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Journal of Pediatric Surgery (2011) 46, 601–603

A simple way to fix a trocar during pediatric laparoscopyCarolina Millán, Horacio Bignon, Enrique Buela, Mariano Albertal,Gastón Bellía Munzón, Esteban Gallino, Marcelo Martinez-Ferro⁎

Department of Surgery, Fundación Hospitalaria, Private Children's Hospital, Ciudad Autónoma de Buenos Aires, Argentina

Received 5 July 2010; revised 11 September 2010; accepted 17 October 2010

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Key words:Pediatric laparoscopy;Trocar fixation;Plastic seal

Abstract We introduce a simple method of fixing trocars to the abdominal wall in children. After thetrocar is inserted into the abdominal wall, we place a 2/0 silk suture through the skin next to the trocar,then a sterile Nylon 6.6 plastic seal (Sumar Inc, Buenos Aires, Argentina) is wrapped around the trocarand the end of one of the sutures. Lastly, both suture ends are tied around the plastic seal. To further easeand speed the procedure, we recently introduced a plastic seal fastening device. This method is simple,fast, efficacious, and inexpensive and can be used with all trocar sizes.© 2011 Elsevier Inc. All rights reserved.

Trocar instability during pediatric laparoscopy is a tied around the plastic seal (Fig. 1D). The plastic seal can be

common problem, especially in small infants. Currentmethods used to prevent trocar displacement have significantlimitations. We present a simple method of trocar fixationduring pediatric laparoscopy.

1. Materials and methods

After the trocar is inserted into the abdominal wall, a 2/0silk suture nicks the skin close to the wound. Then, the sutureexits at the level of the wound next to the trocar (Fig. 1A).One suture end is laid parallel to the trocar (Fig. 1B), whereasthe other end runs parallel to the skin. Then, a sterile Nylon6.6 plastic seal (Sumar Inc, Buenos Aires, Argentina) iswrapped around the trocar including the suture end, which isadjacent to the trocar (Fig. 1C). Lastly, both suture ends are

⁎ Corresponding author. Tel.: +54 11 4704 6006; fax: +54 11 4702116.E-mail address: martinezferro@fibertel.com.ar (M. Martinez-Ferro).

022-3468/$ – see front matter © 2011 Elsevier Inc. All rights reserved.oi:10.1016/j.jpedsurg.2010.10.014

fastened either manually or with a plastic seal fasteningdevice (PSFD). The latter enables a faster and stronger seal(Fig. 1D-F). Plastic seals are available in various sizes,allowing proper fixation of all trocar sizes. All plastic sealsundergo ethylene oxide sterilization before their use. Tominimize skin puncture, we tend to nick the skin close to thewound to exit through the wound. Thus far, neither keloidformation nor skin/body disfiguration has been observedwith this technique.

2. Results

From 2005 to 2009, our group has performed a total of920 pediatric laparoscopic procedures with this method withproper fixation in all cases, even in obese patients (n = 185).Plastic seals were easy to handle and suitable for all trocarsizes. An average of 3 plastic seals per patient (cost, US$0.02-0.04 each) was used. Trocar fixation takes approxi-mately 25 seconds (range, 20-30 seconds) to accomplish.The use of a hand strapping device expedited the procedure

Fig. 1 Trocar fixation. A, After the insertion of a 5-mm trocar, a 2/0 silk suture is inserted into the skin, next to the wound. This suture willexit at the level of the wound, close to the trocar. B, A plastic seal is then placed around the trocar base including only 1 suture end, whereas theother end of the suture is lying parallel to the skin. C, The plastic seal fastened around the trocar base. Note that only 1 suture end has been fixedtogether with the trocar. D, A plastic seal fastening device is used to achieve strong gripping around the trocar. E, The plastic seal fasteningdevice has a sharp blade that enables section of the plastic seal remnants. F, A square knot is tied with both suture ends around the plastic seal.Trocar is successfully anchored preventing both inward and outward displacements.

602 C. Millán et al.

and improved trocar fixation in 107 patients. There were nocomplications related to trocar fixation.

3. Discussion

Proper trocar fixation is paramount during pediatriclaparoscopic surgery because displacement may lead to anarray of intraoperative complications such as air leakage,instrument clash, loss of triangulation, and organ perfora-tion, among others. Nonetheless, trocar fixation cansometimes be cumbersome in infants because of theirsmall body habitus.

Various methods have already been described for theprevention of trocar displacement [1-5]. One of them is theuse of a rubber catheter or sleeve (Red Robinson catheter)that is fixed through the skin and fascia [6]. These sleevesmay be difficult to insert because of their large outerdiameter, particularly in small infants. Furthermore, it isoften a challenge to find the best-suited rubber catheter sizefor each trocar size and brand, often rendering the trocar

either too loose or too tight inside the catheter. Bax and vande Zee [1] have reported another method, which is to tie aknot through the skin/subcutaneous fascia and around theinsufflation nipple of the trocar followed by application ofadhesive tape. We personally try to refrain from usingadhesive material because it may hamper surgical skills andimpregnate surgical instruments. The use of a Hasson trocarmay prevent dislodgement because this type of trocar is tiedto the fascia. In addition, this trocar is wedged into theabdominal wall by a ring, which prevents it from beingpushed in. Yet, its large outer diameter makes it unsuitablefor children. Radially expanding trocars, unlike conven-tional ones, stretch the abdominal wall, enabling adequatefixation with less trauma and abdominal pain than withconventional trocars. However, cost constraints may limittheir use [7,8]. Our method has several advantages. It israther straightforward, inexpensive, and suitable for alltrocar sizes. In addition, the use of PSFD allows for astrong grip with no intraoperative time delay. Thus, werecommend the use of the PSFD during trocar fixation witha plastic seal.

603A simple way to fix a trocar during pediatric laparoscopy

4. Conclusion

We propose our method for all sorts of laparoscopicpediatric procedures because it is an easy and effective wayto perform proper trocar fixation.

References

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