Pneumoperito Neum by Direct Trocar Insertion : Safe Laparoscopic Access

Abstract

Purpose of this study is to access the safety and efficacy of direct trocar insertion (DTI) for accessing the abdominal cavity for operative laparoscopy without prior pneumoperitoneum. DTI is one of the safe and effective alternative to veress needle insertion, open access (Hassan's technique) and visual entry systems (disposable optic trocars and endotip visual cannula) in laparoscopic surgery. METHODS: The study included 2480 patients who has undergone laparoscopic procedures at civil hospital, Jalandhar from Nov. 2003 to Sept. 2012 and at Punjab Institute of Medical Sciences (PIMS) Jalandhar from Sept. 2012 to June 2014. Procedures include 2310 laparoscopic cholecystectomies, 148 laparoscopic appendectomies, 10 cases of TAPP Groin hernia repairs and 12 cases of simple ovarian cysts. For DTI, abdominal wall was lifted and trocar was pushed through the fascia and muscle layer. The surgeon felt click when the trocar had pierced the peritoneum and entered the abdominal cavity. RESULTS: Direct trocar insertion was feasible in 100% of patients. There was no evidence of intestinal or vascular injury during trocar placement. Peritoneal access and creation of laparoscopic workspace were attained faster and more efficiently by the DTI technique. CONCLUSIONS: DTI is a fast, safe and reliable alternative to traditional techniques of primary port placement in laparoscopic procedures for creation of pnuemoperitoneum. KEYWORDS: Direct trocar insertion (DTI), Pneumoperitoneum, veress needle (VN), Laparoscopy. INTRODUCTION:The establishment of pneumoperitoneum is a pre-requisite for most laparoscopic surgeries and the method used is not necessarily dependent on the procedure for which it is intended. Over the last decade rapid increase has occurred in both the applications of operative laparoscopy and the number of surgeons using this technique. Laparoscopic abdominal surgery requires the establishment of successful pneumoperitoneum in the vast majority of patients with more than half of all the complications occurring at the time of entry into abdomen.The rationale for an adequate pneumoperitoneum is that it provides buffer space between the insertion site and pelvis or abdominal viscera. Several techniques and technologies have been introduced over the past 50 years to minimize laparoscopic related injuries. The standard technique of insufflation after insertion of Veress needle, open laparoscopy involving opening of the peritoneum under direct vision (Hasson's method), optical trocar insertion and direct trocar insertion (DTI) as well as variants of these techniques.Recent experiences with laparoscopy has revealed significant complication associated with Veress needle insufflation such as gas embolism, subcutaneous emphysema, failed pneumoperitoneum with resultant failed laparoscopy and bowel and visceral insufflations. (1, 2) Open assess as described by Hasson in 1971 (3) has shown to minimize vascular injuries but does not reduce bowel injury. Also open access is complicated by gas leak and port instability.

Comparative Study of Veress Needle and Visiport in Creating Pneumoperitoneum in Laparoscopic Surgery

“…Ever since the first laparoscopy performed by Jacobeus of Sweden in 1925, different techniques, technologists, and evidence-based guidelines have been introduced to eliminate the risk associated with laparoscopic entry, whatever be the method adopted for first port entry into the abdomen. 4 From studies, it has been proved that in 50% of laparoscopic surgeries, major complications occur prior to the commencement of surgery and a delay in diagnosis of visceral injury will lead to increased morbidity and mortality. 4 Regardless of the methods used, gaining access to the abdomen and initiating pneumoperitoneum remains a source of morbidity and mortality with most common complications being visceral and vascular injuries.…”

“…4 From studies, it has been proved that in 50% of laparoscopic surgeries, major complications occur prior to the commencement of surgery and a delay in diagnosis of visceral injury will lead to increased morbidity and mortality. 4 Regardless of the methods used, gaining access to the abdomen and initiating pneumoperitoneum remains a source of morbidity and mortality with most common complications being visceral and vascular injuries. Over the last three decades, rapid advances have made laparoscopic surgery a well-established entity.…”

The Generation of Pneumoperitonium by DCI Technique

“…insertion of VN, insufflation & introduction of trocar. According to Byron et al all that ----------------------------------------------------------------------------------------Received on 16-04-2022 Accepted on 03-08-2022 is necessary for the safe introduction of a cannula is good relaxation, a sharp cannula, and good lifting of the anterior abdominal wall 7 Therefore, the objective of this study was to assess the safety of DCI technique to generate the pneumoperitonium in our set up.…”