How Do You Know if Your Trocar Injury Is Bad

J Gynecol Endosc Surg. 2009 Jan-Jun; ane(one): 4–xi.

Entry Complications in Laparoscopic Surgery

S Krishnakumar

Nirmiti Fertility and IVF Centre, Thane, India

P Tambe

Nirmiti Fertility and IVF Centre, Thane, India

Abstract

To review the complications associated with laparoscopic surgery and provide clinical direction regarding the best practise based on the all-time available evidence. The laparoscopic entry techniques and technologies reviewed include the classic pneumoperitoneum (Veress/trocar), the open up (Hasson), the direct trocar insertion, the use of disposable shielded trocars, radially expanding trocars and visual entry systems. Medline, Pubmed and Cochrane Databases were searched for English language manufactures published before Dec 2008. Information technology is an evidence based fact that minimal admission surgery is superior to conventional open surgery since this is beneficial to the women, customs and the healthcare organization.Over the past 50 years, many techniques, technologies and guidelines have been introduced to eliminate the risks associated with laparoscopic entry. No single technique or musical instrument has been proved to eliminate laparoscopic entry associated injury. Proper evaluation of the women, supported past surgical skills and good noesis of the technology and instrumentation is the keystone to safe access and prevention of complications during laparoscopic surgery.

Keywords: Directly trocar, entry, laparoscopy complications, laparoscopy, open up access (Hasson) technique, pneumoperitoneum, shielded trocar, veress needle, visual entry arrangement

INTRODUCTION

Laparoscopic surgery has evolved over the by 2 decades to at present be accepted as the method of starting time choice for tackling most gynaecological problems.

A meta-analysis of 27 randomised controlled trials comparison laparoscopy and laparotomy for beneficial gynaecological procedures concluded that the risk of pocket-size complications after gynaecological surgery is 40% lower with laparoscopy than with laparotomy, although the run a risk of major complications is like.[1]

Access into the abdomen is the one challenge of laparoscopy that is particular to the insertion of surgical instruments through small incisions. Access is associated with injuries to the alimentary canal and major blood vessels and at least 50% of these major complications occur prior to commencement of the intended surgery.[two–3] This complication rate has remained the same during the past 25 years.

Abdominal access and the cosmos of a pneumoperitoneum in the initial phase of any laparoscopic surgery carry a significant adventure of bowel and vascular injuries. These are unique to laparoscopic surgery and are rarely seen in an open up surgery.

Increased morbidity and bloodshed effect when surgeons or patients do non recognise injuries early or do not address them quickly.[4] The postoperative rather than intraoperative recognition of these injuries increases the severity of the sequelae as well as the medicolegal liability.

INCIDENCE OF LAPAROSCOPIC ENTRY COMPLICATIONS

In Republic of finland after seventy,607 laparoscopic procedures, 256 complications were reported to the national patient insurance association. The overall rate of major complications was one.4 per ane,000 procedures. This included 0.6 per 1,000 intestinal injuries, 0.3 per 1,000 urological injuries and 0.ane per 1,000 vascular injuries.

In the Netherlands, a multicentric prospective study from 72 hospitals revealed the overall incidence of abdominal injuries and major complications was five.seven per i,000 procedures. 70% of these were related to the master port entry. The overall incidence of laparoscopic entry injuries was iii.3 per 1,000. In that location were 29 cases of gastrointestinal damage (i.3 per i,000) and 27 cases of abdominal vessel injuries (one.05 per 1,000).

To minimise entry-related injuries, several techniques, instruments and approaches have been introduced during the last century. These include the Veress-pneumoperitoneum trocar; classic or closed entry,[5] the open (Hasson) technique,[6] direct trocar insertion without prior pneumoperitoneum,[7] use of shielded disposable trocars,[eight–9] optical Veress needle,[10,11] optical trocars,[12,xiii] radially expanding trocars[14,15] and a trocarless reusable, visual access cannula.[xvi,17] Each of these methods of entry enjoys a sure caste of popularity according to the surgeon'southward training, experience and bias according to regional and interdisciplinary variability.

COMMON ENTRY COMPLICATIONS DURING LAPAROSCOPIC SURGERY

Studies have suggested that thirty-50% of bowel injuries and 13-l% of vascular injuries are undiagnosed at the time of surgery. Since bowel injury is more than common than vascular injury, it is more likely to produce serious sequelae because of the delay in diagnosis. The bloodshed rate from bowel injury is 2.five-5%.[18]

Vascular injuries

Major vascular injury during the initiation of a pneumoperitoneum is a much feared complexity of laparoscopic procedures. Vascular injury is a major cause of death from laparoscopy, with a reported mortality charge per unit of xv%. Major vascular injury can occur when the Veress needle is inserted prior to insufflation or when a trocar is inserted afterwards insufflation.

The reason for these injuries is the close proximity of the anterior abdominal wall to the retroperitoneal vascular structures. In thin patients, this distance may be as piffling as ii centimeters. The distal aorta and correct common iliac avenue are especially prone to injury. This is not surprising given the fact that the take off of the right mutual iliac artery lies straight below the omphalus [Figure ane].

Structures encountered during entry through the omphalus

Minor vascular injuries are so named since these are injuries to vessels of lesser importance than the aorta, junior vena cava and iliac vessels. Still, these are by no means minor in nature.

The near common pocket-sized vascular injury is to the inferior epigastric vessels, occurring in upward to ii.5% of laparoscopic hernia repairs. There were 76 cases of pocket-sized vascular injuries involving principally the epigastric vessels in a review of x,837 patients undergoing a hernia repair. These injuries invariably occur during the placement of the secondary cannulas which should exist placed under directly vision and with prior transillumination of the abdominal wall. Although injury to the epigastric vessels is still possible if these measures are taken, the incidence should be dramatically reduced [Table 1].

Table 1

Factors responsible for large vessel injury

Bowel injuries

Bowel injury is the third crusade of death from a laparoscopic procedure subsequently major vascular injury and anaesthesia. Unlike major vascular injuries where the take a chance and presentation are firsthand, many bowel injuries go unrecognised at the fourth dimension of the procedure. Consequently, patients present postoperatively, frequently after discharge with peritonitis. This delay makes it a pregnant cause of morbidity and mortality.

A big survey of virtually 37,000 gynaecologic laparoscopies in the Usa revealed a 0.16% incidence of bowel injury. 39.8% of vascular and intestinal injuries were caused past the Veress needle, 37.nine% by insertion of the principal trocar and 22% by the insertion of the secondary trocar.

Urological injuries

Unlike vascular or bowel injuries, urological injuries are mostly related to the gynaecological procedure being performed and not to entry lone. The incidence of bladder injury during laparoscopic hysterectomy ranges from 0.02-8.3%.[19] Harkki-Siren noted urinary tract injuries in ii.5 per 1,000 laparoscopies, the majority occurring during laparoscopic hysterectomies.[20]

Ureteric injuries occur in approximately 1% of cases. These are more common in complex surgical procedures such as hysterectomy, urinary stress incontinence and/or genital prolapse procedures and astringent endometriosis resection.

CARBON DIOXIDE GAS EMBOLISM

The incidence of carbon dioxide embolism was 0.001% in a review of 489,335 closed laparoscopies. Several instance reports have detailed fatal or almost-fatal coronary, cerebral or other gas embolism.[21] Such a complexity has not been reported at open laparoscopy.

SUGGESTED STEPS FOR Rubber ENTRY

Classic entry technique and Veress needle safety tests

Bullheaded Veress needle insertion and insufflation followed by blind trocar insertion is the technique most widely used. I third to one one-half of major intra-abdominal vascular and intestinal injuries occurs from the Veress needle itself.

Important procedural steps during insertion of the Veress needle are [Figure 2]:

Veress entry technique and intra-intestinal pressure

The following tests should exist done to confirm the presence of the needle in the peritoneum and not in a visceral organ.

1. Manometer examination – involves connecting the gas tubing to the Veress needle and raising the abdominal wall to create negative pressure.

2. Hissing sound test – involves turning the valve to the off position later on it has been properly positioned. The abdomen is elevated and the valve opened, creating a hissing audio.

3. Aspiration exam – involves attaching a syringe filled with saline to the Veress needle and attempting to aspirate whatsoever fabric. If material is aspirated such equally bowel contents or urine, the Veress needle should be removed. If blood is aspirated, the needle is left in place and training for exploratory laparotomy is fabricated for a presumed vascular injury.

4. If no cloth is aspirated, 5 mL of saline is inserted and a reattempt to aspirate is fabricated. If no fluid can exist aspirated, entry into the peritoneal cavity is confirmed. If the saline is aspirated, an enclosed space was probably entered such as the preperitoneal infinite and the needle should be repositioned.

5. Hanging drib exam – involves placing a driblet of water on the open up cease of the Veress needle and the abdominal wall is elevated. If the needle is correctly positioned, the water should disappear downwards the shaft. Until confirmation of proper position of the needle, insufflation should be low at a rate of ane L/min.

6. Finally, the needle is attached to an insufflator that measures the pressure at the tip. The pressure level will be low (5 mm Hg) if it is accordingly placed. Insufflation to 12-xv mm Hg with carbon dioxide gas follows.

One time this pressure is accomplished, a 10 mm trocar with or without a rubber shield is placed blindly into the abdomen. Information technology must exist emphasized that a full pneumoperitoneum should be established prior to insertion of the bullheaded umbilical trocar. Once again, care must be taken to elevate and stabilise the abdominal wall and to ensure that the trocar is inserted in the midline safely.

Value of prophylactic tests

Although these tests and techniques may be helpful in accessing the peritoneal cavity, the fact that visceral and vascular injuries occur shows that they are not foolproof. A contempo retrospective written report evaluating the double click sound test, aspiration test, hanging drop of saline examination and the syringe test concluded that none of these tests is confirmatory for the intraperitoneal placement of the Veress needle and ended that the most valuable test is to detect the actual insufflation pressure to be viii mm or less and that the gas is flowing freely.[22]

Some surgeons waggle the needle from side to side, believing that this shakes an attached organ from the tip of the needle and confirms correct intra-abdominal placement. Nevertheless, this manoeuvre tin can overstate a 1.6 mm puncture injury to an injury of upwards to ane cm in viscera or blood vessels.[23]

Veress intraperitoneal pressure

Prospective studies have concluded that initial intra-intestinal pressures of 10 mm Hg or below indicate correct placement of the Veress needle, regardless of the adult female'due south body habitus, parity or historic period.[24] A contempo report has confirmed that the initial intraperitoneal insufflation pressure (less than and equal to 10 mm Hg) correlates positively with the patient'due south weight and BMI and negatively with parity.[25]

Angle of Veress needle insertion

Hurd et al. reported on CT scans of 38 unanaesthetised women of reproductive historic period that the position of the umbilicus was found, on average, 0.4 cm, 2.4 cm and 2.9 cm caudal to the aortic bifurcation in normal weight (BMI < 25 kg/one thousandⁱⁱ), overweight (BMI 25-30 kg/m²) and obese (BMI >thirty kg/k²) women respectively. In all cases, the umbilicus was cephalad to where the left common iliac vein crossed the midline at the sacral promontory. Therefore, the angle of Veress needle insertion should vary accordingly from 45 degrees in non-obese women to xc degrees in very obese women [Effigy iii].[26]

Angulation of Veress' needle in obese patients

Number of insertion attempts

Studies take reported placing the Veress needle into the peritoneal crenel on the first endeavour at frequencies of 85.5-86.ix%; two attempts required in 8.5-11.6%, three attempts in 2.half dozen-3.0% and more than three attempts in 0.3-1.6%.

Complexity rates associated are: one attempt 0.8-16.three%, two attempts 16.31-37.v%, three attempts 44.4-64% and more than three attempts 84.six-100%. The complications associated were extraperitoneal insufflation, omental and bowel injuries and failed laparoscopy.[27]

Acceptable pneumoperitoneum

Controversy exists regarding what constitutes an "adequate" pneumoperitoneum prior to insertion of the main trocar. Traditionally it has been defined as achieving a book of 1-4 litres depending on the BMI and parity of the patient. This is unremarkably accomplished past an intra-peritoneal pressure of 10-15 mm Hg.

It has been shown that achieving a high intraperitoneal force per unit area (HIP) entry ranging from 20-25 mm Hg increases the gas bubble and produces greater splinting of the anterior intestinal wall and maintains a distance of at least four centimeters from the abdominal contents. It also increases the altitude between the umbilicus and bifurcation of the aorta from 0.six cm (at force per unit area of 12 mm Hg) to 5.9 cm.[28]

HIP entry thus allows easy entry of the primary trocar and minimises the run a risk of vascular injury. It does not adversely bear on cardiopulmonary function in good for you women.

Culling VERESS NEEDLE INSERTION SITES

Left upper quadrant (LUQ, palmer'southward point)

In patients with a previous laparotomy, Palmer advocated insertion of the Veress needle three centimeters below the left subcostal border in the midclavicular line.[29] This may exist considered in the obese as well as in the very sparse patient. The stomach should exist emptied by nasogastric suction and the needle should be introduced perpendicular to the skin. Patients with previous splenic or gastric surgery, portal hypertension or significant gastropancreatic masses should be excluded.

Transuterine and trans cul-de-sac

Using a long Veress needle, pneumoperitoneum has been established through the fundus of the uterus transvaginally.[thirty] This has especially been helpful in obese women.[31] The posterior vaginal fornix has been reported as another site through which to institute pneumoperitoneum, especially in obese women.[32]

However, these 2 sites are not routinely recommended as they behave the risk of sepsis and the take a chance of perforation of the rectum in the presence of pelvic inflammatory disease or severe endometriosis.

9^thursday or ten^th intercostal infinite

The Veress needle is inserted directly through the intercostals infinite at the anterior axillary line forth the superior surface of the lower rib to avoid injury to the underlying neurovascular bundle.[33]

ALTERNATIVE Means OF ENTRY

Open laparoscopy

In general, trocar injuries to abdominal viscera occur a) when the viscera are unusually close to the point of trocar insertion or b) where the trocar penetrates too far into the intestinal cavity as it is inserted. The former can exist anticipated when the patient has undergone a surgery previously. The best method of fugitive visceral injury in this case is to use the open Hasson technique or if the closed technique is used to identify the first trocar at a site remote from the previous incision.

The concept in the open technique [Figure 4] is to create a tiny incision, directly incise the layers of the abdominal wall, directly cut the peritoneum and enter the abdomen. Since gas can escape around the incision, an olive is placed over the stop of the trocar to occlude the incision and sutures are placed on the abdominal fascia and attached to the cannula.

The proposed advantages for the open technique are avoidance of blind puncture with a needle and subsequent trocar, certainty of establishing a pneumoperitoneum and correct anatomical repair of the abdominal wall incision.

Widespread employ of this technique has been limited to women with previous lower abdominal surgery, pregnant women, children and very thin women where lilliputian space exists betwixt the abdominal wall and the spine. Reasons for limiting the use of the open technique include greater time needed for performance, difficulty with the technique, obese patients and difficulty in maintenance of the pneumoperitoneum.

There are considerably fewer reports of bowel and major vascular injury in the literature using this technique than the Veress needle technique. Penfield noted a 0.06% incidence of bowel injury but the injuries were more often than not partial and were recognised immediately considering of the proximity of the bowel to the wound.

Hasson presented his review of 5,284 women who had open laparoscopies and developed complications related to primary access. 21 had small-scale wound infections, four had minor haematomas, one developed an umbilical hernia that required surgery and one had an inadvertent injury to the modest bowel that was repaired intraoperatively without adverse outcome. Access to the abdominal cavity was more often than not secured within three to ten minutes.[34]

A meta-analysis of 760,890 closed laparoscopy and 22,465 open up laparoscopy cases reported the incidence of vascular injury rate in closed laparoscopy was 0.44% compared with 0% in open laparoscopy. The incidence of bowel injury was 0.7% compared with 0.v% respectively. The authors ended that the open (Hasson) technique eliminates the risk of vascular injury and gas embolism and reduces the take a chance of bowel injury and recommend the open technique to be adopted for primary laparoscopic entry.

Direct trocar entry

Dingfelder in 1978 was the first to advocate this technique in which where the belly is entered with a trocar without prior Veress needle entry and pneumoinsufflation. The advantages of this method are the avoidance of complications related to the utilize of the Veress needle: failed pneumoperitoneum, preperitoneal insufflation, intestinal insufflation and CO₂ embolism.

The direct entry method is faster than any other method of entry but is the least performed laparoscopic technique in clinical practice.

In the United States, a review of 51 publications including 21,547 open up technique, sixteen,739 direct entry technique and 134,917 Veress/trocar reported entry related bowel injuries: 0.xi% (open up), 0.05% (direct entry) and 0.04% (Veress/trocar). Vascular injury rates were 0.01%, 0% and 0.04% respectively.[35]

Dispensable shielded trocars

These are designed with a shield that partially retracts and exposes a sharp tip as it encounters resistance through the abdominal wall. Equally the shield enters the abdominal crenel, it springs forward and covers the sharp tip of the trocar.

Withal, there is a brief moment when the sharp trocar tip is exposed and unprotected as it enters the abdominal crenel.[36]

RADIALLY EXPANDING Admission SYSTEM

These are non recommended as being superior to traditional trocars. They have blunt tips that may provide some protection from injuries by the forcefulness required for entry is significantly greater than with disposable trocars.

Optical trocar/Visual entry systems

The optical trocar allows visualisation of the layers of the intestinal wall on the monitor and these are cutting under vision by advancement of the edge of the cannula which is surgically sharp or conical. This allows the surgeon to advance through the layers to the peritoneum in a clear area where there is no bowel. Jirecek et al. reviewed 1500 patients in whom no major complications were observed in the Optiview insertion group as compared to the group undergoing blind insertion.

Challenging situations

Previous abdominal surgery

This group of patients clearly represents a risk factor for adhesion germination. Brill et al. studied 360 women undergoing operative laparoscopy after a previous laparotomy. Patients with prior midline incisions had significantly more than adhesions (58 of 102) than those with Pfannenstiel incisions (70 of 258). 28% (21 patients) suffered direct injury to the adherent omentum and bowel during the laparoscopic procedure.

Adhesions may exist correct nether a scar or may exist farther away. Some investigators have recommended a preoperative sonographic mapping of adhesions to help decide a safe site for trocar insertion. A midline incision clearly presents a high risk for bowel adhesions under a planned umbilical trocar site; all the same, even scars away from the umbilicus can lead to adhesions at the umbilical site.

Alternative sites may be used for admission with open up or blind access techniques. I advantage of placing the first port in a site abroad from previous scars is the improved ability to see the abdominal cavity because vision is not obscured past adhesions. This allows for amend assessment of location of remaining ports. Also, in that location is appropriate working distance necessary for manipulating the instruments.

Obesity

The almost major technical problem in this group of patients is access to the abdominal cavity, which is especially hard with the needle insertion technique. Attributable to the thickness of the abdominal wall and the preperitoneal fatty, accurate assessment of the location of the needle tip is difficult, making preperitoneal insufflation mutual.

The umbilicus is the thinnest area of the abdominal wall and needle insertion at this point is the easiest. The saline drop test and confirmation of an initial low intra-abdominal pressure are crucial in confirming proper intra-abdominal placement.

Another alternative is the employ of the open insertion technique with a Hasson trocar. Controversy exists over the advantages and disadvantages of this admission technique compared with a closed technique in obese patients. Some investigators believe that a large skin incision is necessary for Hasson trocar insertion in obese patients, leading to preoperative leakage of gas and to increased rates of wound infection postoperatively.

Studies suggest that the utilize of optical trocars may be beneficial and may reduce the unacceptable risk of vascular and bowel injury in this group of women.

Large pelvic mass

In this group of women, selecting an alternative supraumbilical site for principal entry volition allow the greatest freedom of motility for manipulation of instruments equally well every bit offer greater safety vis-à-vis damage to the pelvic mass e.g. fibroid, ovarian tumour or pregnancy.

RECOMMENDATIONS

The patient must exist properly evaluated, including a full clinical history and thorough clinical examination and relevant investigations.

Clear explanations must be offered and information given regarding the associated risks and potential complications associated with laparoscopic surgery and the possibility of conversion to laparotomy if the clinical circumstances so dictate.

The surgeon must have adequate preparation and experience in laparoscopic surgery before intending to perform whatsoever procedure independently. He should be familiar with the equipment and instruments he intends to utilise.

There is no unmarried safe technique that reduces laparoscopic surgery entry complications in low risk patients. The surgeon should select the technique which he feels about comfortable with. It is recommended that the HIP entry be used to optimise the insertion of the primary trocar and cannula.

The open (Hasson) technique and Palmer's indicate pneumoperitoneum should exist considered in the obese patient and those with suspected peri-umbilical adhesions.

The dissimilar Veress needle safe tests are non sensitive indicators for the correct placement of the Veress needle. The most confirmatory test is to observe that the actual intra-peritoneal force per unit area is beneath 8 mm Hg and gas is flowing freely. Excessive move of the needle should be avoided as this will convert a tiny puncture to vessel or bowel from ane.6 mm to 1 cm diameter.

The distension pressure level should be reduced to 12-14 mm Hg once the insertion of the trocar is complete to avert cardiopulmonary complications and gas embolism.

After introduction of the telescope, the bowel should be inspected for obvious injury and abdomen visualised for presence of adherent bowel around the umbilicus.

CONCLUSIONS

The only surgeon who does not encounter complications is one who is non operating. All procedures take their risks. Complications can occur even in the best of hands and information technology is vital that these are recognised promptly and immediately addressed.

The importance of proper grooming and the value of experience is clear. It must exist our goal to train our future laparoscopic surgeons in the necessary skills and encourage the development of specially designed fellowships for those performing the most advanced procedures.

When complications practice occur, excellent training and experience will allow these to be managed past laparoscopy.

Footnotes

Source of Support: Nil

Conflict of Interest: None.

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Source: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3304260/

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