Direct Trocar versus Veress Needle Entry for Laparoscopy: A Randomized Clinical Trial

Abstract

Aims: To compare direct trocar (DT) to Veress needle (VN) entry for the creation of pneumoperitoneum during laparoscopy with regard to the duration of the procedure, volume of gas used, ease of performance, and frequency of complications. Design: A randomized clinical trial. Subjects and Methods: One thousand patients scheduled to undergo diagnostic laparoscopy were recruited for the study. They were randomly allocated to either DT entry (group A, n = 500) or VN (group B, n = 500) for pneumoperitoneum. The laparoscopic procedures were performed by the same surgeon. Outcomes: The duration of the procedure, volume of gas consumption, ease of performance and frequency of complications were analyzed. Results: Patients in the 2 groups had similar demographic characteristics. The mean duration of the procedure was significantly shorter in group A (2.2 ± 0.7 min, 95% CI 2.14–2.26) than in group B (8.2 ± 1.4 min, 95% CI 8.08–8.32; p < 0.0001). The mean gas consumption was significantly less in group A (2.6 ± 0.9 liters, 95% CI 2.52–2.68) than in group B (8.4 ± 2.6 liters, 95% CI 8.17–8.63; p < 0.0001). No major complications in both groups were encountered. Minor complications were significantly less in group A (0.4%, 95% CI 0.77–3.23) than in group B (14%, 95% CI 10.96–17.04; p < 0.0001). Conclusions: DT entry is a safe alternative to the VN entry technique for the creation of pneumoperitoneum. Such an approach has further advantages such as less cost and instrumentation and rapid creation of pneumoperitoneum.

Direct Trocar Insertion for Laparoscopy

“…The method of directly inserting the first trocar for laparoscopy without establishing pneumoperitoneum was first described by Dingfelder more than 32 years ago, but so far, it has been used mainly by gynecologists. 12–17,22 The reported benefits of this method are a shorter operation time, near exclusion of entry failure, and above all the possibility of the immediate recognition of any kind of intraabdominal iatrogenic injuries. 6–22 …”

“…12–17,22 It is undoubtedly true that, although still a blind technique, it reduces the number of “blind steps” from 3 with the Veress needle (insertion, insufflation, and first trocar introduction), to just one, the one of trocar introduction. It is correctly reported that with DTI it is possible to immediately recognize any injury caused by DTI and to laparoscopically repair that injury at once.…”

“…It is correctly reported that with DTI it is possible to immediately recognize any injury caused by DTI and to laparoscopically repair that injury at once. 12–17,22 Some surgeons report the OL technique as the gold standard technique. Yet in the international literature, it is shown that in cases where the midline is not safe to approach, the Veress needle technique is used as a valid alternative with good results and no morbidity.…”

“…They all suggest that one or other technique is superior without, up to now, sufficient corroborating evidence. 1–3,6–8,10,12–21 …”

Y a-t-il des indications et des contre-indications propres à chaque technique (ouverte ou fermée) de réalisation du pneumopéritoine ?

“…Zakherah et al ont réalisé une étude randomisée contrôlée comparant l'accès à la cavité périto-néale sans pneumopéritoine préalable à la technique avec l'aiguille de Veress. Ils ont trouvé que la technique avec accès direct donnait moins de complications et que c'était une technique sûre pour la création du pneumopéritoine [15]. Agresta et al ont montré dans une étude randomisée contrôlée portant sur 598 patients non obèses qu'il n'existait pas de différence significative du taux de complications entre la mise en place du premier trocart sans pneumopéri-toine préalable et la technique avec l'aiguille de Veress (0 vs 0,3 % taux de complications) [16].…”