The safety and efficacy of direct trocar insertion with elevation of the rectus sheath instead of the skin for pneumoperitoneum

Abdominal access in endoscopic surgery carries a finite risk of visceral injury. Bleeding, subcutaneous emphysema, gastrointestinal tract perforation, minor and major vascular injury, and intraperitoneal adhesions are the potential complications associated with abdominal access and creation of pneumoperitoneum. There are 4 basic techniques used to create pneumoperitoneum: blind Veress needle, direct trocar insertion, optical trocar insertion, and open laparoscopy. Veress needle and direct trocar insertion are blind techniques, and their use can result in severe visceral and vascular injuries. To prevent visceral and vascular injuries caused by the technique used for the creation of pneumoperitoneum, laparoscopic surgeons and gynecologists look for safe and effective laparoscopic access techniques. Direct trocar insertion without previous pneumoperitoneum was reported to be a safe alternative to Veress needle insertion. We carried out this study to compare the ease of use, safety, and efficacy of direct trocar insertion with elevation of the rectus sheath and blind insertion of the Veress needle in laparoscopic surgery. In 578 laparoscopic procedures, the patients were assigned to one of the following groups: blind insertion of the Veress needle (group 1, n = 301) and direct trocar insertion with elevation of the rectus sheath using 2 towel clips (group 2, n = 277). Total complication rates were 15.7% (n = 33) and 3.3% (n = 4) in groups 1 and 2, respectively (P < 0.05). Direct trocar insertion with elevation of the rectus sheath using 2 towel clips is an easy, safe, and effective technique.     

Comparison of direct trocar and veress needle insertion in the performance of pneumoperitoneum in laparoscopic cholecystectomy

Veress needle insertion, direct trocar insertion and open technique are different methods of establishing pneumoperitoneum to perform a successful laparoscopic procedure. We conducted this study to compare the use of a Veress needle and direct trocar insertion to create pneumoperitoneum. 274 laparoscopic cholecystectomy operations were evaluated. There were no significant differences in the age and gender between Veress needle and direct trocar entry groups. In this study we have seen that the complication rate while performing pneumoperitoneum by direct trocar entrance was less than in Veress needle usage. Direct trocar entrance also reduces the operation time. In laparoscopic cholecystectomy the direct trocar entrance method is a more reliable and less time consuming method than Veress needle usage.     

Safe Veress needle insertion

Background/Purpose For laparoscopic surgery, the creation of pneumoperitoneum still remains a must. The insertion of a Veress needle or a trocar is never perfectly safe, and almost every kind of intraabdominal organ injury due to these insertions has been reported worldwide. Here, we describe a safe technique for creating pneumoperitoneum. Methods For the creation of pneumoperitoneum, under direct vision, the linea alba was elevated with two towel clips and then the Veress needle was inserted. We reviewed 368 patients operated on with this technique for complication rates. Ultrasound images were obtained before and during abdominal-wall lifting in 10 patients. Results There were no injuries due to the insertion of the Veress needle or trocars. In 90% of the patients, pneumoperitoneum was created successfully on the first attempt. Ultrasound examination demonstrated a mean extra safe area of 11.8 mm during abdominal-wall lifting with this technique. Conclusions Elevating the linea alba during Veress-needle insertion is safe.     

Direct trocar insertion technique: an alternative for creation of pneumoperitoneum.

OBJECTIVES: The direct trocar insertion technique (DTI) for the creation of pneumoperitoneum has been described as an alternative to open and Veress needle (VN) techniques. This study assesses the safety and feasibility of direct trocar insertion without a pre-existing pneumoperitoneum in patients undergoing elective laparoscopic procedures. METHODS: From November 2001 to February 2006, we retrospectively studied 196 (146 women and 50 men) consecutive patients. A single consultant laparoscopic surgeon performed all operations. The mean patient age was 57 years (range, 22 to 81). The procedures included 186 laparoscopic cholecystectomies, 3 laparoscopic appendectomies, 1 laparoscopic Nissen, 5 laparoscopic groin hernia repairs, and 1 conversion to open surgery. RESULTS: Creation of pneumoperitoneum with DTI was feasible in 99.5% of patients. No major complications were associated with the technique. Immediate minor postoperative complications included 1 (0.5%) wound infection and 3 (1.5%) hematomas. At mean follow-up of 23 months, 4 (2%) umbilical wound stitch granulomas and 1 (0.5%) incisional hernia from the umbilical port site were observed. CONCLUSION: This study shows that that when performed by an experienced laparoscopic surgeon the direct trocar insertion technique is a safe and effective alternative for creation of pneumoperitoneum.     

Comparison of Direct Trocar and Veress Needle Insertion in the Performance of Pneumoperitoneum in Laparoscopic Cholecystectomy

Veress needle insertion, direct trocar insertion and open technique are different methods of establishing pneumoperitoneum to perform a successful laparoscopic procedure.

We conducted this study to compare the use of a Veress needle and direct trocar insertion to create pneumoperitoneum. 274 laparoscopic cholecystectomy operations were evaluated. There were no significant differences in the age and gender between Veress needle and direct trocar entry groups.

In this study we have seen that the complication rate while performing pneumoperitoneum by direct trocar entrance was less than in Veress needle usage. Direct trocar entrance also reduces the operation time. In laparoscopic cholecystectomy the direct trocar entrance method is a more reliable and less time consuming method than Veress needle usage.     

New technique for optical control of the first trocar insertion

BACKGROUND: In laparoscopic surgery serious complications caused by the blind insertion of the first trocar have been reported even after the pneumoperitoneum is established by means of a Veress needle. As a consequence, some techniques to safely insert the first port have been developed. Many surgeons advocate a minilaparotomy to position the first port. However, especially in obese patients, the dissection to insert the Hasson's trocar may be difficult and time consuming. As an alternative, optical disposable trocars have been studied and produced to be safely positioned under direct visualization. METHODS: A new technique to insert, under adequate optical control, a non disposable standard port is described. Personal experience in 126 consecutive patients is reviewed. Data were recorded prospectically and insertion time was recorded in every case. RESULTS: Medium time of trocar insertion was 55 sec (range 30-160 sec). Identification of distinct layers of the abdominal wall was always possible. There were no complications related to the insertion of the first reusable cannula under visual control. CONCLUSIONS: This technique may be considered a safe, simple and cost effective method to insert the first trocar.     

High-pressure trocar insertion technique.

BACKGROUND: The majority of laparoscopic complications occur at the time of Veress needle and trocar insertion. Although not very frequent, they increase the morbidity and mortality of both diagnostic and operative laparoscopic procedures. Alternative techniques of trocar insertion have been described but have not completely eliminated the risk of injury. TECHNIQUE: After Veress needle insertion and establishment of pneumoperitoneum to 25 to 30 mm Hg, insertion of a short trocar is performed in the deepest part of the umbilicus without elevation of the anterior abdominal wall. The result is a parietal peritoneal puncture directly beneath the umbilicus. The high-pressure setting used during initial insertion of the trocar is lowered as soon as safe abdominal entry is documented. EXPERIENCE: The trocar insertion technique described above was performed in 3041 procedures. No vascular injury occurred. There were two bowel perforations. No complications related to the increased intra-abdominal pressure were observed. CONCLUSION: The high-pressure abdominal entry technique has the advantage of reducing intra-abdominal trocar-related injuries without requiring additional instrumentation or additional training.     

Comparison between direct trocar and Veress needle insertion in laparoscopic cholecystectomy

Although the Veress needle (VN) is widely used for insufflation of the peritoneum, direct trocar (DT) insertion is going to be more popular. A lot of complications have been reported because of the use of VN. We designed a prospective, nonrandomized study for the comparison of VN and DT insertion techniques. A pneumoperitoneum was created using the VN in 135 patients and using DT insertion technique in 148 patients during a 3-year period. Although no major complication was seen in the DT group, three major complications were seen in the VN group, but there was no statistically significant difference between both groups. More frequent minor complications were seen in the VN group, but it was statistically insignificant. Surgical skill and experience of the surgeon with the entry technique who is using it is an important factor for the selection of the abdominal insufflation technique.     

Experience with the optical access trocar for safe and rapid entry in the performance of laparoscopic gastric bypass

Background In laparoscopic surgery, serious complications caused by the blind insertion of trocars are well known. The open technique is compromised by the leakage of carbon dioxide and can also be time consuming, especially in morbidly obese patients. Our aim was to determine whether the optical access trocar can be used to establish a safe and rapid entry during laparoscopic gastric bypass. Methods The data on a single surgeon’s experience with 370 laparoscopic gastric bypass procedures during a 4-year period were reviewed. The Optiview trocar was used for all except the initial 21 patients. The entry time for the optical trocar was measured in 10 patients. Results Of the 370 patients undergoing laparoscopic gastric bypass from November 2000 to September 2004, the initial 21 were treated using the standard Veress needle to create the pneumoperitoneum. The next 22 were treated using the Veress needle to create the pneumoperitoneum, followed by insertion of the optical access trocar in the left upper quadrant as the initial trocar. From this point to the present, the optical access trocar has been inserted without the use of a Veress needle. There have been no trocar-related bowel or vascular injuries in the entire series. The mean optical trocar insertion time was 28 ± 1.2 s. Conclusions This is the first laparoscopic gastric bypass series to report the results of its experience with the optical access trocar. This device provides a safe and rapid technique for placement of the initial trocar for laparoscopic gastric bypass. Insertion of the optical trocar with a 10-mm laparoscope into the left upper quadrant is our procedure of choice for obtaining the pneumoperitoneum in this patient population.     

The direct trocar technique: an alternative approach to abdominal entry for laparoscopy.

OBJECTIVE: The direct trocar technique is an alternative to Veress needle insertion and open laparoscopy for accessing the abdominal cavity for operative laparoscopy. We review our approach to abdominal entry in 1385 laparoscopies performed between September 1993 and June 2000 by our group at Stanford University Hospital, a tertiary Medical Center. METHODS: We performed a retrospective chart review of 1385 patients who underwent operative laparoscopy during the study years. The mode of abdominal entry, patient demographics, and complications were reviewed. RESULTS: The transumbilical direct trocar entry method was used in 1223 patients. In 133 patients, the Veress needle insertion technique was used. Open laparoscopy was used in 22 patients. Three (0.21%) major complicadons occurred: 1 enterotomy, 1 omental herniation, and 1 bowel hemiation. One complication was related to primary access (0.072%) in a patient who had an open laparoscopy. She sustained an enterotomy during placement of the primary trocar. The bowel was repaired laparoscopically. No trocar-related injuries occurred among the 1223 patients in whom the direct trocar entry technique was used. One patient had an omental herniation and required a repeat laparoscopy on postoperative day 2. The second patient had a repeat laparoscopy on the 12th postoperative day to repair a bowel herniation. None of our patients required a laparotomy. No vascular injuries occurred. CONCLUSION: Based on our experience, the direct trocar technique is a safe approach to abdominal entry for laparoscopic surgery.     

Safe creation of pneumoperitoneum using an optical trocar

The blind insertion of the Veress needle and the first trocar may cause serious complications. Therefore, many surgeons perform a minilaparotomy to safely position the first trocar. However, especially in obese patients, the dissection may be difficult and time consuming. As an alternative, optical trocars can be safely positioned under direct visualization. We report on our experience with the Optiview trocar in 200 patients and describe our preferred insertion technique. In our opinion, optical trocars are safe and easy to handle, offering several advantages over the use of the Veress needle and the minilaparotomy. Received: 19 February 1998/Accepted: 28 May 1998     

Efficacy of establishment of pneumoperitoneum with the Veress needle, Hasson trocar, and modified blunt trocar (TrocDoc): a randomized study

PURPOSE: To compare three techniques of establishment of pneumoperitoneum for efficacy: the Veress needle/first trocar, the Hasson trocar, and a newly developed modified blunt trocar, the TrocDoc. PATIENTS AND METHODS: Between June and December 1999, 62 patients eligible for laparoscopic surgery were randomized. The effectiveness of installation of the pneumoperitoneum using the three techniques was assessed by time-motion analysis. Primary efficacy measures were total time and number of actions required to establish the pneumoperitoneum. Secondary efficacy measures were procedure-related complications, wound complications, and occurrence of CO2 leakage. RESULTS: Two patients were withdrawn from inclusion. The three groups were comparable for age and body mass index. Total time was shortest using the TrocDoc rather than the Veress needle/first trocar and the Hasson trocar (respectively, 138 +/- 58 v 237 +/- 56 v 350 +/- 103 seconds), and the number of actions was lowest for the Veress needle/first trocar combination: 22 +/- 7 v 32 +/- 12 (TrocDoc) v 53 +/- 17 (Hasson). There was no morbidity related to the installation of pneumoperitoneum nor trocar wound complications. Gas leakage occurred in five of the Hasson introductions. CONCLUSIONS: Establishment of the pneumoperitoneum is more efficient using the TrocDoc compared with the Veress needle/first trocar and the Hasson trocar. The TrocDoc might replace the two alternatives because of its efficacy and open method of introduction.     

Direct Trocar Insertion without Pneumoperitoneum and the Veress Needle in Laparoscopic Cholecystectomy: a Comparative Study

Purpose: The purpose of this study is to compare the safety and complications of direct trocar insertion without pneumoperitoneum (DTI) with Veress needle (VN) in laparoscopic cholecystectomy (LC). Methods: We studied 84 patients admitted to our hospital for LC, in a random simple blind design, 42 patients were assigned to DTI and 42 to VN. The variables analysed were: procedure complications, laparoscope insertion time and duration of surgery.

Results: Complication percentages between the groups were significantly different (DTI 2.3% versus VN 23.8%, p = 0.009). The duration of surgery between the two groups was also significantly different (DTI 56 ±31 versus VN 71 ± 28 minutes, p < 0.02). Finally, laparoscope insertion time between the two techniques was significantly different (DTI 1.5 ± 0.5 versus VN 3.0 ± 0.4 minutes p < 0.001).

Conclusions: Our results show DTI to be a safe, efficient, rapid and easily-learned alternative technique, reducing the number of procedure-related complications.     

Safety of the Veress needle in pediatric laparoscopy

PURPOSE: To better establish the complication rate with the Veress needle technique for establishing a pneumoperitoneum in pediatric laparoscopy. PATIENTS AND METHODS: We reviewed all pediatric laparoscopy cases performed by a single surgeon from 1996 to 2003. There were 257 patients ranging in age from 4 months to 19 years. Infraumbilical placement of the Veress needle was used to create a pneumoperitoneum. All instances of preperitoneal insufflation, vessel/viscus injury, and forced conversion to open surgery were recorded. The length of time required to establish pneumoperitoneum was reported in the last 139 patients. RESULTS: The average length of time required to gain access to the peritoneum was <2 minutes. Of these procedures, 138 were performed for nonpalpable undescended testicles, 101 for varicoceles, 13 for duplication anomalies, and 5 for intersex disorders. There were 18 cases (7.0%) of preperitoneal insufflation. No cases resulted in vessel/visceral injury, conversion to open surgery, conversion to use of the Hassan trocar technique, or inability to complete the procedure because of complications in establishing a pneumoperitoneum. In all cases of preperitoneal insufflation, proper access was achieved by pulling the needle out and reinserting it at a different angle, with pneumoperitoneum being achieved easily in each case. CONCLUSION: The use of the Veress needle to establish pneumoperitoneum in children of all ages is safe, fast, and efficacious.     

Establishment of pneumoperitoneum with a modified blunt trocar

Veress needle and trocar-related accidents have caused many surgeons to adopt the Hasson technique for establishment of pneumoperitoneum, but this technique also has drawbacks. A modification of the sharp trocar has been developed that overcomes the disadvantages of the Veress needle and Hasson trocar.     

Modification of the peritoneoscopic technique of peritoneal dialysis catheter insertion: experience of an interventional nephrology program

Bowel perforation is a well-recognized complication of peritoneal dialysis catheter insertion and is associated with increased morbidity and cost of medical care. In this article we describe our 2-year experience (August 2001-October 2003) with a modified peritoneoscopic technique of peritoneal dialysis catheter insertion to minimize the incidence of bowel perforation. Seventy patients underwent 82 consecutive peritoneal dialysis catheter insertions using the innovative technique. The modified technique is very similar to the traditional peritoneoscopic procedure except for the following differences. To gain access to the peritoneal cavity, a Veress insufflation needle (Ethicon Endo-Surgery Inc., Cincinnati, OH) is utilized instead of the trocar. In contrast to the sharp tip of the trocar, the Veress needle has a blunt, self-retracting end. In addition, the Veress needle is only 14 gauge as opposed to the 2.2 mm diameter of the trocar. Upon introduction of the Veress needle into the abdominal cavity, two "pops" are discerned similar to the trocar. After introduction, 400-500 cc of air are infused and the needle is removed. The infusion of air creates a space between the peritoneal surface of the anterior abdominal wall and the bowel loops. At this point, the cannula with trocar is inserted into the space created. The rest of the steps of the procedure are the same as the traditional peritoneoscopic technique. Utilizing the innovative technique, all 82 catheter insertions were performed successfully without a single bowel perforation. No other complications except for catheter migration (n = 2) were noted. The extra cost of the needle (35 USD) should be viewed in the context of the costs associated with management of a bowel perforation. Large-scale studies are needed to confirm the superiority of this innovative technique over the traditional peritoneoscopic insertion found in our case series. In the interim, however, the increased morbidity and cost associated with bowel perforation calls for logical measures to be taken to avoid this dreaded complication.     

Safety of Veress needle for laparoscopic entry in children: Myth or reality?

IntroductionRecent reports suggested that blind laparoscopic entry techniques, including Veress needle (VN), might increase the risks of potentially fatal complications.Materials and methodsAll consecutive patients who underwent laparoscopy in two Pediatric Hospitals with the use of a Veress needle during a 14-year period have been included. In all cases the first trocar was a radially expanding one (STEP). Complications related to the insertion technique are reported as well as those related to the whole laparoscopic technique.ResultsA total of 3463 patients younger than 18 years of age underwent laparoscopy between January 2006 and December 2019. Of these, 205 (5.9%) were younger than 6 months of age at surgery. Two-hundred-eighty-four patients (8.2%) previously underwent abdominal surgery. During first trocar insertion no major or minor vascular injuries occurred. Two patients (0.06%) experienced bowel lesions. Nine (0.26%) experienced failed entry. Fourteen patients (0.4%) experienced postoperative issues related to trocars positioning, namely, 9 omental eviscerations through port site insertion and 5 cases of hemoperitoneum owing to epigastric vessels lesion during operative trocar positioning. No other issues strictly related to laparoscopic entry technique have been recorded during the study period. No specific risk factors predisposing to complications have been identified but the presence of a positive history of previous abdominal procedures proved to be significantly related to a higher occurrence of bowel injury during Veress needle insertion (p = 0.0067).Discussion and conclusionsAlthough with a number of biases and limitations, our study suggests that creation of pneumoperitoneum with VN combined to first trocar entry with STEP technology in children can represent a safe alternative. An exception is represented by patients who underwent previous abdominal surgeries who should be approached with caution, possibly with an open approach. Anyway, given the relatively poor quality of high-quality studies on this regard, we strongly support the implementation of well-designed RCT in children in order to answer this delicate topic.Type of studyRetrospective.Level of evidenceIV     

Our choice of the method to induce pneumoperitoneum in videolaparoscopic surgery

BACKGROUND: In laparoscopic surgery, pneumoperitoneum may be obtained either by a blind or an open access technique. These two techniques and the advantages of Hasson technique are compared. METHODS: Through January 1998 and May 1999, 262 unselected patients underwent laparoscopic surgery; pneumoperitoneum was obtained with a random technique, while in the patients previously operated on the open technique was always performed. In 161 cases (61.5%) pneumoperitoneum was obtained with Hasson technique and in 101 (38.5%) with Veress technique. All the patients were clinically evaluated after surgery and then after 30-40 days. The complications encountered were always associated with the Veress needle blind access: peritoneal space insufflation in 3 cases, greater omentum insufflation in 3 cases, 4 cases of difficult management and only one case of incisional hernia on the umbilical wound. RESULTS: Our data confirm that Hasson open technique is safer than Veress blind technique as the risk of severe early and late complications is lower. CONCLUSIONS: The open laparoscopic technique with the Hasson trocar is recommended as it showed to be a quicker, safer and superior technique for obtaining pneumoperitoneum.     

Open Veress Assisted technique. Results in 2700 cases

AIM: The risks of specific complications of the laparoscopic technique, caused by pneumoperitoneum and by insertion of the first trocar, although rare, are frequently reported in literature. METHODS: A retrospective study of the complications we had in the period from October 1998 to December 2006 was made on 2700 patients who did not need any trocars in the umbilicus or with scars due to previous surgery, who were treated with a particular technique of pneumoperitoneum induction and the insertion of the first trocar, named 'Open Veress Assisted' (OVA). RESULTS: We had two visceral complications (0,07%) (ileal perforations). CONCLUSION: Although no surgical technique is without risks, we believe that the use of our technique is safer than a blind insertion of the first trocar, especially among the patients with scars due to previous surgery.     

Major and minor injuries during the creation of pneumoperitoneum. A multicenter study on 12,919 cases

Background: Lap Group Roma was established in 1999 to promote and control the development of laparoscopic surgery in the area of Rome and its province. Complications during the creation of pneumoperitoneum were given a high priority of investigation, and a retrospective enquiry was immediately carried out. Methods: A questionnaire about all laparoscopic surgical practice performed from January 1994 to December 1998 was sent to the supervisors of 28 centers of general surgery in the area of Rome and its province participating to the Lap Group Roma, requesting demographics, type of procedure for the creation of pneumoperitoneum, type and timing of operation, and major vascular, visceral, and minor vascular injuries related to the creation of pneumoperitoneum. Results: The questionnaire was returned by 57% of the centers, for a total of 12,919 laparoscopic procedures. The type of procedure used to create the pneumoperitoneum involved a standard closed approach (Veress needle + first trocar) in 82% of the cases, an open (Hasson) approach in 9% of the cases, and the use of an optical trocar in 9% of the cases. There were seven major vascular injuries (0.05%), eight visceral lesions (0.06%), and nine minor vascular lesions (0.07%), for an overall morbility of 0.18%. There was no death related to these complications. The rate of complications differed significantly (p < 0.0001) depending on the type of approach used. It was 0.27% with the optical trocar (3 of 1,009 cases), 0.18% with the closed approach (20 of 10,664 cases), and 0.09% with the open approach (1 of 1,135 cases). Conclusions: There is no foolproof technique for the creation of pneumoperitoneum, and this inquiry confirms the need of a constant search for prevention and early treatment of complications encountered during this obligatory phase of any laparoscopic approach. A well-conducted and prolonged prospective audit of clinical practice could help in identifying the risk factors that can make an alternative approach (open or video controlled) preferable to the widely used closed approach. apd: 3 April 2001