Trocar

Issues

In

Laparoscopy

Dr.T.Varun Raju

D.N.B (Surgery),FIAGES,FMAS

Consultant Laparoscopic Surgeon

Durgabai Deshmkh Hospital & Research Centre

Hyderabad,Telangana State

First Trocar Entry

This initial step in establishing

pneumoperitoneum is done blindly with

either a Veress needle or trocar.

The initial trocar insertion is the most

dangerous aspect of trocar use and likely

the most dangerous step in minimally

invasive surgery

It is well established that over 50% of the trocar-related injuries to the bowel and vasculature are during the initial entry.*

Unfortunately, 30-50% of the bowel injuries and 15-50% of the vascular injuries are not diagnosed at the time of injury.

(Vilos GA, Vilos AG, Abu-Rafea B, Hollett-Caines J, Nikkhah-Abyaneh Z, Edris F. Three simple steps during closed laparoscopic entry may minimize major injuries. Surg Endosc. 2009; 23:758-764)

There are also several non-life threatening complications including wound infection and incisional hernia that are important as well.

Best site of insertion

Understanding of abdominal wall anatomy and its relationship with the viscera and vessels below is crucial for safe placement of trocars.

The umbilicus is the best site for insertion of the Veress needle or primary trocar because the skin is attached to the fascia and anterior peritoneum with minimal intervening muscle or fat.

Away from the midline

Once one gets away from the midline, the major vessels that can be injured are the superior and inferior mesenteric arteries. These course just beneath the rectus abdominis muscles.

Their usual location is in the mid portion of the rectus sheath running longitudinally.

By transilluminating the abdominal wall, many of these can be seen and avoided.

Vascular Injuries

In thin people, the distance between the abdominal wall and the retroperitoneal vessels may be less than 2 cm.

Also, the distal aorta and right common iliac artery are particularly vulnerable to injury since the junction of these two vessels is directly below the umbilicus.*

( Anaise D. Vascular and Bowel Injuries During Laparoscopy. Internet. www.danaise.com/vascular_and_bowel_injuries_duri.htm. Aug. 16, 2009)

Chances of Adhesions

According to Vilos et al. the rates of adhesions are 0%to 0.68% in those without any previous abdominal surgery, 0% to 15% in those with previous laparoscopy, 20% to 28% in those with previous laparotomy through a low transverse incision and 50% to 60% in those with a previous midline laparotomy.*

(Vilos GA, Ternamian A, Dempter J, Laberge PY. Laparoscopic Entry: A Review of Techniques, Technologies, and Complications. J Obstet Gynaecol Can. 2007;29(5):433-447)

Primary and Secondary Trocars

The initial trocar that is inserted is called the primary trocar and all others are secondary trocars.

There are two broad categories to consider for insertion of the primary trocar.

These are the percutaneous or the open method.

In addition, if the percutaneous method is chosen, then one must decide whether or not to establish pneumoperiteum with a Veress needle prior to insertion of the primary trocar.

Real fact

The fact that there are various techniques for insertion confirms that none has proved to be totally efficacious or complication free.2

(Mahajan NN, Gaikwad NL. Direct Trocar Insertion: A Safe Laparoscopic Access. The

Internet J of Gynecol and Obstetrics. 2007; Vol 8, No. 2)

Alternative sites

If the patient has a BMI greater than 30, a history of midline incision or failed three attempts at passage of the Veress needle, an alternate site is recommended for insertion.

The preferred site is Palmer’s point, which is 3 cm below the left costal margin in the midclavicular line.*

Other alternative sites such as trans-uterine and trans-culdesachave been described but should not be used due to a high risk of complications.**

( Vilos GA, Ternamian A, Dempter J, Laberge PY. Laparoscopic Entry: A Review of Techniques, Technologies, and Complications. J Obstet Gynaecol Can. 2007;29(5):433-447)

** (As M. Laparoscopic entry: Techniques complications and recommendations for prevention of laparoscopic injury. Internet. www.laparoscopyhospital.com. Aug 24, 2009)

Safety technique

Lifting the abdominal wall may improve safety by increasing the distance between the abdominal wall and the viscera.

Lifting the abdominal wall by placing towel clips within 2 cm of the umbilicus has been shown to provide significant elevation of the peritoneum (6.8 cm above the viscera) that was maintained during insertion.*

(Vilos GA, Ternamian A, Dempter J, Laberge PY. Laparoscopic Entry: A Review of Techniques, Technologies, and Complications. J Obstet Gynaecol Can. 2007;29(5):433-447)

Confirmation Tests

Teoh has shown that the most effective way to confirm intraperitoneal placement of the Veress needle is initial gas pressure <10 mmHg.

The other techniques, including the double click test, the aspiration test, and the saline drop test are not useful in confirming placement.8

There is danger in wiggling the needle back and forth once in place, as a puncture to a vessel or bowel loop made by the Veress needle can increase from 1.6 mm to 1 cm.

(Teoh B, Sen R, Abbott J. An evaluation of four tests used to ascertain Veres needle placement at closed laparoscopy. J Min Invasive Gynecol. 2005; Mar-Apr; 12(2): 153-8)

Conversion Various authors have studied this and an intraabdominal

pressure of 10-15 mmHg seems most appropriate.

If unsuccessful in placing the Veress needle after three attempts, one should consider using Palmer’s point for the Veress needle insertion or convert to an open technique.7

(As M. Laparoscopic entry: Techniques complications and recommendations for prevention of laparoscopic injury. Internet. www.laparoscopyhospital.com. Aug 24, 2009)

Trocar A trocar has 2 components to it.

There is an inner, removable obturator and the outer port or cannula, which remains in place to allow instruments to pass through.

There are two major designs that are found in the majority of trocars, cutting and dilating trocars.

The cutting trocars have a metal or plastic blade that cuts through the tissue as force is applied.

The dilating system uses a blunt, tapered tip that separates and dilates the tissue as it is inserted.*

(Passerotti CC, Begg N et al. Safety Profile of Trocar and Insufflation Needle Access Systems in Laparoscopic Surgery. J Am Coll Surg. 2009; Vol 209(2): 222-32)

Trocar

There are two major designs that are found in the majority of trocars, cutting and dilating trocars.

The cutting trocars have a metal or plastic blade that cuts through the tissue as force is applied.

The dilating system uses a blunt, tapered tip that separates and dilates the tissue as it is inserted.

Dilating versus Cutting

The study by Shafer comparing the insertion forces, removal forces, and defect size shows that radially dilating trocars require the most insertion force with the cutting systems requiring the least.

The defect sizes were larger with the bladed trocars compared to the dilating systems

Direct Entry This was first described by Dingfelder in 1978.

This is done with either via direct trocar insertion or optical trocar insertion.

It has been shown that direct entry techniques do decrease operative time by decreasing the laparoscope insertion time from 5.9 minutes with the Veress needle approach to 2.2 minutes with the direct entry approach.*

(Mahajan NN, Gaikwad NL. Direct Trocar Insertion: A Safe Laparoscopic Access. The Internet J of Gynecol and Obstetrics. 2007; Vol 8, No. 2)

No Technique is safe

There have been many studies done comparing the safety of the open technique to the closed and direct entry techniques.

There have been variable results.

There has been no obvious advantage of one technique over another

Optical Trocar

There are several problems with the other approaches in the obese patient.

There are multiple studies showing the optical trocar to be a safe and effective method of entry in the obese (35 kg/m2).*

( Rabl C, Palazzo F, Aoki H, Campos GM. Initial Laparoscopic Access Using an Optical Trocar Without Pneumoperitoneum Is Safe and Effective in the Morbidly Obese. Surgical Innovation. 2008; Vol 15(2): 126-31)

Predicting Adhesions

It has been found that 75-90% of patients who have had previous abdominal surgery have adhesions.

More importantly, autopsy studies have shown that 10% of patients that have had no abdominal surgery show adhesions.

Even scars away from the midline may result in umbilical adhesions.*

(Anaise D. Vascular and Bowel Injuries During Laparoscopy. Internet. www.danaise.com/vascular_and_bowel_injuries_duri.htm. Aug. 16, 2009)

Convert to open surgery Once a potentially serious vascular injury is

suspected, immediate conversion to an open procedure must be considered.

Direct compression of the bleeding site is the quickest and safest way to gain initial control of blood loss, especially with a venous injury.

If the patient exhibits unstable vital signs, adequate volume replacement, while controlling the blood loss, must take place prior to attempting repair of the injury.

Vascular repair

If the bleeding site is difficult to see, early and wide exposure of the site and the surrounding structures must be obtained.

The vessel wall must be repaired with precise intima to intima apposition without tension.

Take help of a Vascular surgeon

Venous injuries may be best handled by ligation rather than suture repair if the patient is unstable.

If ligation of a vessel does not lead to ischemia, definitive repair may be postponed until the patient is stable and/or when the appropriate vascular surgeon is available.

Minor bleeding

In some circumstances of minor venous bleeding occur, hemostasis can be done by applying pressure, increasing the insufflationpressure, and a clip or suture closure.*

(Pemberton RJ, Tolley DA, van Velthoven RF. Prevention and Management of Complications in Urological Laparoscopic Port Site Placement. European Urology. 2006; 50:958-68)

Abdominal wall vessels

Routine injection of lidocaine with epinephrine may decrease skin edge bleeding.

Direct pressure by rotating the tip against the bleeding site.

A foley catheter can be passed into the port site, and after inflating the balloon, outward traction is applied to put pressure on the abdominal wall

Abdominal wall bleeding

If transmural suturing is done, the sutures need to be removed early (around 24 hours) to prevent full thickness abdominal wall necrosis.

One should also visualize all ports after trocarremoval to ensure that there is no bleeding that was tamponaded by the trocar itself.

This bleeding can often be stopped by cautery or pressure.

Transillumination

Delayed bleeding can usually be managed conservatively with observation.

Bleeding from the smaller abdominal wall vessels can usually be avoided by not placing trocars or the Veress needle into the location of the epigastric vessels and transilluminatingthe abdominal wall prior to inserting secondary trocars.

Repair Immediately

According to Bhoyrul,the injuries happen if the viscera is unusually close to the point of insertion and when the trocar penetrates too far into the abdominal cavity.*

If a bowel injury is recognized at the time of the injury, it needs to be repaired at that time.

(Bhoyrul S, Vierra MA, Nezhat CR, Krummel TM, Way LW. Trocar Injuries in Laparoscopic Surgery. J Am Coll Surg. 2001; 192:677-83)

Repair Immediately

The surgeon has to then decide if he has the ability to repair the damage laparoscopically or convert to open.

For visceral injuries, liver and spleen, management includes applying pressure, increasing the insufflation pressure and consideration of suturing and thrombin sealants for ongoing bleeding.

(Pemberton RJ, Tolley DA, van Velthoven RF. Prevention and Management of Complications in Urological Laparoscopic Port Site Placement. European Urology.2006; 50:958-68)

Delayed injuries

Injuries that are at higher risk for complications, such as those found in a delayed fashion, are best handled by open repair, washout, and proximal diversion.

Subcutaneous emphysema This can cause increased CO2 absorption leading

to respiratory acidosis and hypercapnia.

This is best prevented by keeping insufflationpressures around 12 mmHg and accurate port placement prior to insufflation.

If the hypercapnea is severe, mechanical hyperventilation and possible cardiovascular support may be necessary.*

(Pemberton RJ, Tolley DA, van Velthoven RF. Prevention and Management of Complications in Urological Laparoscopic Port Site Placement. European Urology. 2006; 50:958-68)

Gas embolism

If gas embolism is suspected, insufflationshould be stopped and the peritoneal cavity vented.

The patient should be placed in the left lateral decubitus position and Trendelenburg (head down).

In addition, a central line can be inserted into the right ventricle and gas bubbles may be aspirated.20

Delayed complications

There are also delayed complications regarding trocar insertion.

These include trocar site infection, tumor implantation, endometriosis implantation and incisional hernia.

Wound infection

The principles for treatment are antibiotics, local wound and drainage of pus if abscess is found

The ways to attempt to prevent these wound infections are prophylactic antibiotics for the specific procedure that is being done, placing any contaminated specimen inside a protective pouch prior to removing it from the skin and irrigation of the port sites prior to closure.

Implantation of tumor cells The incidence is quite low, about 1% for colorectal and 2.3

% for gynecologic malignancies.*

Poor surgical technique such as improper handling of the tissue is the most likely cause.

There are other mechanisms investigated including hematogenous spread, aerosolization, and direct wound implantation.

Various preventative strategies including retrieval bags for specimens, wound protectors, intraperitoneal agents, port site excision, alternative insufflations strategies, and peritoneal wound closures have been tried.*

(Nagarsheth NP, Rahaman J, Cohen CJ, Gretz H, Nezhat F. The Incidence of Port-Site Metastases in Gynecologic Cancers. JSLS. 2004; 8: 133-39)

Endometriosis Endometriosis in port sites is quite rare.

This can be found in patients with known endometriosis and those undergoing laparoscopic hysterectomy without evidence of endometriosis.

The treatment is excision of the implant.

Preventative measures include avoidance of implantation of fragments during morcellization.

(Farace F, Gallo A, Rubino C, Manca A, Campus GV. Endometriosis in a trocar tract: is it really a rare condition? A case report. Minerva Chir. 2005 Feb;60(1):67-9)

Incision hernia

The incidence of incision hernias in a

trocar site is 21/100,000.*

The most prevalent recommendations are

that all fascial puncture sites that are 10

mm or more should undergo fascial

closure.*(Sirito R, Puppo A, Centurioni MG, Gustavino C. Incisional hernia on the 5-mm trocar

port site and subsequent wall endometriosis on the same site: A case report. Am J Obstst Gynecol. 2005; 193: 878-80)

CONCLUSIONS No single technique or instrument has been proven to

completely eliminate laparoscopic entry associated injury.

The decision on which method of laparoscopic entry to use comes down to each individual surgeon’s choice.

Safe access depends on adhering to well recognized principles of trocar insertion, knowledge of abdominal anatomy, and recognition of the hazards imposed by previous surgery.

If a complication is encountered, timely and thorough investigation and repair will limit patient morbidity and mortality.

THANK YOU