Trocar Sheath Research Articles

The Chennai port closure method: A novel simple technique for laparoscopic port closure

PurposeLarge-size ports used for laparoscopic and robotic procedures will require appropriate closure to reduce the probability of trocar site complications including hematoma and hernia. Closure of these ports is done by various methods like the open method extending skin incisions, S-retractor, Carter Thomason method, and so on. Chennai port closure (CHC) method, a novel technique that had been in practice in our unit for more than 2 years, ensures direct visualization of the suture placement, and hence, the abdominal wall fascia and peritoneum are secured. Materials and MethodWe herein describe an easy technique for fascial closure in port size (≥10 cm) after minimally invasive surgery, including both laparoscopic and robotic procedures, using a cobbler needle in 151 patients in the study period between February 2017 and March 2020 for various urological procedures. This technique was done before the introduction of the trocar sheath and ensures direct visualization of the abdominal fascial closure. ResultsThere were no major intraoperative events, additional operating time, and need for any costly instruments. No bowel injuries or trocar site hernias were documented during a mean follow-up of 28 months. Presently, this technique is used by many surgeons in our hospital without much difficulty. ConclusionThe Chennai port site closure technique is an effective, simple, easy-to-apply, and safe procedure.

Percutaneous trans-abdominal external looped needle with two holes in the trocar sheath for port-site closures in difficult obese cases.

Port closure is essential after successful laparoscopic surgery to prevent incisional hernia. However, good fascial closure still represents a problem, especially in obese patients and when the port wound is oblique. We report a novel technique for port-site closures in such cases. This study involved 67 obese patients who underwent laparoscopic surgery. We used a novel technique for port-site closure that employed a looped needle passed through two holes in the port sheath. The method was used in 67 patients (45 laparoscopic cholecystectomies, 22 laparoscopic hernia repairs), with a mean BMI of 35.7 kg/m2 . No intraoperative incidents or port-site hernias were reported during follow-up (mean, 22 months). Our procedure is safe, easy, and effective for fascial port site closures, especially in cases of difficult obese patients and oblique port wounds.

Effective, simple, easy procedure for laparoscopic port closure in difficult cases.

BackgroundLaparoscopic and rebotic surgery is widely practiced in modern medicine. The operative procedure is not complete until the port sites are closed with a fascial closure. Good fascial closure still represents problem, especially in difficult obese patients. This study reported simple technique is suitable in such cases.Material and methodsWe herein describe a simple technique for fascial closure after Laparoscopic surgery using percutaneous transabdominal approach by using two looped needles in 87 obese patients. This technique was done while the trocar sheath in its position.ResultsThe procedure was used in 87 patients (69 females and 18 males) after laparoscopic cholecystectomy with mean body mass index 35.5 kg/m2 and mean age 47.1 years from May 2013 through June 2015. No intra-operative incidents and no port sites hernias were reported during a mean follow up of 18 months.ConclusionThe procedure is easy to perform, safe, and effective for fascial port site closure in difficult obese (thick abdominal wall and oblique port wound) cases.

Robotic assisted radical prostatectomy in morbidly obese patients: how to create a cost-effective adequate optical trocar.

Obesity is a major health issue in modern society, and with the progressive widespread employment of robotic assisted radical prostatectomy (RALP), the urologist-robotic surgeon is increasingly involved in the treatment of obese patients. However, the vast majority of urological departments are not equipped with a complete set of bariatric instruments. One of the potential difficulties of robotic surgery on the morbidly obese patient is the relatively short length of the optical trocar sheath, as the optical robotic arm requires some very valuable centimeters of the sheath to hang onto. This condition may make it impossible to properly reach the peritoneal cavity with the optical trocar during the RALP procedure. We present a series of four morbidly obese patients (BMI ranging from 42.1 to 46.2) with localized prostate cancer treated with RALP. We have developed an effective and "easy-to-implement" solution to the problem of properly elongating the sheath of the optical trocar which involves the use of the plastic cylindrical transparent protective tube of a disposable 26-Ch Amplatz sheath. The Amplatz sheath, with an internal diameter of 13mm and length of 25cm, perfectly fits outside of the 13-mm trocar usually employed for the optical trocar. Additionally, the cylindrical tube perfectly fits and hangs onto the robotic optical arm system. Mean operative time was 202.5min (range 185-220 min). Mean blood loss was 284mL (range 185-380 mL). Catheterization time and hospital stay were 5 and 6days, respectively, in all patients. All procedures were safely completed, and no minor or major complications were reported. The optical trocar lengthening technique allowed us to properly perform RALP procedures even in severely morbidly obese patients in an urological setting not equipped for bariatric minimally invasive surgery.

Trocar-Assisted Sling Suspension for Stress Urinary Incontinence

In this video, we present a procedure, Trocar-Assisted Sling Suspension (TASS), to correct stress urinary incontinenc. The surgical procedure is briefly stated as follows. The periurethral space and thicker parts of the pubocervical fascia were opened from the vagina. A 0.5-cm incision was made on both sides of the lower abdomen and was measured 4-cm lateral to the linea album and 2–3-cm above the pubic bone. A trocar was used to penetrate the incision site to the space of Retzius. A 2-cm×30-cm folded polypropylene mesh was placed inside the vagina and was then pulled out of the trocar sheath by a laparoscopic forceps.

Technical Notes and Tips: Use of a Peel-Away Trocar Sheath to Assist Suprapubic Catheter Replacement

Suprapubic catheter replacement, particularly after recent insertion, can be difficult and may be complicated by bladder retraction and loss of the track. We present a simple technique to aid catheter replacement using the peel-away trocar sheath found in most suprapubic catheter sets (Fig. 1). The patient is given prophylactic antibiotics and prepared using sterile technique. The sheath is placed around the existing catheter after removal of the peel-away section (Fig. 2). The sheath is then advanced 2–3 cm into the bladder using lignocaine gel for lubrication. The existing catheter can then be exchanged safely, followed by removal of the sheath. Figure 1 Typical suprapubic catheter set. Figure 2 Peel-away trocar sheath.

OC116: Trocar‐assisted selective laser photocoagulation of communicating vessels

Objectives: Selective laser photocoagulation of communicating vessels (SLPCV) for twin–twin transfusion syndrome (TTTS) in patients with an anterior (ANT) placenta is known to be technically more challenging than in patients with posterior (POST) placentas. We describe a new trocar-assisted (TA) technique to address this issue. Methods: Four surgical techniques were used for SLPCV in ANT placentas: standard, rigid scope; flexible scope; side-firing, twoport; and TA, whereby the anastomoses were lasered from within the trocar sheath after identification with an angled diagnostic endoscope. The protocol was approved by the Institutional Review Board and all patients signed informed consent. Results: SLPCV was performed in 269 patients from February 2003 to May 2005, of which 88 (47.6%) had ANT placentas. Only 7/88 (7.9%) patients with ANT placentas were treated with a flexible scope or a two-port technique and neither of these techniques was used after November 2003. Perinatal survival was independent of placental location (89.7% vs. 85.2%, POST vs. ANT placentas) or ANT placenta techniques. Gestational age at delivery (median 33.1 (range, 17.6–39.4) weeks), and incidence of premature rupture of membranes within 21 days of surgery, was no different between techniques in patients with ANT. However, operating time was significantly less in the TA group (P < 0.05). In 50/88 patients with ANT placentas available for analysis, only one had patent anastomoses in the TA group (2.9%), compared to none in the other techniques (P = 0.7). Conclusions: Laser treatment of TTTS patients with an ANT placenta that requires more than a simple rigid endoscope can be effectively achieved with a TA technique. TA allows orthogonalization of the angle of fire, eliminating the need for a two-port or flexible endoscope technique. TA is also useful in exposing the entire vessel wall in patients with POST placentas with a tangential angle of entry.

Trocar-Assisted Sling Suspension for Stress Urinary Incontinence: Three-Year Follow-up

Study Objective To evaluate 3-year outcomes of trocar-assisted sling suspension (TASS) for genuine stress incontinence. Design Retrospective review (Canadian Task Force classification II-2). Setting University-based, tertiary-level center for endoscopic surgery. Patients One hundred forty women with genuine stress incontinence with bladder neck hypermobility. Intervention After standard surgery preparation and general endotracheal anesthesia, TASS was performed. The periurethral space and thicker parts of the pubocervical fascia were opened from the vagina. A 0.5-cm incision was made on both sides of the lower abdomen and was measured 4-cm lateral to the linea album and 2–3-cm above the pubic bone. A trocar was used to penetrate the incision site to the space of Retzius. A 2-cm × 30-cm folded polypropylene mesh was placed inside the vagina and was then pulled out of the trocar sheath by a laparoscopic forceps. Measurements and Main Results All patients completed the procedures without exception. The average blood loss was less than 50 mL (range 10–200 mL). The operative time ranged from 20 to 90 minutes with a mean time of 32 ± 12 minutes. Eleven patients had voiding difficulty. Six of them voided well after intermittent self-catheterization performed 28 days postoperatively. Seven patients had poor healing of the anterior vaginal wall; therefore, removal of mesh and wound repair were performed. One patient suffered from a retroperitoneal hematoma, and one patient had an intraoperative bladder injury. The overall complication rate was 14.3%. During 12–36 months of follow-up, 134 of 140 patients (95.7%) were satisfied with the surgery. Conclusions Based on the results of our pilot study, TASS is quite feasible as a method of treatment for stress urinary incontinence. The surgery is not difficult to perform when compared with Burch colposuspension. Moreover, it encompasses the simplicity and effectiveness of tension-free vaginal tape surgery. In addition, TASS also can correct lateral wall defects such as cystocele.

Influence du type des trocarts utilisés en cœlioscopie sur la qualité du mouvement : étude expérimentale du frottement

Objective. – To keep the pneumoperitoneum and the tightness of the abdominal and pelvic cavity during a laparoscopy, the sheaths of trocar are provided with a device (valvule, membranes etc.) inducing a friction during the handling of the instrument. The objective of this article is to analyse friction from different types of trocar’s port. Materials and methods. – We present here the experimental results obtained during a testing bench of three different trocar sheaths. The mechanism of tightness of the first trocar sheath is made of a fine membrane associated to a valve, of a thick membrane for the second trocar sheath, whereas the third trocar sheath is made of two membranes, a fine and a thick, associated to a valve. After reporting the experimental device and the analytic model adopted to describe the relationship between the measured physical parameters, we lay out our results. The identification of parameters of this model makes it possible to objectively compare the three trocars. Results. – Our results revealed that, under experimental conditions, the amplitude of friction was significantly lower with trocar’s port provided with a valve and a fine membrane than with both other ports (fivefold weaker). Discussion and conclusion. – We evoke the importance of the possible disruption brought by these frictions while referring these values to those of other measurements concerning interactions between instrument and organs. These different behaviours of the material could have some consequences in choosing the tools for the performance of precise gestures.

A neglected but frustrating ergonomic issue: the thoracoscopic trocar

One of the problems encountered during thoracoscopic operations is the frequent soiling of the endoscope by blood dripping along the trocar sheath. This study was conducted in order to evaluate the reality of this problem. The study consisted of three parts: a questionnaire was sent to surgeons performing thoracic procedures, data were collected during thoracoscopic operations, and a literature study was done in the patents index. The questionnaire was sent to 210 surgeons. Sixty‐eight of them replied. During 44 operations the following data were recorded: Type and duration of the operation, number of times the lens and the trocar had to be cleaned. On the Internet and in a patents index [1] a search was conducted with the key words “thoracoscopy”, “trocar” and “bleeding”. All solutions for the problem mentioned above were listed. Ninety‐seven percent of surgeons answered and recognised the problem: 68% of the respondents considered it is a troublesome one. Data were collected during 44 operations. In 41% of the operations the problem did not occur, which means it was not necessary to clean either the lens or the cannula. In 34% it happened one to two times and in 25% of the procedures it occurred even more often. If it occurred, the scope had to be cleaned on average once in about 10 minutes and the trocar had to be cleaned once in about 15 minutes. The longer the operation lasted the more often the lens and/or the trocar had to be cleaned. Out of the 11 procedures that lasted less than 15 minutes, the trocar was never cleaned, and the lens had to be wiped only 0.18 times per procedure. Out of the 18 procedures that lasted more than 20 minutes, the lens was cleaned 2.8 times per procedure and the trocar 1.6 times per procedure. Soiling of the endoscope during thoracoscopic procedures is a real concern that calls for new technical solutions in order to make video‐assisted thoracic surgery safer for the patient and more pleasant to the surgeon.

A novel approach to hysterotomy using a verres needle with an innerdyne sheath: an unusual presentation of molar pregnancy requiring hysterotomy.

Objective: To describe a novel approach to hysterotomy in management of a molar pregnancy in a patient with a large cervical fibroid. The fibroid, measuring 18 × 14 × 12 cm had stretched and attenuated the cervical canal, rendering a transcervical approach an unsafe option. Design: Case Report. Materials/Methods: A 28 year old primigravida presented at 8 weeks gestation with a non viable intrauterine pregnancy suspicious for a hydatidiform mole, a serum β hCG level of 100,000 mIU/ml and status post failed methotrexate treatment. The patient had a large cervical fibroid measuring 18 × 14 × 12 cm that had elongated and attenuated the cervical canal, precluding transcervical evacuation. A minilaparotomy and hysterotomy was performed for evacuation of products of conception. Under intraoperative transuterine ultrasound guidance, a verres needle with an innerdyne sheath was introduced through the uterine fundus into the uterine cavity. The innerdyne sheath was expanded to accommodate a 10 mm laparoscopic trocar sheath. An 8 mm flexible suction curette was introduced through the trocar sheath and the uterine contents were evacuated by suction curettage. Results: Complete evacuation of the uterine cavity was confirmed on intraoperative transuterine ultrasound. There was minimal bleeding during the procedure and virtually no spillage of uterine contents. Following removal of the trocar sheath, the resulting myometrial defect was less than 1 cm and closed with a single stitch of 0 chromic catgut. Conclusions: Utilization of the verees needle with the innerdyne sheath for hysterotomy provided an atraumatic entry with separation of myofibers rather than transection as seen with classic hysterotomy, minimizing the possibility of dehiscence in a subsequent pregnancy. A complete mole was confirmed on histopathology of products. The postoperative course was significant for a rapid decline in serum β HCG levels to normalization within 4 weeks post evacuation.

A New Method of Laparoscopic Cholecystectomy Using Three Trocars Combined with Suture Retraction of Gallbladder

Since the establishment of laparoscopic cholecystectomy (LC) for benign gallbladder lesions, the four-trocar method has been the standard procedure. However, the fourth trocar generally is used just for fundic retraction of the gallbladder. We have developed a three-trocar method for LC and performed it in 132 patients. After the creation of the pneumoperitoneum, the first 10-mm trocar sheath was inserted in the subumbilicus for the endoscope, the second 5-mm trocar in the epigastric paramedian point for the working port, and the third 5-mm trocar in the subcostal area for grasping forceps. Monofilament nylon with a straight needle was inserted through the right 7th intercostal space in the anterior axillary line, and the seromuscular layer of the gallbladder fundus was punctured and retracted toward the anterior abdominal wall. After that, usual cholecystectomy was performed. Among the 132 patients who underwent the three-trocar method, 10 cases (8%) needed a fourth trocar. No patient was converted to open cholecystectomy. There were no significant differences in the operating time, the length of hospital stay after the operation, or the use of analgesics between the three-trocar and the four-trocar methods. No major complication was recognized. This method also has cosmetic advantages. Therefore, we believe this method might be recommended for LC.

The antero-inferior (transmuscular) approach for arthroscopic repair of the bankart lesion: An anatomic and clinical study

In order to find a direct approach to the antero-inferior third of the glenoid rim, an anatomic study was performed on a total of 89 shoulders (48 cadavers). To obtain defined reference points for the anterior inferior third of the glenoid cavity, it was compared with the hour markings on a clock face. The 4:30 position on the right shoulder and the 7:30 position on the left shoulder were defined as the relevant reference points. The average distance between the palpable end of the coracoid process and the 4:30 and 7:30 positions was 19 mm. The average distance to the point of intersection of the musculocutaneous nerve with the medial margin of the conjoined tendon was more than 5 cm, and was never less than 2 cm. The average distance of the axillary nerve from the 4:30 position was 2.5 cm in the horizontal plane, with a minimum of 1.5 cm. Radially, the average distance of the axillary nerve was 1.7 cm, with a minimum of 1.3 cm. The anatomic study was followed by a clinical study of 264 patients. An antero-inferior portal located maximium 2 cm distal from the palpable coracoid tip was selected for the introduction of a trocar sheath and blunt trocar, passing through the subscapularis muscle to access the antero-inferior area of the glenoid rim. As additional protection for the musculocutaneous nerve, the direction of the trocar was adjusted during introduction. Reattachment of the labrum-capsule complex was performed extra-articularly. In all cases, at least one implant was located inferior to the 4:30 or 7:30 position. No neurovascular complications arose out of the choice of portal. Out of the 264 patients, the first 100 shoulders (98 patients) were followed-up after an average time of 35 months (18 to 62 months). The recurrance rate was 9%. Excluding the first 30 shoulders (30 patients) from the development phase of the technique, the recurrance rate is only 5.7%. The rate of return to overhead sports activities was 62% and to collision sports activities 70%.

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.

Technical progress in pelvic surgery via operative laparoscopy

The development of an optimal set of instruments for perfect grasping, cutting, sucking, and ligating and of a new system to perform hemostasis by endocoagulation through a trocar sheath 7 to 11 mm in diameter permits effective laparoscopic surgery. A total of 2,000 operative laparoscopies were performed safely between 1973 and 1976. Since 1977, laparoscopic surgery has been extended to the following procedures: mymectomy (subserous), adnexectomy, ovarian cyst resection, removal of a cystoma, and tubectomy in cases of tubal pregnancy. In 82 such cases, no intraoperative or postoperative complications occurred. The normal postsurgical healing procedure has been checked during 18 second-look laparoscopies and two consecutive laparotomies. These technical advances have opened up a new era of gynecologic surgery based on operative laparoscopy.

Arthroscopic examination of the posteromedial compartment of the knee joint.

In a series of 356 arthroscopies of the knee joint 127 patients were explored by arthrotomy. A Storz arthroscope was introduced through the patellar tendon, and we alternated between the 30 degrees and 70 degrees optical systems in the same trocar sheath. The 30 degrees system was used for inspection of the superior, anterior, medial and lateral compartments, and to lead the tip of the instrument to the posterior part of the joint. The 70 degrees telescope was then used, providing a good view of the posterior cruciate ligament and the posterior horn of the menisci and their attachments. It also allowed direct inspection of the posterolateral and posteromedial compartments. No major diagnostic error was made by the arthroscopist in the 127 patients operated on as a result of the findings of endoscopic examination. Arthroscopy with the use of both 30 degrees and 70 degrees telescopes at the same session gives high diagnostic accuracy and detailed, exact pre-operative diagnosis.