All laparoscopic procedures, laparoscopic or robotic-assisted, start with a trocar entry. Unfortunately unknown to most, this is an extremely important part of the surgery, as 80% of major vascular injuries and 50% of intestinal injuries occur during this procedure. Laparoscopic first entry is often delegated to trainees with little experience, wrongly assuming that laparoscopic entry is similar to incisional entry at laparotomy. This may result in patient death (mortality of major vascular injuries is 11% and unrecognized intestinal injuries is 5%) or significant temporary or permanent morbidity.
Highlights
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Direct trocar entry and open Hasson technique seem to be associated with less complications.
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The use of Veress needle is more frequently associated with major complications.
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Noninvasive diagnostic tools can be used preoperatively to detect and locate abdominal wall adhesions.
Introduction
Trocar placement is an important step in laparoscopic and robotic surgery. The position, size, and number of trocars depending on planned surgery, patient’s body mass index (BMI), and previous abdominal or pelvic surgeries. The overall complication rate for gynecologic laparoscopic surgery is 0.6%, with mortality rate estimated at 1 per 30,000 patients . Because >50% of complications are related to the use of entry technique , particularly intestinal and major vascular injuries, trocar insertions should be always performed under the guidance of an experienced laparoscopist, after careful preoperative planning. Secondary trocar insertion must always be performed under direct vision, such that no visceral injury occurs.
Entry trocar injuries are serious, but avoidable, occurring five times more commonly with the blind (or closed) technique. Between 1993 and 1996, 629 trocar injuries were reported in the United States with all types of laparoscopic surgery, of which 64% (408 cases) were major vessel injuries, 28% (182 cases) were bowel injuries, and 8% were injuries of abdominal wall vessels. A total of 32 deaths occurred, of which 26 (81.5%) were due to major vessel injuries. The use of safety shields and direct-view trocars did not prevent major vessel injuries .
Laparoscopic first entry is commonly performed at the umbilicus, which is the shortest distance between the skin and peritoneum. This is true only if the incision is made at the deepest part of the umbilicus. There are two types of blind techniques: (1) direct trocar entry and (2) use of Veress needle to create a pneumoperitoneum followed by direct trocar entry. The open or Hasson technique consists of performing a small skin incision followed by fascia and peritoneum, and then safe entry with a blunt trocar. These techniques will be reviewed in this study, providing evidence regarding safety and feasibility.
Blind entry techniques
Blind entry of Veress needle and first trocar
Transumbilical
Establishing the pneumoperitoneum using this technique requires blind insertion of a needle (Veress or another type), followed by a blind primary trocar insertion. Despite this technique being the most frequently used among surgeons worldwide , important anatomical aspects should always be considered to reduce complications.
The deepest part of the umbilicus is the thinnest portion of the abdominal wall, which makes it preferable for first entry. This entry point is in close proximity to the aortic bifurcation, the distance being 0.4, 2.4, and 2.9 cm caudally in nonobese, overweight, and obese patients, respectively .
The angle of needle insertion is also important, which ranges from 45° (normal BMI patients) to 90° (obese patients) . Different safety tests have been recommended to verify the intraperitoneal placement of Veress needle. Only initial gas pressures <10 mmHg have a diagnostic value of correct placement of the Veress needle .
A safety measure consists in creating a high-pressure pneumoperitoneum of 25 mmHg to increase the distance between the anterior abdominal wall, small bowel and colon, and major vessels. The first trocar is randomly inserted at an angle of 45°, pointing toward the pelvis, with the patient in supine position ( Fig. 1 ) . A rule that is often ignored to follow is to proceed with an immediate exploration of the peritoneal cavity for the presence of free blood, visceral injuries, or a retroperitoneal hematoma, which would indicate a retroperitoneal vascular injury.
In a series of 3545 laparoscopic surgeries, eight cases of intraoperative bleeding were reported, two of which occurred during dissection of the hepatic hilum and were controlled by laparotomy. The remaining six cases occurred due to Veress or trocar insertion, with two aortic lesions requiring immediate conversion and the remaining four lesions involving omental or mesenteric vessels, of which three were repaired laparoscopically and one required laparotomy (colic artery hematoma) .
Left upper quadrant entry (Palmer’s point)
Palmer’s point access is an alternative to the classic transumbilical entry, which is used routinely by some surgeons, but more commonly reserved for patients who had previous abdominal or pelvic surgeries ( Fig. 2 ). The patient is in supine position with the stomach being decompressed with a nasogastric (NG) tube. The exact point of needle insertion in the left upper quadrant (LUQ) is 3 cm below the center of the left costal margin, perpendicular to the skin . Compared with the umbilicus, Palmer’s point is, on an average, at a distance of 10 cm from the aorta and 11.5 cm from the left kidney . The LUQ needle insertion should be considered in women with risk factors of periumbilical adhesions (midline incision) and a large pelvic mass . This technique involves the introduction of a 5-mm camera on the LUQ for intra-abdominal inspection and safe entry of the remaining trocars, such as the umbilical trocar . However, this is not free of complications. Gastric entry and spleen injury may occur in cases of stomach distention and splenomegaly .
Blind Trocar Entry (without Veress needle)
Direct trocar entry avoids the complications associated with the use of Veress needle, but does not eliminate injuries related to trocar. After a transumbilical skin incision, the abdominal wall is elevated and a sharp trocar is inserted at a random location in the peritoneal cavity pointing toward the pelvic hollow, with constant descending pressure. After successful insertion, CO 2 is connected to the trocar and a rapid pneumoperitoneum is obtained. The successful entry is verified by inserting a laparoscope, and the abdominal cavity is inspected for the presence of free blood, visceral injuries, and retroperitoneal hematoma .
Blind entry techniques
Blind entry of Veress needle and first trocar
Transumbilical
Establishing the pneumoperitoneum using this technique requires blind insertion of a needle (Veress or another type), followed by a blind primary trocar insertion. Despite this technique being the most frequently used among surgeons worldwide , important anatomical aspects should always be considered to reduce complications.
The deepest part of the umbilicus is the thinnest portion of the abdominal wall, which makes it preferable for first entry. This entry point is in close proximity to the aortic bifurcation, the distance being 0.4, 2.4, and 2.9 cm caudally in nonobese, overweight, and obese patients, respectively .
The angle of needle insertion is also important, which ranges from 45° (normal BMI patients) to 90° (obese patients) . Different safety tests have been recommended to verify the intraperitoneal placement of Veress needle. Only initial gas pressures <10 mmHg have a diagnostic value of correct placement of the Veress needle .
A safety measure consists in creating a high-pressure pneumoperitoneum of 25 mmHg to increase the distance between the anterior abdominal wall, small bowel and colon, and major vessels. The first trocar is randomly inserted at an angle of 45°, pointing toward the pelvis, with the patient in supine position ( Fig. 1 ) . A rule that is often ignored to follow is to proceed with an immediate exploration of the peritoneal cavity for the presence of free blood, visceral injuries, or a retroperitoneal hematoma, which would indicate a retroperitoneal vascular injury.
In a series of 3545 laparoscopic surgeries, eight cases of intraoperative bleeding were reported, two of which occurred during dissection of the hepatic hilum and were controlled by laparotomy. The remaining six cases occurred due to Veress or trocar insertion, with two aortic lesions requiring immediate conversion and the remaining four lesions involving omental or mesenteric vessels, of which three were repaired laparoscopically and one required laparotomy (colic artery hematoma) .
Left upper quadrant entry (Palmer’s point)
Palmer’s point access is an alternative to the classic transumbilical entry, which is used routinely by some surgeons, but more commonly reserved for patients who had previous abdominal or pelvic surgeries ( Fig. 2 ). The patient is in supine position with the stomach being decompressed with a nasogastric (NG) tube. The exact point of needle insertion in the left upper quadrant (LUQ) is 3 cm below the center of the left costal margin, perpendicular to the skin . Compared with the umbilicus, Palmer’s point is, on an average, at a distance of 10 cm from the aorta and 11.5 cm from the left kidney . The LUQ needle insertion should be considered in women with risk factors of periumbilical adhesions (midline incision) and a large pelvic mass . This technique involves the introduction of a 5-mm camera on the LUQ for intra-abdominal inspection and safe entry of the remaining trocars, such as the umbilical trocar . However, this is not free of complications. Gastric entry and spleen injury may occur in cases of stomach distention and splenomegaly .
