The Safety of Laparoscopy Performed by Direct Trocar Insertion and Carbon Dioxide Insufflation Under Vision

Abstract

The records of 6,173 laparoscopies performed by specialist gynaecologists in the course of routine gynaecological care using the technique of direct insertion of the umbilical trocar and insufflation of carbon dioxide under vision were reviewed to ascertain the incidence of serious complications. A review of the published literature on laparoscopy methodology was also undertaken to complement the data obtained from this study. The nature of the records precluded accurate assessment of both indications and minor complications. There were 4 perforating bowel injuries (0.06%) requiring laparotomy (s small intestine, 2 large intestine). There were no cases of major vascular injury or gas embolus necessitating surgical or resuscitative measures. On 3 of the 4 occasions where bowel injury occurred the patients had undergone prior abdominal surgery and had midline vertical subumbilical incisions. Review of the published literature demonstrated bowel or vessel perforation rates (requiring laparotomy or resuscitation) of 1 in 1,000 regardless of whether the method of gaining peritoneal access was open (Hasson) technique, Verres needle insufflation, or direct trocar. Direct trocar insertion may reduce the risk of gas embolism by insufflating only after intraperitoneal replacement has been confirmed, moreover it allows immediate recognition and rapid treatment of major blood vessel laceration, both of which have been identified as being crucial in reducing laparoscopy associated mortality. When compared to other available methods of gaining peritoneal access for laparoscopy, direct trocar insertion followed by insufflation of carbon dioxide under vision can be performed with the same degree of safety for the patient. It is simply wrong to deduce from the available data that one particular technique of gaining peritoneal access is superior to another. Each have their individual advantages and disadvantages and similar morbidity when performed by experienced operators with appropriate indications. In light of this observation, each alternative should be considered by the individual surgeon to assess which would best suit his or her operating technique and the particular circumstance of each patient. Indeed preference should be given to the method with which the surgeon is most comfortable or with which he or she has the most experience.

Trocar and Veress needle injuries during laparoscopy

“…Introduction of both the first trocar and the Veress needle near the umbilicus and at the suprapubic site is associated with a higher rate of perforating injuries [5,18]. In the current series, 17 of 26 TI and NI were related to one of these two locations.…”

“…Thereafter, the first trocar, which is often placed near the umbilicus, is introduced blindly into the peritoneal cavity. Alternatively, the first trocar can be inserted blindly without prior creation of the pneumoperitoneum [4,18]. However, this modified closed technique has rarely been adopted by general surgeons in Switzerland due to the increased risk of bowel perforations.…”

“…Special attention should be paid to small bowel injuries because their recognition is often delayed; subsequently, the morbidity is markedly increased [14,15,18]. If there is only a slight leakage without obvious extravasation, the laceration is likely to remain unrecognized intraoperatively.…”

The First Trocar Entry in the Laparoscopic Cholecystectomy, Which Technique?

“…Major blood vessel injury risk is 3-9/10000 dir [10]. The most imminent complications are damage to the large blood vessels, empty organ injuries and formation of gas emboli [11]. No significant differences could be found between DT insertion and VN methods in the prospective randomized comparative studies [5][6][7][8][9][10][11][12].…”

“…The most imminent complications are damage to the large blood vessels, empty organ injuries and formation of gas emboli [11]. No significant differences could be found between DT insertion and VN methods in the prospective randomized comparative studies [5][6][7][8][9][10][11][12]. Although the minor complication rate of the VN group was observed higher than that of the DT group in our investigation, no significant differences regarding major complication rates were observed between both groups.…”