ultrasound-guided aspiration of brain abscesses through a single burr hole.

Surgical aspiration and/or drainage of brain abscesses is considered to be the first-line treatment for abscesses larger than 25 mm. This is ususally performed with the aid of CT-guided stereotaxy. A method of ultrasound guidance is presented that allows a single burr hole approach with real-time imaging of the whole procedure. A bayonet-like shaped ultrasound probe with tip dimension of 8 x 8 mm only (EUP-NS 32, Hitachi/Ecoscan) with frequencies of 3.5 and 5 MHz is used. After placement of a burr hole the target is identified by transdural insonation, a guideline is adjusted and a mounted puncture-adapter guides the cannula towards the lesion under real-time imaging control. Up to now 12 abscesses in 10 patients were treated. Visualization was always excellent. A second aspiration had to be performed twice. One abscess did not contain enough pus to be cured by aspiration and was removed by open surgery, another could not be tapped by the blunt cannula and was aspirated under stereotactic control using a sharp trocar. Outcome was excellent in 6 patients and fair in 2 patients but this was due to the pre-existing disease. Two patients admitted in deep coma died despite an emergency operation. The presented method has proven to be a very powerful guiding tool in the surgical treatment of brain abscesses through a single burr hole approach.

Recent advances in endoscopic entry techniques

The most important and potentially dangerous first step in laparoscopy is safe and successful insertion of theprimary cannula. Several entry techniques and instruments are reviewed to illustrate different entry options available to endoscopists. Conventional entry methods use the push-through trocar and cannula design. Considerable axial penetration force is applied to thrust a sharp trajectory into the abdomen. Concern regarding their safety has been expressed when used at primary port, especially in high risk patients and those who have had previous abdominal surgery. Different variations of this blind entry technique attempt to render port insertion safer. However, the push-through principal is retained and surgeons cannot anticipate, avoid or recognise entry injury. Most surgeons agree that visually controlled entry techniques infer added safety and render the processinteractive. Newer optical entry methods allow error recognition when accidents occur and error recovery is possible before the accident progresses to patient harm. Visually controlled entry systems that require no sharp trocar, apply no axial penetration force, and render this critical first step in laparoscopy more error tolerant. Visual systems allow error analysis and improve our understanding of laparoscopic entry complications. Ultimately, endoscopists must be well versed in more than one entry technique, as primary port insertion must be tailored to meet the specific physical and medical needs of each patient. Surgeons must use those entry methods and instruments that they are schooled in and feel safest in their hands.

Radially-expanding access device for laparoscopic surgery: efficacy and safety in comparison with sharp laparoscopic cannulae

Until recently, access to the abdominal cavity for laparoscopic procedures has primarily required the use of sharp trocars (ST). Despite careful placement by experienced surgeons, ST-related complications have been and continue to be a serious, sometimes life-threatening problem. In 1994, a new laparoscopic access design became available that uses a Veress needle for placement, a radially-dilating expandable sleeve, and a blunt dilator and cannula. A review of evidence-based medical literature has demonstrated that this radially-expanding access (REA) device reduces the risk of abdominal-wall bleeding, major vascular injury, visceral injury, post-operative incisional hernias and deaths, as compared with any sharp trocar system. In addition, operative times have been reduced, post-operative pain reduced, and cost-savings realised.

Access-related complications - an analysis of 6023 consecutive laparoscopic hernia repairs

In order to investigate incidence rates and types of access-related complications that may occur during laparoscopic hernioplasty, we carried out a systematic analysis of our collected results. The aim was to identify risk factors and to develop useful modifications of the surgical technique and the instrumentation used. Since we first introduced laparoscopic hernioplasty in our clinic, we have carried out standardised, prospective documentation of relevant data from all consecutive operations in an electronic database. We performed a systematic analysis of access-related complications and their possible influencing factors, taking into special account the type of instruments used, port-site and prior intra-abdominal operations. Between April 1993 and March 2000, 4857 consecutive patients received a total of 6023 laparoscopic hernia repairs. In 510 patients three-edged, sharp trocars were used and in 4347 patients conical obturators were used to insert the port. The incidence of access-related complications was 0.9% (44/4857) in the total collection (incision hernias 0.5%, bleeding from abdominal-wall vessels 0.2%, bowel injury 0.06%, wound infections 0.06%). Injuries to intra-abdominal or retroperitoneal vessels were not observed. A differentiated analysis of the various trocar types, taking into consideration the number of inserted ports, showed that for incisions outside the linea alba the incidence of bleeding from abdominal-wall vessels was 12 times higher (0.7%, 7/1020 versus 0.06%, 5/8694). The incidence of incision hernias increased significantly (1.2%, 12/1020 versus 0.02%, 2/8694; p = 0.03) when three-edged trocars were used, as opposed to conical obturators. Our results demonstrate that, outside the linea alba, three-edged trocars should no longer be used for portinsertion. The results of our differentiated analysis of laparoscopic hernia repairs, taking into account the type of obturator, the port-site and number of ports inserted, also can be applied to other laparoscopic operations.

Establishment of pneumoperitoneum with a modified blunt trocar.

Veress needle and trocar-related accidents have caused many surgeons to adopt the Hasson technique for establishment of pneumoperitoneum, but this technique also has drawbacks. A modification of the sharp trocar has been developed that overcomes the disadvantages of the Veress needle and Hasson trocar.

Retroperitoneal laparoscopy: do we really need the sharp trocars for establishing secondary ports?

While sharp trocars are necessary for establishing secondary ports during transperitoneal laparoscopy, their use during retroperitoneal laparoscopy is unwarranted and could even be dangerous in the hands of a beginner because of the confined space. This paper describes our recent experience of the use of blunt trocars in establishing secondary ports for retroperitoneal laparoscopy.

Making the case for the radially expanding access system

ObjectiveTo report data on the case of the radially expanding access device for laparoscopic surgery.DesignA narrative based on personal and industry‐wide evidence‐based outcome data on abdominal injuries caused by sharp trocars, compared with the safety associated with the radially expanding access system.SubjectsPatients undergoing laparoscopic gynaecological and general surgical procedures.ConclusionsUse of the radially expanding access device is associated with far fewer abdominal injuries, reduced pain and a much lower incidence of incisional hernia.