Comparison of total versus partial laparoscopic fundoplication in the management of gastroesophageal reflux disease

Multi-society consensus conference and guideline on the treatment of gastroesophageal reflux disease (GERD)

BACKGROUND

Gastroesophageal reflux disease (GERD) is one of the most common diseases in North America and globally. The aim of this guideline is to provide evidence-based recommendations regarding the most utilized and available endoscopic and surgical treatments for GERD.

METHODS

Systematic literature reviews were conducted for 4 key questions regarding the surgical and endoscopic treatments for GERD in adults: preoperative evaluation, endoscopic vs surgical or medical treatment, complete vs partial fundoplication, and treatment for obesity (body mass index [BMI] ≥ 35 kg/m²) and concomitant GERD. Evidence-based recommendations were formulated using the GRADE methodology by subject experts. Recommendations for future research were also proposed.

RESULTS

The consensus provided 13 recommendations. Through the development of these evidence-based recommendations, an algorithm was proposed for aid in the treatment of GERD. Patients with typical symptoms should undergo upper endoscopy, manometry, and pH-testing; additional testing may be required for patients with atypical or extra-esophageal symptoms. Patients with normal or abnormal findings on manometry should consider undergoing partial fundoplication. Magnetic sphincter augmentation or fundoplication are appropriate surgical procedures for adults with GERD. For patients who wish to avoid surgery, the Stretta procedure and transoral incisionless fundoplication (TIF 2.0) were found to have better outcomes than proton pump inhibitors alone. Patients with concomitant obesity were recommended to undergo either gastric bypass or fundoplication, although patients with severe comorbid disease or BMI > 50 should undergo Roux-en-Y gastric bypass for the additional benefits that follow weight loss.

CONCLUSION

Using the recommendations an algorithm was developed by this panel, so that physicians may better counsel their patients with GERD. There are certain patient factors that have been excluded from included studies/trials, and so these recommendations should not replace surgeon-patient decision making. Engaging in the identified research areas may improve future care for GERD patients.

North Pacific Surgical Association Presidential Address 2017- From Cayman to Vancouver: One surgeon's journey

This is the Presidential Address at the 104th Annual Meeting of the North Pacific Surgical Association held in Vancouver, BC, Canada, November 10-11, 2017.

Pre-operative clinical and instrumental factors as antireflux surgery outcome predictors

Gastroesophageal reflux disease (GERD) is nowadays a highly prevalent, chronic condition, with 10% to 30% of Western populations affected by weekly symptoms. Many patients with mild reflux symptoms are treated adequately with lifestyle modifications, dietary changes, and low-dose proton pump inhibitors (PPIs). For those with refractory GERD poorly controlled with daily PPIs, numerous treatment options exist. Fundoplication is currently the most commonly performed antireflux operation for management of GERD. Outcomes described in current literature following laparoscopic fundoplication indicate that it is highly effective for treatment of GERD; early clinical studies demonstrate relief of symptoms in approximately 85%-90% of patients. However it is still unclear which factors, clinical or instrumental, are able to predict a good outcome after surgery. Virtually all demographic, esophagogastric junction anatomic conditions, as well as instrumental (such as presence of esophagitis at endoscopy, or motility patterns determined by esophageal high resolution manometry or reflux patterns determined by means of pH/impedance-pH monitoring) and clinical features (such as typical or atypical symptoms presence) of patients undergoing laparoscopic fundoplication for GERD can be factors associated with symptomatic relief. With this in mind, we sought to review studies that identified the factors that predict outcome after laparoscopic total fundoplication.

Identification of preoperative risk factors for persistent postoperative dysphagia after laparoscopic antireflux surgery

BACKGROUND

Postoperative dysphagia is common after antireflux surgery and generally runs a self-limiting course. Nevertheless, part of these patients report long-term dysphagia. Inadequate surgical technique is a well documented cause of this result.

AIM

This retrospective study evaluated the preoperative risk factors not surgery-related for persistent dysphagia after primary laparoscopic antireflux surgery.

METHODS

Patients who underwent laparoscopic antireflux surgery by the modified technique of Nissen were evaluated in the preoperative period retrospectively. Postoperative severity of dysphagia was evaluated prospectively using a stantardized scale. Dysphagia after six weeks were defined as persistent. Statistical tests of association and logistic regression were used to identify risk factors associated with persistent dysphagia.

RESULTS

A total of 55 patients underwent primary antireflux surgery by a single surgeon team. Of these, 25 patients had preoperative dysphagia (45,45%). Persistent postoperaive dysphagia was reported by 20 (36,36%). Ten patients (18,18%) required postoperative endoscopic dilatation for dysphagia. There was statistical association between satisfaction with surgery and postoperative dysphagia and requiring the use of antireflux medication after the procedure; and between preoperative dysphagia and postoperative dysphagia. Logistic regression identified significant preopertive dysphagia as risk factor for persistent postoperative dysphagia. No correlations were found with preoperative manometry.

CONCLUSIONS

Patients with significant preoperative dysphagia were more likely to report persistent postoperative dysphagia. This study confirms that the current manometric criteria used to define esophageal dysmotility are not reliable to identify patients at risk for post-fundoplication dysphagia. Minucious review of the clinical history about the presence and intensity of preoperative dysphagia is important in the selection of candidates for antireflux surgery.

Identification of risk factors for postoperative dysphagia after primary anti-reflux surgery

BACKGROUND

Transient postoperative dysphagia is not uncommon after antireflux surgery and usually runs a self-limiting course. However, a subset of patients report long-term dysphagia. The purpose of this study was to determine the risk factors for persistent postoperative dysphagia at 1 year after surgery.

METHODS

All patients who underwent antireflux surgery were entered into a prospectively maintained database. After obtaining institutional review board approval, the database was queried to identify patients who underwent primary antireflux surgery and were at least 1 year from surgery. Postoperative severity of dysphagia was evaluated using a standardized questionnaire (scale 0-3). Patients with scores of 2 or 3 were defined as having significant dysphagia.

RESULTS

A total of 316 consecutive patients underwent primary antireflux surgery by a single surgeon. Of these, 219 patients had 1 year postoperative symptom data. Significant postoperative dysphagia at 1 year was reported by 19 (9.1%) patients. Thirty-eight patients (18.3%) required postoperative dilation for dysphagia. Multivariate logistic regression analysis identified preoperative dysphagia (odds ratio (OR), 4.4; 95% confidence interval (CI), 1.2-15.5; p = 0.023) and preoperative delayed esophageal transit by barium swallow (OR, 8.2; 95% CI, 1.6-42.2; p = 0.012) as risk factors for postoperative dysphagia. Female gender was a risk factor for requiring dilation during the early postoperative period (OR, 3.6; 95% CI, 1.3-10.2; p = 0.016). No correlations were found with preoperative manometry. There also was no correlation between a need for early dilation and persistent dysphagia at 1 year of follow-up (p = 0.109).

CONCLUSIONS

Patients with preoperative dysphagia and delayed esophageal transit on preoperative contrast study were significantly more likely to report moderate to severe postoperative dysphagia 1 year after antireflux surgery. This study confirms that the manometric criteria used to define esophageal dysmotility are not reliable to identify patients at risk for postfundoplication dysphagia, and that there is need for standardization of contrast swallow assessment of esophageal function.

Preoperative lower esophageal sphincter manometry data neither impact manifestations of GERD nor outcome after laparoscopic Nissen fundoplication

BACKGROUND

Experience with laparoscopic antireflux surgery (LARS) in patients with gastroesophageal reflux disease (GERD) and manometrically intact lower esophageal sphincter (LES) is limited. The disease pattern may be different and LARS may fail to control reflux or result in higher rates of dysphagia. This is the first study investigating the impact of preoperative LES manometry data not only on manifestations of GERD and subjective outcome alone but also on objective outcomes 1 year after LARS.

METHODS

Three hundred fifty-one GERD patients underwent LARS and had subjective symptom and quality of life assessment, upper gastrointestinal endoscopy, barium swallow esophagogram, 24-h esophageal pH monitoring, and manometry pre- and 1 year postoperatively. Patients were divided into those with a preoperatively intact versus defective LES based on intraabdominal length and resting pressure. Baseline and 1-year postoperative follow-up data were compared.

RESULTS

Preoperative manifestations of GERD were similar in each group. Postoperatively, all symptoms except flatulence, quality of life scores, and objective manifestations improved significantly in each group.

CONCLUSIONS

The preoperative manometric character of the LES neither impacts the manifestations of GERD nor subjective and objective outcomes after LARS. Patients with GERD and manometrically intact LES have no higher risk for postoperative dysphagia.

Ten-year clinical outcome of a prospective randomized clinical trial of laparoscopic Nissen versus anterior 180( degrees ) partial fundoplication

BACKGROUND

A randomized trial of laparoscopic Nissen fundoplication and anterior 180 degrees partial fundoplication was undertaken to determine whether the anterior procedure might reduce the incidence of dysphagia and other adverse outcomes following surgery for gastro-oesophageal reflux disease. This study evaluated clinical outcomes after 10 years.

METHODS

Some 107 patients were randomized to undergo laparoscopic Nissen or anterior 180 degrees partial fundoplication. Ten-year data were not available for 18 patients. Information was obtained from 89 patients (48 Nissen, 41 anterior fundoplication) using a standard clinical questionnaire that focused on symptoms of reflux, potential postoperative side-effects and overall satisfaction with the outcome of surgery.

RESULTS

There were no significant differences between the two groups with regard to reflux symptoms, dysphagia, abdominal bloating, ability to belch and overall satisfaction. Between 5 and 10 years after surgery, revisional surgery was required for reflux in two patients after anterior fundoplication. Two patients had revision after Nissen fundoplication, for reflux and recurrent hiatus hernia.

CONCLUSION

Both laparoscopic anterior 180 degrees partial and Nissen fundoplication are safe, effective and durable at 10 years' follow-up. Most patients are satisfied with the clinical outcome.

The Stretta procedure versus proton pump inhibitors and laparoscopic Nissen fundoplication in the management of gastroesophageal reflux disease: a cost-effectiveness analysis

BACKGROUND

The Stretta procedure is an endoscopic therapy for gastroesophageal reflux disease.

OBJECTIVE

To evaluate the cost-effectiveness of the Stretta procedure and that of competing strategies in the long-term management of gastroesophageal reflux disease.

METHODS

A Markov model was designed to estimate costs and health outcomes in Canadian patients with gastroesophageal reflux disease over five years, from a Ministry of Health perspective. Strategies included the use of daily proton pump inhibitors (PPIs), laparoscopic Nissen fundoplication (LNF) and the Stretta procedure. Probabilities and utilities were derived from the literature. Costs are expressed in 2006 Canadian dollars. Units of effectiveness were symptom-free months (SFMs) and quality-adjusted life years (QALYs), using a five-year time horizon.

RESULTS

In the analysis that used SFMs, the strategy using PPIs exhibited the lowest costs ($40 per SFM) and the greatest number of SFMs, thus dominating both the LNF and Stretta systems. But the cost-effectiveness analysis using QALYs as the measure of effectiveness showed that PPIs presented the lowest cost-effectiveness ratio, while both the LNF and Stretta strategies were associated with very high incremental costs (approximately $353,000 and $393,000, respectively) to achieve an additional QALY. However, the PPI strategy did not dominate the two other strategies, which were associated with better effectiveness.

CONCLUSIONS

If SFMs are used as the measure of effectiveness, PPIs dominate the Stretta and LNF strategies. However, if QALYs are used, the PPIs still present the lowest cost and LNF gives the best effectiveness. Regardless of the units of effectiveness or utility used in the present cost analysis, an approach of prescribing PPIs appears to be the preferred strategy.

Preoperative esophageal manometry does not predict postoperative dysphagia following anti-reflux surgery

This prospective study was undertaken to determine the value of manometric studies in predicting postoperative dysphagia in patients undergoing laparoscopic Toupet fundoplication. Two hundred and twenty-nine out of 401 patients (57%) had preoperative dysphagia, and 26 patients had late postoperative dysphagia (6.5%). Eight patients who had no preoperative dysphagia developed dysphagia following surgery. There were no significant differences in esophageal motility for patients without postoperative dysphagia (n = 375) compared with those with postoperative dysphagia (n = 26). Among patients with postoperative dysphagia as a new symptom (n = 8), six had normal preoperative distal esophageal pressures, and none had esophageal hypomotility. In those with both pre- and postoperative dysphagia 15 of 18 had normal esophageal motility and hypomotility was only found in one. The positive predictive values of distal esophageal hypomotility and other measures for postoperative dysphagia are poor. In conclusion, preoperative manometry does not predict postoperative dysphagia following laparoscopic Toupet partial fundoplication.

The effect of total and anterior partial fundoplication on antireflux mechanisms of the gastroesophageal junction

BACKGROUND

The effect of total (Nissen) and anterior partial fundoplication (APF) for the surgical treatment of gastroesophageal reflux disease (GERD) on the motor behavior of the esophagogastric axis has not been fully assessed. The purpose of this study was to assess any alterations in lower esophageal sphincter (LES) and gastric fundus motor parameters in GERD patients after Nissen or APF fundoplication.

METHODS

Twenty four patients with documented GERD underwent either laparoscopic Nissen fundoplication (n = 12) or laparoscopic APF (n = 12). Preoperative and postoperative stationary esophageal manometry included assessment of LES resting and postdeglutition relaxation pressures, intragastric pressure, and LES transient relaxations in the left lateral and upright positions and after gastric distension.

RESULTS

Both types of fundoplication resulted in significant increases in LES resting (P <0.001) and postdeglutition relaxation pressure (P <0.001) in both positions and after gastric distention. Intragastric pressure increased only after Nissen fundoplication in the postgastric distention state (P = 0.01). Transient LES relaxations were equally abolished after both procedures. All postoperative changes were to a similar level after either procedure with the exception of intragastric pressure after gastric distention, which was significantly higher after total than after partial fundoplication (P = 0.04).

CONCLUSIONS

Both procedures equally increase LES resting and postdeglutition relaxation pressures and abolish transient LES relaxations at all states. The significantly higher intragastric pressure at the postgastric distention state after Nissen fundoplication could possibly explain the higher incidence of epigastric fullness and discomfort after this type of antireflux surgery.

André Toupet: surgeon technician par excellence

André Toupet is best known for the posterior fundoplication that bears his name, currently used for the treatment of gastroesophageal reflux disease (GERD) or completing Heller's myotomy and subject today to intense discussions. This was not different in 1963, when Toupet proposed his technique at a time when the Nissen fundoplication was emerging as the treatment of choice for GERD. Behind the procedure, we discover a man with great surgical talent and meticulous attention to technical details who opposed criticism with hard work and strong family values.

[Clinical and functional results after Laparoscopic fundoplication. Prospective evaluation]

OBJECTIVE

To prospectively assess the medium- and long-term clinical and functional results in consecutive patients undergoing laparoscopic procedures for gastroesophageal reflux.

PATIENTS AND METHOD

The series included the interventions performed or assisted by the first author in 325 patients referred for surgical evaluation between December 1992 and June 2000. Forty patients were excluded from the study because they did not fulfil the inclusion criteria for laparoscopic surgery. A further 20 patients who underwent laparoscopic surgery were excluded because they required conversion to open surgery. Thus, 265 patients were included in the study. One hundred ninety-six total fundoplications (Nissen-Rossetti) and 69 partial fundoplications(42 posterior-Toupet and 27 anterior-Dor) were performed. The surgical technique employed was a slight modification of that described by Dallemagne et al with five-trocars. Preoperative evaluation was established by clinical features, endoscopy with biopsy, barium contrast radiography, esophageal manometry and esophageal pH monitoring.

RESULTS

The mean follow-up was 47.1 3.3 months (range: 4-92 months). Heartburn, regurgitation, and dysphagia were relieved in 92.5%, 97.7%, and 88.1% of patients respectively. Complete relief of symptoms was achieved in all patients who presented preoperative respiratory symptoms as a complication of gastroesophageal reflux. Esophagitis healed in 98.2% of patients with preoperative esophagitis. Correction of lower esophageal sphincter pressure and lower esophageal sphincter length were statistically significant compared with preoperative status (p = 0.006 and p = 0.003, respectively). Pre- and postoperative differences in the percentage of patients with a pH < 4 in 24-hour ambulatory esophageal pH monitoring were also significant (p = 0.005), confirming correction of acid reflux. Morbidity appeared in 6.7% of patients and there was no mortality. Conversion to open procedures was required in 7.5%. The mean operative time was 115 6.3 minutes.

CONCLUSIONS

These preliminary results suggest that when performed by experienced surgeons laparoscopic fundoplication provides an excellent alternative in selected patients with gastroesophageal reflux. Both medium- and long-term clinical and functional results, as well as morbidity, were satisfactory and were similar to those of open fundoplication.

Dysphagia after antireflux surgery

BACKGROUND

Dysphagia is experienced by many patients after antireflux surgery. This literature review examines factors associated with the development, prediction and management of postoperative dysphagia.

METHODS

Published studies examining issues related to dysphagia, gastro-oesophageal reflux and fundoplication were reviewed.

RESULTS

Postoperative dysphagia is usually temporary but proves troublesome for 5--10 per cent of patients. Technical modifications, such as a partial wrap, division of short gastric vessels and method of hiatal closure, have not conclusively reduced its incidence. There is no reliable preoperative test to predict dysphagia.

CONCLUSION

It is uncertain whether postoperative dysphagia arises from patient predilection or is largely a consequence of mechanical changes created by fundoplication. Anatomical errors account for a significant proportion of patients referred for correction of dysphagia but these are uncommon in large single-institution studies. Abnormal manometry cannot predict dysphagia and, on current evidence, 'tailoring' the operation does not prevent its occurrence.

[Laparoscopic posterior fundoplication in gastroesophageal reflux: mid-term results]

STUDY AIM

The aim of this study was to report the mid-term results of the surgical management of gastroesophageal reflux disease (GERD) by laparoscopic posterior partial fundoplication (Toupet technique) in 100 patients, and to evaluate their post-operative quality of life.

PATIENTS AND METHOD

Between November 1993 and January 2000, 100 patients were surgically treated for a medically refractory GERD. Laparoscopic posterior partial fundoplication was performed by the Toupet technique. In the postoperative period, the patients were asked to answer a questionnaire by telephone. The aim of this survey was three-fold: to identify clinical symptoms indicative of recurrence; to evaluate postoperative functional impairment; to assess the postoperative quality of life. pH monitoring was also proposed in asymptomatic patients at a minimum follow-up of two years, and in all patients with clinical symptoms of GERD recurrence.

RESULTS

Six laparotomy conversions were necessary. The mean duration of follow-up was 18 months (range: 6 to 57 months). The rate of clinically diagnosed recurrence was 7.6%. Intermittent dysphagia was observed in 2.3% of cases. Postoperative digestive functional disorders were noted in 53% of patients without clinical recurrence, and 95.3% of them were satisfied or very satisfied with the results of surgery.

CONCLUSION

Laparoscopic posterior partial fundoplication by the Toupet technique can satisfactorily treat GERD without mid-term recurrence in about 94% of cases. Patient satisfaction seems mainly to depend on the disappearance of clinical symptoms of GERD. It was found that postoperative functional disorders frequently occurred, but were well tolerated. Their etiology has not yet been determined, and it is considered that factors other than the surgical procedure may also play a role.

Complete fundoplication is not associated with increased dysphagia in patients with abnormal esophageal motility

Abnormal esophageal motility is a relative contraindication to complete (360-degree) fundoplication because of a purported risk of postoperative dysphagia. Partial fundoplication, however, may be associated with increased postoperative esophageal acid exposure. Our aim was to determine if complete fundoplication is associated with increased postoperative dysphagia in patients with abnormal esophageal motor function. Medical records of 140 patients (79 females; mean age 48 +/- 1.1 years) who underwent fundoplication for gastroesophageal reflux disease (GERD) were reviewed retrospectively to document demographic data, symptoms, and diagnostic test results. Of the 126 patients who underwent complete fundoplication, 25 met manometric criteria for abnormal esophageal motility (#30 mm Hg mean distal esophageal body pressure or #80% peristalsis), 68 had normal esophageal function, and 33 had incomplete manometric data and were therefore excluded from analysis. Of the 11 patients who underwent partial fundoplication, eight met criteria for abnormal esophageal motility, two had normal esophageal function, and one had incomplete data and was therefore excluded. After a median follow-up of 2 years (range 0.5 to 5 years), patients were asked to report heartburn, difficulty swallowing, and overall satisfaction using a standardized scoring scale. Complete responses were obtained in 72%. Sixty-five patients who underwent complete fundoplication and had manometric data available responded (46 normal manometry; 19 abnormal manometry). Outcomes were compared using the Mann-Whitney U test. After complete fundoplication, similar postoperative heartburn, swallowing, and overall satisfaction were reported by patients with normal and abnormal esophageal motility. Likewise, similar outcomes were reported after partial fundoplication. This retrospective study found equally low dysphagia rates regardless of baseline esophageal motility; therefore a randomized trial comparing complete versus partial fundoplication in patients with abnormal esophageal motility is warranted.

Day-case laparoscopic fundoplication for gastro-oesophageal reflux disease

BACKGROUND

Based on a series of successful outpatient laparoscopic cholecystectomies, day-case laparoscopic fundoplication for gastro-oesophageal reflux disease was introduced in January 1997. The initial results are reported.

METHODS

Inclusion criteria were American Society of Anesthesiologists grade I-II, living within 30 min travel from the hospital, and adult company at home. Initially only selected patients were offered day-case treatment, but later it was adopted as routine. The patients underwent general intravenous anaesthesia with propofol and remifentanil, and were given ketorolac, propacetamol, droperidol and ondansetron as prophylaxis against postoperative pain and nausea. The surgical procedure was Nissen-Rosetti fundoplication or semifundoplication depending on oesophageal manometric results.

RESULTS

Forty-five patients were included. Four patients were admitted; 41 were discharged as planned 3-8 h after operation, and five of these patients were readmitted. One underwent reoperation for necrosis of the gastric fundus. A further five patients visited the outpatient department without need for admission. At follow-up 31 patients were satisfied with the day-case treatment, five were indifferent, and five were dissatisfied because of pain. If offered a similar operation in the future, 26 patients would have preferred and seven would have accepted day-case treatment, and eight would not.

CONCLUSION

Outpatient laparoscopic fundoplication is safe and well tolerated by the majority of patients.

Heartburn is More Likely to Recur after Toupet Fundoplication than Nissen Fundoplication

Toupet (270°) fundoplication is commonly recommended for patients with gastroesophageal reflux (GER) and esophageal dysmotility. However, Toupet fundoplication may be less effective at protecting against reflux than Nissen (360°) fundoplication. We therefore compared the effectiveness and durability of both types of fundoplication as a function of preoperative esophageal motility. From January 1992 through January 1998, 669 patients with GER underwent laparoscopic fundoplication (78 Toupet, 591 Nissen). Patients scored heartburn, regurgitation, and dysphagia preoperatively, and at 6 weeks and 1 year postoperatively, using a 0 (“none”) to 3 (“severe”) scale. We compared symptom scores (Wilcoxon rank sum test) and redo fundoplication rates (Fisher exact test) in Toupet and Nissen patients. We also performed subgroup analyses on 81 patients with impaired esophageal motility (mean peristaltic amplitude, <30 mm Hg or peristalsis <70% of wet swallows) and 588 patients with normal esophageal motility. Toupet and Nissen patients reported similar preoperative heartburn, regurgitation, and dysphagia. At 6 weeks after operation, heartburn and regurgitation were similarly improved in both groups, but dysphagia was more prevalent among Nissen patients. After 1 year, heartburn and regurgitation were re-emerging in Toupet patients, and dysphagia was again similar between groups. Patients with impaired motility who have Nissen fundoplication are no more likely to suffer persistent dysphagia than their counterparts who have Toupet fundoplication. In addition, patients with normal motility are more likely to develop symptom recurrence after Toupet fundoplication than Nissen fundoplication, with no distinction in dysphagia rates. We conclude that since Toupet patients suffer more heartburn recurrence than Nissen patients, with similar dysphagia, selective use of Toupet fundoplication requires further study.

Laparoscopic surgery complications associated with trocar tip design: review of literature and own results

In the last 10 years, there has not been an abdominal surgical procedure that has not been performed by laparoscopic means. The enthusiasm of surgeons active in this field often neglects problems, especially with basic instruments which are important vehicles for the laparoscopic technique. The purpose of this study was to focus on trocar-related problems with special respect to the tip design. On the basis of a prospective study of laparoscopic transperitoneal hernia repair (TAPP) and laparoscopic Nissen fundoplication, we evaluated our data concerning trocar-related complications at the abdominal wall. We compared two groups of patients treated in a nonrandomized design with either sharp cutting single-use trocars or cone-shaped non-cutting reuseable trocars. The evaluation of our own data showed an incisional hernia in 1.83% of patients treated with a sharp trocar tip, a complication which could be significantly lowered, to 0.17%, with a conic tip design. Similar results could be seen with trocar-related bleeding events at the insertion site in the abdominal wall. In most publications, trocar design and related complications are unmentioned. Our data demonstrate a reasonable benefit for a conic tip design, which enables atraumatic insertion through the abdominal wall. The reuseable steel version furthermore holds a considerable cost-saving potential.