This document discusses trocar issues in laparoscopy. It notes that the initial trocar insertion is the most dangerous step and can result in injuries to the bowel or vasculature in over 50% of cases. It recommends inserting the first trocar at the umbilicus as it has minimal intervening tissue. Away from the midline poses risks of injuring major blood vessels. Direct trocar insertion is an alternative that may decrease operative time compared to Veress needle. However, no single technique is proven safest and complications can occur regardless of approach. Immediate conversion to open surgery is needed if a vascular injury is suspected.

1. 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

2. 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

3.  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)

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

5. 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
theVeress needle or primary trocar because
the skin is attached to the fascia and anterior
peritoneum with minimal intervening muscle
or fat.

6. 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.

7. 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)

8. Chances of Adhesions
 According toVilos 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)

9. 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 aVeress needle prior to
insertion of the primary trocar.

10. 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. DirectTrocar Insertion: A Safe Laparoscopic Access. The
Internet J of Gynecol and Obstetrics. 2007;Vol 8, No. 2)

11. Alternative sites
 If the patient has a BMI greater than 30, a history of midline incision
or failed three attempts at passage of theVeress 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-culdesac
have been described but should not be used due to a high risk of
complications.**
( Vilos GA,TernamianA, Dempter J, Laberge PY. Laparoscopic Entry:A Review ofTechniques,
Technologies, and Complications. J ObstetGynaecolCan. 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)

12. 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)

13. Confirmation Tests
 Teoh has shown that the most effective way to confirm
intraperitoneal placement of theVeress 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 theVeress needle
can increase from 1.6 mm to 1 cm.
(Teoh B, Sen R, AbbottJ. An evaluation of four tests used to ascertainVeres needle placement at closed laparoscopy. J
Min Invasive Gynecol. 2005; Mar-Apr; 12(2): 153-8)

14. Conversion
 Various authors have studied this and an intraabdominal
pressure of 10-15 mmHg seems most appropriate.
 If unsuccessful in placing theVeress needle after three
attempts, one should consider using Palmer’s point for
theVeress 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)

15. 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 ofTrocar and Insufflation Needle Access Systems in
Laparoscopic Surgery. J AmColl Surg. 2009;Vol 209(2): 222-32)

16. 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.

17. 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

18. 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
theVeress needle approach to 2.2 minutes with the
direct entry approach.*
(Mahajan NN, Gaikwad NL. DirectTrocar Insertion:A Safe LaparoscopicAccess.
The Internet J of Gynecol and Obstetrics. 2007;Vol 8, No. 2)

19. 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

20. 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
TrocarWithout Pneumoperitoneum Is Safe and Effective in the Morbidly Obese.
Surgical Innovation. 2008;Vol 15(2): 126-31)

21. 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)

22. 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.

23. 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.

24. 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.

25. Minor bleeding
 In some circumstances of minor venous
bleeding occur, hemostasis can be done by
applying pressure, increasing the insufflation
pressure, and a clip or suture closure.*
(Pemberton RJ,Tolley DA, vanVelthoven RF. Prevention and Management of Complications in
Urological Laparoscopic Port Site Placement. European Urology. 2006; 50:958-68)

26. 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

27. 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 trocar
removal to ensure that there is no bleeding that
was tamponaded by the trocar itself.
 This bleeding can often be stopped by cautery or
pressure.

28. 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 theVeress needle into the location
of the epigastric vessels and transilluminating
the abdominal wall prior to inserting
secondary trocars.

29. 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, KrummelTM,Way LW.Trocar Injuries
in Laparoscopic Surgery. J Am Coll Surg. 2001; 192:677-83)

30. 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, vanVelthoven RF. Prevention and Management of
Complications in Urological Laparoscopic Port Site Placement. European Urology.
2006; 50:958-68)

31. 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.

32. Subcutaneous emphysema
 This can cause increased CO2 absorption leading
to respiratory acidosis and hypercapnia.
 This is best prevented by keeping insufflation
pressures 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, vanVelthoven RF. Prevention and Management of Complications
in Urological Laparoscopic Port Site Placement. European Urology. 2006; 50:958-68)

33. Gas embolism
 If gas embolism is suspected, insufflation
should be stopped and the peritoneal cavity
vented.
 The patient should be placed in the left lateral
decubitus position andTrendelenburg (head
down).
 In addition, a central line can be inserted into
the right ventricle and gas bubbles may be
aspirated.20

34. Delayed complications
 There are also delayed complications
regarding trocar insertion.
 These include trocar site infection, tumor
implantation, endometriosis implantation
and incisional hernia.

35. 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.

36. 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)

37. 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)

38. 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)

39. 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.

40. THANK YOU