Entry complications in laparoscopic surgery

A randomised clinical trial to study postoperative abdominal and shoulder tip pain following low and standard pressure laparoscopic cholecystectomy

Background

Laparoscopic cholecystectomy (LC) has become the gold standard for the management of symptomatic gallstone disease. The complications related to different pressure ranges of pneumoperitoneum have been studied widely with no definite conclusion till date. The current study was planned to determine the effect of standard versus low pressure laparoscopic cholecystectomy (LPLC) on postoperative abdominal and shoulder tip pain (STP).

Methods

The present randomised clinical trial included 84 patients divided into two groups: standard pressure laparoscopic cholecystectomy (SPLC) (13 mmHg) and LPLC (9 mmHg). The variables tested were abdominal pain at 3, 6, 12 and 24 h (by verbal rating scale), the incidence and intensity of STP, post-operative nausea and vomiting (PONV) and surgeon's comfort for the two techniques.

Results

The demographic characteristics of patients were similar in both groups. In LPP group, the postoperative abdominal pain at 6, 12 and 24 h was significantly less than SPLC; p = 0.02. Incidence of shoulder pain was significantly less in low pressure group (7.14%) compared with standard pressure (28.57%).

Conclusions

Low-pressure pneumoperitoneum (LPP) is safe and feasible surgery with reduced abdominal and STP.

Mechanical Characterization of the Human Abdominal Wall Using Uniaxial Tensile Testing

It is generally accepted that the human abdominal wall comprises skin, subcutaneous tissues, muscles and their aponeuroses, and the parietal peritoneum. Understanding these layers and their mechanical properties provides valuable information to those designing procedural skills trainers, supporting surgical procedures (hernia repair), and engineering-based work (in silico simulation). However, there is little literature available on the mechanical properties of the abdominal wall in layers or as a composite in the context of designing a procedural skills trainer. This work characterizes the tensile properties of the human abdominal wall by layer and as a partial composite. Tissues were collected from fresh-never-frozen and fresh-frozen cadavers and tested in uniaxial tension at a rate of 5 mm/min until failure. Stress-strain curves were created for each sample, and the values for elastic moduli, ultimate tensile strength, and strain at failure were obtained. The experimental outcomes from this study demonstrated variations in tensile properties within and between tissues. The data also suggest that the tensile properties of composite abdominal walls are not additive. Ultimately, this body of work contributes to a deeper comprehension of these mechanical properties and will serve to enhance patient care, refine surgical interventions, and assist with more sophisticated engineering solutions.

Open Technique

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Safety of Laparoscopic Entry Points in Patients With a History of Abdominal Surgery: A Research Article

INTRODUCTION

This study aimed to assess the safety of laparoscopic entry sites in patients with previous abdominal surgery who subsequently required re-operation.

MATERIAL AND METHODS

This is a prospective study wherein the data of 118 patients who had undergone previous abdominal surgery and were subsequently re-operated at our center (Bakırköy Doctor Sadi Konuk Research and Study Hospital) were collected from October 2015 to October 2016. Careful attention was paid to gathering information regarding patients' age, parity, body mass index (BMI), type of previous surgery, type of incision made during previous surgery, and medical history. For this study, the abdomen was topographically divided into nine parts. During the operation, all quadrants were examined and evaluated for adhesion and the content of adhesion.

RESULTS

Adhesions were found in 44% (55 out of 118) of the patients, while 56% (66 patients) had no adhesions in the abdomen. The majority of cases (74%) had a history of cesarean section, and 87% had a Pfannenstiel incision. Adhesions were reported in 37.5% (33 out of 88) of the patients with a previous history of cesarean section. A significant proportion of subjects with adhesion (83%) had anterior abdominal wall adhesions, including only the omentum, whereas 11.5% (six subjects) had umbilical adhesions. Subjects with a history of umbilical hernia repair had more adhesions.

DISCUSSION

The present study sought to assess the safety of laparoscopic entry points in individuals with prior abdominal surgery. The rise in laparoscopic surgeries, favored for reduced wound infections and quicker recovery times, brings forth concerns about potential complications in those with previous abdominal operations. Historically, postoperative adhesions have been observed in a significant number of patients after gynecological procedures. Our research, however, found a lower adhesion rate, which could be due to the smaller size of our sample and fewer gynecological cases. Existing adhesions can complicate subsequent surgeries, increasing operational times and posing injury risks. Adhesions also elevate healthcare costs and patient morbidity and mortality. Moreover, complications like Trocar-related injuries, including damage to major organs, are pivotal. While certain trocar insertion techniques may have fewer complications, our results align with previous findings suggesting higher adhesion rates after non-gynecological surgeries. Therefore, alternative entry points or methods, such as the palmer site or direct trocar entry, are recommended for those with an abdominal surgery history. Notably, our study's limited sample size may affect its generalizability, urging future studies for broader insights. Comprehensive pre-surgery assessments are crucial to anticipate complications. Our research supports that laparoscopic surgeries are safe for many with prior abdominal surgery, but for certain patients, non-umbilical entry sites are advised to further mitigate risks.

CONCLUSION

The umbilicus is one of the safest entry sites for primary trocar insertion in patients with a history of Pfannenstiel incision. However, the probability of umbilical adhesions is high in patients who have undergone umbilical mesh repair, median incision, or major abdominal surgery. In these patients, surgeons should prefer other laparoscopic entry sites, especially Palmer's point, rather than the umbilicus.

Prospective Cohort Study Quantifying the Effect of the LevaLap 1.0 on the Distance between the Abdominal Wall and Intra-abdominal Viscera

STUDY OBJECTIVE

More than 13 million laparoscopic procedures are performed globally every year. The LevaLap 1.0 device may facilitate safe abdominal access when using the Veress needle for initial abdominal insufflation during laparoscopic surgery. We undertook this study to test the hypothesis that use of the LevaLap 1.0 would increase the distance from the abdominal wall to underlying viscera and the retroperitoneum, including from major vessels.

DESIGN

Prospective cohort study.

SETTING

Referral center.

PATIENTS

Eighteen patients scheduled to undergo an interventional radiology procedure under general anesthesia and muscle relaxation.

INTERVENTIONS

Application of the LevaLap 1.0 device on the umbilicus and on Palmer's point, during computed tomography scanning.

MEASUREMENTS

Distance from the abdominal wall to the underlying bowel and to retroperitoneal blood vessels and more distant intra-abdominal organs before and after vacuum was applied to the LevaLap 1.0.

MAIN RESULTS

The device did not significantly increase the distance from the abdominal wall to the immediate underlying bowel. Alternatively, the LevaLap 1.0 created a significant increase in the distance between the abdominal wall at the access point and more distant intra-abdominal organs at the umbilicus and at Palmer's point (mean ± SD: +3.91 ± 2.32 cm, p = .001, and +3.41 ± 3.12 cm, p = .001, respectively). At the umbilicus, the device increased the distance between the abdominal wall and the anterior wall of the vena cava by +5.32 ± 1.22 cm (p = .004) or the anterior wall of the aorta by 5.49 ± 1.40 cm (p = .004). At Palmer's point, the device increased the distance between the anterior abdominal wall and the colon and/or small bowel by 2.13 ± 1.81 cm (p = .023). No adverse events were reported.

CONCLUSIONS

The LevaLap 1.0 increased the distance between abdominal wall and major retroperitoneal blood vessels by >5 cm, promoting safer access during Veress needle insufflation when performing laparoscopic surgery.

Safe insertion of Veress needle for the induction of pneumoperitoneum: a technical note

Techniques for the induction of pneumoperitoneum for laparoscopic surgery remain varied as complication risk remains with all techniques. Veress needle is used for the induction of pneumoperitoneum as a technique of preference or when an open technique is considered challenging as in obese patients. We present a novel safe technique for insertion of Veress needle by measuring the depth of the anterior abdominal wall prior to insertion. Accurate measurements help in the safe insertion of the Veress needle for inducing pneumoperitoneum and hence reduce the incidence of intra-abdominal injuries.

Major and minor complications in Veress needle (VN) and direct trocar insertion (DTI) for laparoscopic closed-entry techniques: an updated systematic review and meta-analysis

OBJECTIVE

Direct insertion of the trocar is an alternative method to Veress needle insertion for the creation of pneumoperitoneum. We conducted a systematic review and meta-analysis to compare these two entry closed techniques.

DATA SOURCE

A systematic review of the literature was done on PubMed, MEDLINE, Embase, Scopus, and EBSCO.

METHODS

The literature search was constructed until May 01, 2022, around search terms for "Veress," "direct trocar," "needle," "insertion," and "laparoscopic ways of entry." This systematic review was reported according to the PRISMA Statement 2020.

RESULTS

Sixteen controlled trials (RCTs) and 5 observational studies were included in the systematic review. We found no significant differences in the risk of major complication during the access manoeuvres between DTI and VN: bowel injuries (OR = 0.76, 95% CI: 0.24-2.36, P = 0.63), major vascular injuries (OR = 1.74, 95% CI 0.56-5.38, P = 0.34), port site hernia (OR = 2.41, 95% CI: 0.28-20.71, P = 0.42). DTI has a lower risk of minor complications such as subcutaneous emphysema (OR = 5.19 95% CI: 2.27-11.87, P < 0.0001), extraperitoneal insufflation (OR = 5.93 95% CI: 1.69-20.87, P = 0.006), omental emphysema (OR = 18.41, 95% CI: 7. 01-48.34, P < 0.00001), omental bleeding (OR = 2.32, 95% CI: 1.18-4.55, P = 0.01), and lower number of unsuccessful entry or insufflation attempts (OR = 2.25, 95% CI: 1.05-4.81, P = 0.04). No significant differences were found between the two groups in terms of time required to achieve complete insufflation (MD =  - 15.53, 95% CI: - 91.32 to 60.27, P = 0.69), trocar site bleeding (OR = 0.66, 95% CI, 0.25-1.79, P = 0.42), and trocar site infection (OR = 1.19, 95% CI, 0.34-4.20, P = 0.78).

CONCLUSION

There were no statistically significant differences in the risk of major complications during the access manoeuvres between DTI and VN. A lower number of minor complications were observed in DTI compared with those in Veress access.

Heart rhythm irregularities during laparoscopy: Description of a novel technique to manage severe intra-operative bradycardia - A case report

INTRODUCTION & IMPORTANCE

Minimally invasive abdominal surgeries need insufflation of a gas (usually carbon dioxide) into the peritoneal cavity for creating a pneumoperitoneum. Laparoscopic techniques have its own set of inherent complications. In order to maintain the operative space, constant gas flow is required to assist various surgeries. Increase in intraabdominal pressure due to high flow rate of gas during peritoneal insufflation is considered to be a probable cause of intraoperative vagal-mediated bradycardia resulting due to stretching of peritoneum. Intraoperative bradycardia during laparoscopic surgery can potentially lead to cardiac arrest and untoward outcomes.

CASE PRESENTATION

We report a case of a middle-aged hypertensive, hypothyroid patient with history of angle closure glaucoma who was undergoing elective laparoscopic cholecystectomy after proper pre-operative anesthesia/ physician and Ophthalmology clearance. Patient underwent general anesthesia (GA) and developed severe sinus bradycardia after insufflation, during stretch over gall bladder. Insufflation was stopped and abdomen deflated immediately. In view of glaucoma, atropine was contraindicated. 10 mL of 1% lignocaine was infiltrated into Calot's triangle and peri-gallbladder area. Surgery was resumed after 5 min and completed laparoscopically.

CLINICAL DISCUSSION

Bradycardia can occur during laparoscopic surgery mostly during rapid inflow of gas leading to peritoneal stretching with the added effect of vagotonic drugs used for general anesthesia. Use of intraperitoneal local anesthesia drugs for postoperative pain has been thoroughly studied and recommended due to statistically significant reduction in early postoperative abdominal pain. The management of intraoperative bradycardia should be prompt as it may be an early warning for cardiac arrest.

CONCLUSION

Vagal response following creation of pneumoperitoneum for minimally invasive abdominal surgeries is thought to be the most common cause for bradycardia. The effect of local anesthetic infiltration into peritoneum to reduce post operative pain is probably be due to blockade of afferent nerve endings in the peritoneum. Local anesthesia infiltration into Calot's triangle can be safely administered to mitigate localised vagal reflex.

Comparison Between Closed and Open Methods for Creating Pneumoperitoneum in Laparoscopic Cholecystectomy

Background: To study the efficacy of closed and open methods for creating pneumoperitoneum in laparoscopic cholecystectomy by comparing the two in terms of their outcome and complication. Study Design: Single-centre, prospective, observational study. Materials and study: Purposive sampling method where the inclusion criteria were all patients with cholelithiasis who were advised and consented to laparoscopic cholecystectomy of age 18-70 years were included in the study group. Exclusion criteria include patients with a paraumbilical hernia, a history of upper abdominal surgery, uncontrolled systemic illness, and local skin infection. Sixty cases of cholelithiasis satisfying exclusion and inclusion criteria who underwent elective cholecystectomy during the study period were included. Thirty-one of these cases underwent the closed method, while in the remaining 29 patients open method was adopted. Cases in which pneumoperitoneum created by closed technique were grouped as group A and those by open technique as group B. Parameters comparing the safety and efficacy of the two methods were studied. The parameters were access time, gas leak, visceral injury, vascular injury, need for conversion, umbilical port site hematoma, umbilical port site infection, and hernia. Patients were assessed on the first postoperative day, the seventh postoperative day, and then two months after surgery. Some follow-ups were done telephonically. Results: Out of 60 patients, 31 underwent the closed method, while 29 underwent the open method. Minor complications like gas leak during the procedure was observed more in the open method. The mean access time in the open-method group was less than in the closed-method group. Other complications like visceral injury, vascular injury, need for conversion, umbilical port site hematoma, umbilical port site infection, and hernia were not observed in either group during the allocated follow-up period in the study. Conclusion: Open technique for pneumoperitoneum is as safe and effective as the closed technique.

Laparoscopic Major Vascular Injuries Report of Two Cases and Review

Laparoscopic surgery is the standard of care for various abdominal pathologies due to its apparent advantages. Unintentional and accidental injuries of the intraabdominal organs and vessels caused by trocars and Veress needles are rare, but potentially fatal complications of laparoscopic surgery. Veress needle and trocar can cause major vascular, bowel, or urinary tract injuries. We report two cases of vascular laparoscopic entry injuries. Laparoscopic entry injuries are rare but life-threatening and can cause multiple organ dysfunctions. Therefore, early recognition, aggressive resuscitation, and appropriate management of laparoscopic entry injuries are vital for better outcomes.

Interactive 3D Force/Torque Parameter Acquisition and Correlation Identification during Primary Trocar Insertion in Laparoscopic Abdominal Surgery: 5 Cases

Laparoscopic procedures have become indispensable in gastrointestinal surgery. As a minimally invasive process, it begins with primary trocar insertion. However, this step poses the threat of injuries to the gastrointestinal tract and blood vessels. As such, the comprehension of the insertion process is crucial to the development of robotic-assisted/automated surgeries. To sustain robotic development, this research aims to study the interactive force/torque (F/T) behavior between the trocar and the abdomen during the trocar insertion process. For force/torque (F/T) data acquisition, a trocar interfaced with a six-axis F/T sensor was used by surgeons for the insertion. The study was conducted during five abdominal hernia surgical cases in the Department of Surgery, Faculty of Medicine, Ramathibodi Hospital, Mahidol University. The real-time F/T data were further processed and analyzed. The fluctuation in the force/torque (F/T) parameter was significant, with peak force ranging from 16.83 N to 61.86 N and peak torque ranging from 0.552 Nm to 1.76 Nm. The force parameter was observed to positively correlate with procedural time, while torque was found to be negatively correlated. Although during the process a surgeon applied force and torque in multiple axes, for a robotic system, the push and turn motion in a single axis was observed to be sufficient. For minimal tissue damage in less procedural time, a system with low push force and high torque was observed to be advantageous. These understandings will eventually benefit the development of computer-assisted or robotics technology to improve the outcome of the primary trocar insertion procedure.

Surgeons' requirements for a surgical support system to improve laparoscopic access

Creating surgical access is a critical step in laparoscopic surgery. Surgeons have to insert a sharp instrument such as the Veress needle or a trocar into the patient’s abdomen until the peritoneal cavity is reached. They solely rely on their experience and distorted tactile feedback in that process, leading to a complication rate as high as 14% of all cases. Recent studies have shown the feasibility of surgical support systems that provide intraoperative feedback regarding the insertion process to improve laparoscopic access outcomes. However, to date, the surgeons’ requirements for such support systems remain unclear. This research article presents the results of an explorative study that aimed to acquire data about the information that helps surgeons improve laparoscopic access outcomes. The results indicate that feedback regarding the reaching of the peritoneal cavity is of significant importance and should be presented visually or acoustically. Finally, a solution should be straightforward and intuitive to use, should support or even improve the clinical workflow, but also cheap enough to facilitate its usage rate. While this study was tailored to laparoscopic access, its results also apply to other minimally invasive procedures.

A Study of the Safety and Morbidity Profile of Closed versus Open Technique of Laparoscopic Primary Peritoneal Access Port in Patients Undergoing Routine Laparoscopic Cholecystectomy at a Tertiary Care Hospital in Northeastern India

Introduction. Laparoscopic cholecystectomy (LC) is the gold standard operation for gallstone disease. Primary port placement into the abdomen is a blind procedure and is challenging with chances of unforeseen complications. The complication rate has remained the same during the past 25 years. Both closed/Veress and open/Hasson’s techniques are commonly employed and have their typical indications for use. Materials and Methods. This prospective study was carried out in the Department of General Surgery, North Eastern Indira Gandhi Regional Institute of Health and Medical Sciences (NEIGRIHMS), Shillong, from January 2014 to January 2016, with the aim to compare the safety profile of closed/Veress and open/Hasson’s methods of access to the abdomen during laparoscopic cholecystectomy (LC). The study had 400 eligible cases undergoing LC who were randomly allotted into 2 groups with 200 cases each: group A: closed/Veress needle method and group B: open/Hasson’s method. Results. Closed/Veress and open/Hasson’s method of establishing pneumoperitoneum in laparoscopic cholecystectomy is equally safe in terms of major complications. The closed/Veress method gives faster access to the abdomen as compared to the open method (5.62 ± 2.23 minutes and 7.18 ± 2.52 minutes, respectively, $p$ value <0.0001). The open/Hasson’s method is associated with more primary port site complications (9/200 vs. 0/200, $p$ value 0.0036) and troublesome intraoperative gas leaks (39/200 vs. 2/200, $p$ value <0.0001). The open technique for primary peritoneal access port for laparoscopic cholecystectomy does not impart any additional benefits in terms of safety and morbidity profile in patients undergoing LC. Conclusion. The closed/Veress method of establishing pneumoperitoneum in laparoscopic cholecystectomy is equally safe in terms of major complications and gives quicker access to the abdomen as compared to the open method.

Comparison of Two Entry Methods and Their Cosmetic Outcomes in Creating Pneumoperitoneum: A Prospective Observational Study

Background  The main challenge in laparoscopic surgery is creating pneumoperitoneum using various surgical techniques. Every procedure has its own advocates. The aim of this study was to determine the cosmetic outcomes of the two of the major surgical techniques (open—Hasson technique versus closed—Veress technique) used in laparoscopic surgery.

Methods  This was a prospective, observational, comparative study conducted from October 2017 to September 2018 in 132 patients, who presented to our center and fulfilled our selection criteria. For all the patients, pneumoperitoneum was performed using either open (Hasson) or closed technique (Veress). A database was created for all the patients and the technique dependent cosmetic outcomes were assessed and reported.

Results  There were a total of 66 patients in each group (open and closed). The mean age of the open group was 51.56±11.42 years and closed group was 54.36±14.78 years, respectively. The major comorbidities found in both the groups were diabetes mellitus (6/66, group A; 7/66, group B) and hypertension (3/66, group A; 4/66, group B). In open group, umbilical (58/66, p =0.001) and in closed group infraumbilical (35/66, p =0.001) were the most commonly used incisions.

Conclusion  As benefits outweigh the risks, the better cosmetic outcomes were observed in patients underwent closed technique over open technique ( p <0.05).

Is transvaginal natural orifice transluminal endoscopic surgery (vNOTES) indicated in patients with previous extensive pelvic surgeries? A case report

Transvaginal natural orifice transluminal endoscopic surgery (vNOTES) has been increasingly applied to perform multiple gynecologic procedures. However, evidence is lacking on whether this surgical approach is feasible for patients with prior extensive abdominopelvic surgeries.

We report a case of prophylactic bilateral salpingo-oophorectomy (BSO) performed in a 51-year-old patient with previous laparotomic radical hysterectomy and pelvic lymphadenectomy for cervical cancer. The patient underwent rectovaginal examination and evaluation of the transvaginal sonographic sliding sign as preoperative screening to exclude the obliteration of the pouch of Douglas. The abdominal cavity was accessed by cautious endoscopic access to the pouch of Douglas. The BSO was realized in accordance with risk-reducing surgery guidelines. No intraoperative or postoperative complications were observed.

We suggest that selecting patients carefully prior to operation and adapting intraoperative techniques could be a safe method for conducting vNOTES interventions in patients with extensive abdominopelvic adhesions.

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vNOTES has been increasingly applied to perform multiple gynecologic procedures.

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There is a lack of evidence for its feasibility for patients who have previously had extensive surgery.

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Careful preoperative evaluations and intraoperative adaptations are needed.

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Extensive pelvic adhesiolysis by vNOTES appears feasible.

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We report a vNOTES intervention in a patient with previous extensive surgery.

A negative pressure-based visualization technique for abdominal Veress needle insertion

PURPOSE

Abdominal Veress needle insertion is commonly performed to generate a pneumoperitoneum during laparoscopy. Various safety tests are conducted to confirm accurate needle tip positioning into the abdominal cavity. However, these occasionally yield unclear results and do not help directly visualize the peritoneum puncture. We validated a negative pressure-based technique that helps instantly visualize the moment of the Veress needle entry into the abdominal cavity.

METHODS

This study included 761 patients who underwent laparoscopic hernioplasty between 2003 and 2021 that entailed pneumoperitoneum creation using a Veress needle. They were divided into conventional technique (CON) and negative pressure visualization technique (NPV) groups. The patients were propensity score-matched (1:1) to minimize selection bias. To determine whether the technique gave a clear result to the surgeon and precisely informed the moment of entry, failed entry and emphysematous complications were compared between the groups.

RESULTS

The propensity score-matching yielded 105 pairs in the matched CON and NPV groups. Failed entry did not occur in the NPV group, whereas it occurred in 8 patients (7.6%) in the CON group (p = 0.004). No patient experienced extraperitoneal emphysema in the matched NPV group, whereas 7 patients (6.7%) in the CON group did (p = 0.007). The groups did not differ in the incidence of omental or mesenteric emphysema.

CONCLUSION

The NPV eliminated the incidence of failed entry and decreased the incidence of extraperitoneal emphysema, indicating that it could simply and adequately inform the moment of needle entry into the abdominal cavity.

Needle-Probe Optical Coherence Tomography for Real-Time Visualization of Veress Peritoneal Needle Placement in a Porcine Model: A New Safety Concept for Pneumoperitoneum Establishment in Laparoscopic Surgery

The safe establishment of pneumoperitoneum is a critical step in all laparoscopic surgeries. A closed pneumoperitoneum is usually obtained by inserting a Veress needle into the peritoneal cavity. However, there is no definite measure to visually confirm the position of the Veress needle tip inside the peritoneal cavity. This study aimed to describe a method of real-time visual detection of peritoneal placement of the Veress needle using an incorporated optical coherence tomography (OCT) probe in a porcine model. A 14-gauge Veress needle was incorporated with a miniature fiber probe to puncture the piglet’s abdominal wall into the peritoneal cavity. A total of 80 peritoneal punctures were attempted in four piglets. For each puncture, continuous two-dimensional OCT images of the abdominal wall were acquired for real-time visual detection of the needle placement into the peritoneal cavity. Characteristic OCT image patterns could be observed during the puncturing process, especially a deep V-shaped concave pattern before the peritoneum puncture, which was a crucial feature. A statistical difference in the OCT signal standard deviation value also indicated the differentiability of images between the peritoneum and extra-peritoneal tissue layers. A success rate of 97.5% could be achieved with the guidance of the OCT images. OCT images translate the blind closed technique of peritoneal access into a visualized procedure, thus improving peritoneal access safety.

Prospective Observational Study of Comparison Between Direct and High-Pressure Primary Trocar Entry in Gynaecological Laparoscopy in Teaching Hospital

Background

Laparoscopic port entry is crucial and vital step in any laparoscopic surgery. As laparoscopy is widely used, complications related to it are also increasing which are not seen in conventional laparotomy.

Aim

The present study was undertaken to compare the ease of primary trocar entry after pneumoperitoneum at 20 mmHg pressure and direct trocar entry without pneumoperitoneum.

Methods

Total 100 nulliparous patients who presented for elective gynaecologic laparoscopic surgery were enrolled for the study. In operating theatre, randomization of patients was done using a sealed envelope technique which divides patients into two equal groups and assigned as either low-pressure group or high-pressure group. Verres needle insertion and trocar entry was done by fellowship trainee in laparoscopy assisted by senior laparoscopy surgeon.

Result

In high-pressure group we had trocar entry in first attempt in 80% of patient, second attempt in 20% where as in direct trocar entry group required first attempt in 88%, second attempt in 10% and third attempt in 2%. Time taken for trocar entry between two groups was significantly different requiring 4.42 ± 0.55 min for high pressure and 1.2 ± 0.28 min for direct trocar entry.

Conclusion

The study concluded that high-pressure trocar entry requires more time; require less attempts, easier and surgeon will be more comfortable in repeating the same technique than direct trocar entry.

A Comparison of Times Taken for the Placement of the First Portal and Complication Rates between the Veress Needle Technique and the Modified Hasson Technique in Canine Ovariectomy Laparoscopic Surgery

Minimally invasive surgery is increasingly being used in veterinary medicine. Laparoscopic procedures have several advantages compared with open surgery. These include the magnification of the field of surgery, reduced post-surgical pain and associated stress, reduced post-operative infection rates, and decreased hospitalization time. The establishment of a pneumoperitoneum is a critical step; however, this procedure can prolong the operation time, and most of the complications associated with laparoscopic surgery have been attributed to the insertion of devices into the abdominal cavity. Two main techniques have been employed to create pneumoperitoneum: the closed-entry method using the Veress needle and the open Hasson technique. The first portal is necessary to start insufflation and, subsequently, to realize the operative channel to insert the laparoscopic instruments into the abdomen. Many authors have compared the time necessary to create the first portal using different techniques in human medicine, but studies on this topic in veterinary medicine are lacking. In the veterinary medicine literature, complications associated with the creation of a pneumoperitoneum and the placement of ports include spleen, bowel, or bladder injuries; pneumothorax; and subcutaneous emphysema. The aim of the present study was to compare the times required for the placement of the first portal and the creation of pneumoperitoneum, and the rates of intraoperative complications using the Veress needle technique (VNT) and the open modified Hasson technique (MHT). The sample population comprised 30 female dogs who underwent laparoscopic ovariectomies. The dogs were randomly organized into two groups and two different entry techniques were used: Veress needle (VNT = group A) and the modified Hasson technique (MHT = group B). Complications related to abdominal entry were classified as major, in cases of organ perforation, and minor, in cases of subcutaneous emphysema and gas leakage. The VNT and MHT required 374.0 s and 242.9 s, respectively, for the placement of the first portal and for establishing pneumoperitoneum (p < 0.05). Their major complications rates were 20% and 0%, respectively (p < 0.05). Their minor complications rates were 20% and 35%, respectively (p < 0.05). No surgical procedures required laparotomy. The MHT was associated with a lower major complication rate and required less time to create the first portal, compared with the Veress needle technique.

Extraperitoneal Laparoscopy in Severe Intra-abdominal Adhesions: A Safe Alternative to Laparotomy

Surgery in a frozen abdomen can be difficult and dangerous with a significant risk of visceral injuries. We report a case of a 26-year-old lady with chronic pelvic pain diagnosed to have large bilateral adnexal cysts on magnetic resonance imaging with normal tumor markers. She had previous two laparotomies for benign conditions. Laparoscopy was planned, but pneumoperitoneum could not be created due to dense intraperitoneal adhesions. Direct entry was done into the preperitoneal space followed by insufflation of gas in this space. Blunt and sharp dissection of this space was done without breaching the peritoneum to reach the adnexa. The adnexal cyst was found to be encysted collection due to adhesions from previous surgeries. Deroofing was done followed by the visualization of pelvic structures intraperitoneally. Extraperitoneal laparoscopy may be used as a safe alternative to laparotomy in patients with dense intra-abdominal adhesions with the advantage of faster postoperative recovery.

Endovascular management of pelvic trauma

Traumatic pelvic injuries are an important group of acquired pathologies given their frequent association with significant vascular compromise. Potentially fatal as a consequence of rapid hemorrhage, achievement of early hemostasis is a priority; endovascular management of traumatic pelvic arterial injuries is an important potential option for treatment. Precipitated by any number of mechanisms of trauma, pelvic vascular injury necessitates timely patient assessment. Variable patterns of arterial injury may result from blunt, penetrating or iatrogenic trauma. Selection of the most appropriate imaging modality is a priority, ensuring streamlined access to treatment. In the case of CT, this is complemented by acquisition of the most appropriate phase of imaging; review of both arterial and delayed phase imaging improves the accuracy of detection of low-flow hemorrhage. In cases where surgical intervention is not deemed appropriate, endovascular treatment provides an alternative means for cessation of hemorrhage associated with pelvic injuries. This may be achieved in a selective or nonselective manner depending on the patient's clinical status and time constraints. Consequently, a detailed understanding of vascular anatomy is essential, including an appreciation of the normal variant anatomy between males and females. Additional consideration must be given to variant anatomy which may co-exist in both sexes. This review article aims to provide a synopsis of endovascular management of pelvic vascular injury. Through case examples, available treatment options will be discussed, including thrombin injection and transcatheter arterial embolization. Furthermore, potential adverse complications of pelvic arterial embolization will be highlighted. Finally, in view of the potential severity of these injuries, a brief overview of initial management of the hemodynamically unstable patient is provided.

Laparoscopic Major Vascular Injuries in Gynecologic Surgery for Benign Indications: A Systematic Review

OBJECTIVE

To identify the incidence, location, etiology, and mortality of major vascular injuries in gynecologic laparoscopy for benign indications.

DATA SOURCES

A systematic review of PubMed, EMBASE, Cochrane Library, ClinicalTrials.gov, and MEDLINE was conducted.

METHODS OF STUDY SELECTION

One thousand ninety-seven studies were screened for inclusion with 147 full-text articles reviewed. Sixty-six studies published between 1978 and 2016 met inclusion criteria, representing 197,062 surgeries. Articles that were included reported the incidence of major vascular injuries during gynecologic laparoscopy for benign indications. Exclusion criteria included surgery for gynecologic malignancy, duplicated data, case series and reports, manuscripts not in English, and studies published only as abstracts.

TABULATION, INTEGRATION, AND RESULTS

Injuries to the aorta, inferior vena cava, iliac (common, external, or internal), and inferior epigastric vessels were recorded, as were injuries denoted as major but not otherwise specified. A total of 179 major vascular injuries were reported with an incidence of 0.09% (95% CI 0.08-0.10). The inferior epigastric vessels were the most commonly injured vessel (0.04%, 95% CI 0.03-0.05), comprising 48% (95% CI 40-55) of all injuries. The majority of injuries occurred during abdominal entry (82%, 95% CI 76-89), and the remainder occurred during surgical dissection (18%, 95% CI 11-24). Most injuries were recognized intraoperatively (93%, 95% CI 87-100), and approximately half (55%, 95% CI 46-63) required laparotomy for repair. Only two of the 179 major vascular injuries resulted in death, for an overall mortality rate from vascular injuries of 0.001% (95% CI 0.000-0.004).

CONCLUSION

The incidence of major vascular injury during gynecologic laparoscopy found in this review is very low, and the vast majority of injuries did not result in death. Laparoscopy remains a safe surgical technique in relation to vascular injuries when performed for benign gynecologic disease.

Jain point: an alternate laparoscopic non-umbilical first blind entry port to avoid vessel, viscera, adhesions and bowel (VVAB)

The Jain point entry is based on the concept of non-umbilical entry to avoid sudden catastrophic injury to major retroperitoneal vessels, viscera, adhesions and bowel which could happen before the start of procedure by blind umbilical entry. To study the safety and efficacy of a novel first non-umbilical blind entry port. Tertiary referral centre for advanced laparoscopic surgeries with active training and fellowship programs. A large retrospective study of 7802 cases done at Vardhman Infertility & Laparoscopy Centre from January 2011 to December 2020. In all cases, first blind entry was by veress needle and 5 mm trocar and telescope through a non-umbilical port, The Jain point, irrespective of BMI, large masses, lax abdomen, previous surgery and complex situations. Patients’ demographic profile, types of surgeries performed and entry-related complications were recorded and analysed. Mean age of patients was 33 years with BMI ranging from 12.66 to 54.41 kg/m². Thus, Jain point can be applicable for all ranges of BMI, all types of surgeries from simple to complex and large masses. Entry related minor complications were in 3.4% cases while major complication involving bowel occurred in one case. No case of injury to major retro-peritoneal vessel was seen. Jain point entry is a novel, first blind 5 mm non-umbilical, entry technique in a variety of surgeries and previous scars and patients with wide range of BMI. It has a short learning curve and continues as main ergonomic working port.

Complications of Veress Needle Versus Open Technique in Abdominal Surgeries

Introduction

In any laparoscopic procedure, the first and most important step is abdominal entry. This is followed by the creation of pneumoperitoneum, which is essential for lifting the abdominal wall off of the internal organs and visualizing the entered space. However, the entry and establishment of pneumoperitoneum are not without risks and complications, the most serious of which include vascular injuries and bowel perforations in all the different techniques used. The most commonly used techniques for abdominal entry are the closed (Veress) and open (Hasson) techniques, the choice of which varies according to the surgeon’s preference and other regional and local factors.

Aim

To compare the outcomes between the open technique and the Veress needle for accessing the peritoneum during laparoscopic surgery.

Methodology

This was a retrospective cohort study that aimed to compare the outcomes between the Veress needle and the open technique for entering the peritoneum in laparoscopic surgeries. A chart review was used as an instrument to collect data. The study was conducted in King Abdul-Aziz Medical City, Riyadh, Saudi Arabia. All patients who underwent abdominal laparoscopic surgery from 2006 to 2016 were included.

Results

We analyzed 365 patients who underwent laparoscopic abdominal surgery. The mean age of the patients was 32.6 years. The most common postoperative complication occurring during the admission period was abdominal pain (40.5%). Postoperative complications during admission were significantly associated with the type of needle used (χ2=10.641; p=0.001).

Conclusion

The type of technique used for entry and peritoneal access was associated with the occurrence of postoperative complications in abdominal surgeries. Thus, the choice of open or Veress technique for peritoneal access should be individualized based on factors such as patient sex, clinical diagnosis, and most importantly, the surgeons’ experience and preference.

Trocar-Related Safety Events in Minimally Invasive Surgical Procedures: Risks for Organ and Vascular Complications

A trocar is a hollow device used during minimally invasive surgery that serves as an entry port for optical scopes and surgical equipment. Insertion of this device into the body is determined using anatomical landmarks taking into consideration the patient’s history and physical attributes, e.g., scars or abdominal size. Insertion of the first trocar is the time of highest risk of injury. Intestinal and vascular injuries are two potentially life-threatening injuries that can occur. A retrospective review of trocar-related events submitted to the Pennsylvania Patient Safety Reporting System (PA-PSRS) between January 1, 2014, and June 30, 2020, identified 268 events. Internal organ and vascular injuries accounted for 81.0% of events; trocar site skin integrity injuries, bleeding/hemorrhage, and hernias accounted for 17.2% of events; and vasovagal responses accounted for 1.9% of events. Internal injuries occurring during the initial insertion of the trocar, Veress needle, or incision in preparation for a trocar insertion was reported in 64.5% of events. Adhesions were identified in 13.5% of internal injury events. Many internal injury events identified a single injury; however, in 17 instances patients sustained two trocar-related injuries. Conversion to open surgery, return to the operating room during the same admission, postoperative intensive care unit admission, ambulatory surgical facility transfer to a hospital, readmission, postdischarge return to the operating room, and death are outcomes identified in the event reports.

Palmer's test usefulness in the correct positioning of the Veress needle and the reduction of complications during laparoscopic access maneuvers

AIM

Abdominal cavity access accounts for 50% of complications during laparoscopic surgery. Different safety maneuvers have been used to try to diminish these. Our study aims to establish the usefulness of Palmer's test in the correct positioning of the Veress needle and the reduction of complications during laparoscopic access maneuvers, when used in addition to the determination of intraabdominal pressure.

METHODS

Prospective observational analytic multi-centered cohort study with 370 patients undergoing gynecologic laparoscopy between July 2014 and November 2019, comparing the additional use of Palmer's test in 185 patients (Palmer-Test-Yes, PTY), with intraabdominal pressure determination alone in 185 patients (Palmer-Test-No, PTN).

RESULTS

Intergroup homogeneity was described for the basic characteristics of both population samples, except for mean age and percentage of previous laparotomy. A total of 19 complications were recorded, 10 in PTY and 9 in PTN, with no significant differences (P = 0.814). No differences were found in the analysis of these complications, except for the rate of conversion to laparotomy, which occurred four times in the PTY group and none in PTN (P = 0.044). Furthermore, no differences were found once fixed for the history of previous laparotomy (P = 514.), nor for the percentage of successful access after the first attempt between both groups (P = 0.753).

CONCLUSION

Palmer's test, when used in addition to intraabdominal pressure determination, has not shown to be effective in preventing failed access to abdominal cavity or reducing complications associated with access maneuvers with the Veress needle. Hence, its systematic use is not justified, since it could generate a sense of false security.

Dry Mopping vs. Saline Irrigation of Gallbladder Fossa After Bile Spillage During Laparoscopic Cholecystectomy: Randomized Control Trial

Introduction The laparoscopic approach, as compared to open cholecystectomy, is still considered the gold standard, despite a higher incidence of micro insults. The most common approach to treat spilled biliary contents and lost stones in laparoscopic cholecystectomy is the retrieval of the stone through an open approach, or laparoscopically, ending with a peritoneal wash and aspiration. Material and methods We conducted a double-blinded randomized controlled trial. In the study group, patients with bile spillage during cholecystectomy underwent suction of all spilled bile and evacuation of all visible stones followed by dry mopping of the gallbladder fossa with gauze swab through an epigastric port. In the control group, after suction of all bile and visible stones, the gallbladder fossa was washed with 250 ml of saline, and fluid was aspirated through the epigastric port. Results Sixty patients were included (30 patients in each group), 71.6% were female and the rest were male. There was a statistically significant difference in pain scores between the two groups (p=0.001). The dry mopping group had lower pain scores as compared to the other group postoperatively. The incidence of the intraabdominal collection in both groups are statistically insignificant, however, port site infection and intraabdominal collection are higher in the control group (irrigation group). Conclusion Although there is not much literature on the best approach to biliary spillage in laparoscopic cholecystectomy. We believe that dry mopping had better postoperative patient outcome as compared to the saline wash.

Role of para-cervical block in reducing immediate postoperative pain after total laparoscopic hysterectomy: a prospective randomized placebo-controlled trial

Objective

To study the efficacy and safety of 0.5% bupivacaine in paracervical block to reduce immediate postoperative pain after total laparoscopic hysterectomy.

Methods

A prospective, randomized, double-blind, placebo-controlled study was conducted at a tertiary referral center involving thirty women each in the treatment and placebo groups. Paracervical block with 10 mL of 0.5% bupivacaine (treatment group) or 0.9% saline (placebo group) was administered following general anesthesia and prior to proceeding with total laparoscopic hysterectomy. Visual analogue scale (VAS) scores at 30 and 60 minutes post extubation and mean VAS score (average VAS score at 30 and 60 minutes) were compared. Adequate pain control was defined as mean VAS score ≤5. Additional postoperative opioid requirement, hospital stay, and readmissions were also compared.

Results

Baseline variables such as age, previous history of cesarean section, operating time, and weight of the specimen were comparable in both groups. VAS scores at 30 (5.0±2.8 vs. 7.0±1.4) and 60 minutes (5.2±2.8 vs. 7.0±0.8) and the mean VAS score (5.1±2.7 vs. 6.8±0.9) were significantly lower in the treatment group. Adequate pain control (mean VAS score ≤5) was 57% higher and additional opioid consumption was 47% lower in the treatment group. No significant difference was found in the duration of hospital stay and readmission rate.

Conclusion

Paracervical block with bupivacaine was useful in reducing immediate postoperative pain with a 25% reduction in mean VAS score and a 47% reduction in opioid consumption in the first hour after total laparoscopic hysterectomy.

Method for safe Verres needle entry at the umbilicus, with modification for first trocar entry to reduce the complication rate of first entry

Background

Initial intraperitoneal access and first trocar entry are responsible for nearly half of all complications of laparoscopic surgery. The purpose of this article is to detail our method of initial intraperitoneal access with Veress needle and first trocar at the umbilicus used over the past 28 years.

Patients and Methods

Since 1990, a single surgeon performed laparoscopic surgery in 7600 patients. From 1992 onward, 6975 patients underwent laparoscopic surgery. On assessment, 739 cases (10.6%) were found unsuitable for Veress needle entry at the umbilicus. The remaining, 6236, patients form the study group for this article. Every patient was operated in the identical, repetitive manner. Every detail was considered important. The method of the first trocar entry is modified to minimise complications of this manoeuvre.

Results

The average time from cleaning umbilicus again to Veress needle tip in peritoneum was 1 min 40 s (25 s-7 min). Out of the 4228 patients in whom no adhesions were observed at first trocar entry (Group 1), the Veress needle insertion was successful at first attempt in 3829 (90.5%) patients, at second attempt in 322 (7.6%) and at third attempt in 30 (0.7%). In the 2008 patients with significant adhesions observed after first trocar entry (Group 2), successful insertion of the Veress needle was achieved at first attempt in 1700 (84.6%) patients, at second attempt in 182 (9%) and at third attempt in 19 (0.9%). In this group, there was one bowel injury (0.05%) and 3 (0.15%) minor vascular injuries. There was no mortality in either group. In the overall series, the Veress needle was successfully introduced in 6082 of the 6236 patients (97.5%) and 154 patients (2.4%) failed Veress needle entry. The incidence of bowel injury in the series was 0.016% and that of minor vascular injuries was 0.048%.

Conclusions

Initial intraperitoneal access must be performed with utmost caution after adequate training and proctorship. This paper stresses with meticulous attention to every detail, this safe, method of initial intraperitoneal access leads to low complication rates.

Presentation of an open entry technique for laparoscopy through a congenital defect in the umbilical fascia

OBJECTIVE

We present and describe a modification of the Hasson open entry technique to gain access to the abdominal cavity for laparoscopy in which a congenital defect in the umbilical fascia is identified for entry into the peritoneum and insertion of the primary port.

METHODS

A single centre, prospective, observational, pilot study has been conducted with no change in clinical practice. Data regarding the success of the technique, time to laparoscope insertion, complications and patient risk factors were collected and presented.

RESULTS

The team enrolled 114 patients that had the St Helier technique attempted for entry in the abdominal cavity. Entry was achieved for all patients. The technique had 82.5 % success rate while this reduced to 65 % in patients with previous laparoscopies. The mean time to insertion of the laparoscope was 220 s, and there was no significant difference in success with variation in BMI. We recorded no minor or significant intra-operative complications. The superficial wound infection rate was 2.6 % with no other postoperative complications identified at 6-week follow-up.

CONCLUSIONS

The presented technique is a safe and successful method of laparoscopic entry with a presumed shorter time until laparoscope insertion than other techniques used. The absence of complications could be attributed to the avoidance of sharp dissection of the umbilical fascia. The less invasive nature could reduce risks of hematoma, infection or hernia that are associated with the standard entry techniques used. Formal studies of long-term outcomes are required, as well as evaluating use in emergency and contaminated cases.

Effects of intra-abdominal pressure on laparoscopic working space in domestic rabbits (Oryctolagus cuniculus)

OBJECTIVE

To assess the effects of 3 intra-abdominal pressures (IAPs) on pneumoperitoneal (laparoscopic working space) volume in domestic rabbits (Oryctolagus cuniculus).

ANIMALS

6 female New Zealand White rabbits.

PROCEDURES

A Latin-square design was used to randomly allocate sequences of 3 IAPs (4, 8, and 12 mm Hg) to each rabbit in a crossover study. Rabbits were anesthetized, subumbilical cannulae were placed, and CT scans were performed to obtain baseline measurements. Each IAP was achieved with CO₂ insufflation and maintained for ≥ 15 minutes; CT scans were performed with rabbits in dorsal, left lateral oblique, and right lateral oblique recumbency. The abdomen was desufflated for 5 minutes between treatments (the 3 IAPs). Pneumoperitoneal volumes were calculated from CT measurements with 3-D medical imaging software. Mixed linear regression models evaluated effects of IAP, rabbit position, and treatment order on working space volume.

RESULTS

Mean working space volume at an IAP of 8 mm Hg was significantly greater (a 19% increase) than that at 4 mm Hg, and was significantly greater (a 6.9% increase) at 12 mm Hg than that at 8 mm Hg. Treatment order, but not rabbit position, also had a significant effect on working space. Minor adverse effects reported in other species were observed in some rabbits.

CONCLUSIONS AND CLINICAL RELEVANCE

A nonlinear increase in abdominal working space was observed with increasing IAP. Depending on the type of procedure and visual access requirements, IAPs > 8 mm Hg may not provide a clinically important benefit for laparoscopy in rabbits.

Unexpected Intraoperative Findings, Situations, and Complications in Bariatric Surgery

BACKGROUND

Bariatric surgery is considered a safe therapy to treat obesity. Postoperative complications are well known; however, there is a lack of data describing intraoperative complications and/or unexpected findings, and if there is further impact on outcomes.

METHODS

Retrospective study with patients operated between 2013 and 2016 at a single institution. All operative information was collected prospectively and aimed to analyze the incidence and causes of unexpected intraoperative findings, complications, change in surgical plan, extra surgeries, and procedure interruption in patients submitted to bariatric surgery. Secondarily, a morbidity analysis was performed, correlating intraoperative complications with postoperative complications and length of stay.

RESULTS

Four-hundred and five patients were included. Female sex comprised 82% of cases, and a median age of 38 years old was observed; almost 90% were gastric bypass. In 29.3% of cases, there were intraoperative findings, mainly adhesions, abdominal wall hernias, positive methylene blue test, hiatal hernias, and gastrointestinal stromal tumors. Associated surgeries were performed in 8.6% cases, and intraoperative adverse events reported in 7.1%, where organ injury and anastomosis problems were the most frequent. A change in the operative plan was done in 0.9% and surgery interruption in 1.2% of the cases. Early complications were observed in 6.6%. There was no correlation between intraoperative complications and length of stay or early complications.

CONCLUSION

Unexpected intraoperative findings/complications are common in bariatric surgery, but without increasing morbidity or length of stay. Surgery suspension, change in the planned technique, or adding extra (non-bariatric) procedures may occur.

A novel abdominal wall entry suction device to increase Veress needle safety: A prospective cohort pilot study

Background

In laparoscopic surgery, the Veress needle technique is most often used to initiate a pneumoperitoneum. Although low, entry-related injuries of the intestines and major vascular structures occur in 0.04–0.1% of cases. Up to 50% of these injuries remain undiagnosed at the time of surgery, resulting in mortality rates between 2.5 and 30%. In an effort to minimize such injuries we objectively assessed a novel abdominal wall entry suction device (AWESD) that was hypothesized to lift the abdominal wall and create an additional post-peritoneum safe margin for safer Veress needle introduction.

Materials and methods

A prospective pilot study was conducted in which CT-scans with and without AWESD application (centered above the umbilicus) were assessed to determine its effect on the distance from the linea alba to the intestines, vena cava and abdominal aorta. Paired measurements were subjected to the Wilcoxon signed rank test.

Results

Twelve participants were included. The AWESD significantly increased the median distance towards the intestines in the axial and sagittal plane (P = 0.01 and P = 0.006) from 0.93 (Inter Quartile Range (IQR): 0.33–1.51) and 0.85 (IQR: 0.32–1.47) to 1.35 (IQR: 0.39–2.27) and 1.25 (IQR: 0.42–2.10) centimeters, respectively. Similarly, for the median axial distances towards the vena cava and abdominal aorta (both P = 0.002) that were increased from 10.00 (IQR: 7.18–11.12) and 9.33 (IQR: 6.55–10.28) to 13.23 (IQR: 11.76–14.31) and 12.49 (IQR: 10.98–13.32) centimeters, respectively.

Conclusion

The AWESD significantly increased the distances between the peritoneum and main intra-abdominal structures. However, conclusions on subsequent increased safety cannot be drawn as high-volume studies are required to determine its clinical relevance.

•

Veress needle related injuries are rare but associated with high mortality rates.

•

A novel abdominal entry suction device to increase Veress needle safety was studied.

•

The device increased the distance between peritoneum and intra-abdominal structures.

•

The increased distance was greatest for the vena cava and abdominal aorta.

•

Despite the increased distances, the devices' clinical relevance remains unknown.

A Radial Clutch Needle for Facile and Safe Tissue Compartment Access

Efficient and safe access to targeted therapeutic sites is a universal challenge in minimally invasive medical intervention. Percutaneous and transluminal needle insertion is often performed blindly and requires significant user skill and experience to avoid complications associated with the damage of underlying tissues or organs. Here, we report on the advancement of a safer needle with a radial mechanical clutch, which is designed to prevent overshoot injuries through the automatic stopping of the needle once a target cavity is reached. The stylet-mounted clutch system is inexpensive to manufacture and compatible with standard hypodermic or endoscopic needles, and therefore can be adapted to achieve safe access in a myriad of minimally invasive procedures, including targeted drug delivery, at-home and in-hospital intravenous access, laparoscopic and endo- and trans-luminal interventions. Here, we demonstrate the clutch needle design optimization and illustrate its potential for rapid and safe minimally invasive cannulation.

Direct trocar insertion without previous pneumoperitoneum versus insertion after insufflation with Veress needle in laparoscopic gynecological surgery: a prospective cohort study

The aim of this study was to determine whether direct trocar entry without prior pneumoperitoneum at umbilical level (DTI) can be a safe alternative to access the abdominal cavity in gynaecological laparoscopic surgery. We present a prospective observational analytical study of cohorts, comparing DTI with umbilical entry with trocar after previous insufflation with a Veress needle at umbilical level (V). The study period was performed from June 2013 to April 2016; data was collected on 600 patients who underwent gynaecological laparoscopic surgery. There were no significant differences in the risk of suffering a complication during the access manoeuvres between DTI (6.49%) and V (7.39%), OR 0.89 (95% CI: 0.42-1.81). The duration of the access manoeuvres was 69 s in DTI and 193 s in V (p < .001). The percentage of patients in whom two or more access attempts were performed was lower in DTI (7.8%) than in V (12.3%) (p > .05). We concluded that DTI is at least as safe as V, regarding the risk of suffering complications arising from access into the abdominal cavity. DTI has advantages with regard to V, such as: the shorter duration of access manoeuvres or the lesser number of unsuccessful entry or insufflation attempts. Impact statement What is already known on this subject? There are few international publications comparing DTI and V. When we conducted a search in PubMed for the terms 'Veress needle and direct trocar insertion', 51 publications were obtained. When we increased the restriction and added the terms 'laparoscopic entry and laparoscopy complications', 27 publications were obtained; thus, the uniqueness of our study. What do the results of this study add? We present a 3-year observational prospective study of cohorts that included 600 patients. The aim of this study was to determine that in laparoscopic gynaecological surgery, DTI is an access method to the abdominal cavity at least as safe as V, with respect to the risk of complications. On the other hand, DTI has some advantages such as the shorter duration of access manoeuvres or the lower number of failed entry attempts. What are the implications of these findings for clinical practice and/or further research? Given the limited number of publications that compared both techniques, our study indicates that DTI can be a safe alternative for access to abdominal cavity in gynaecological surgery, compared to the traditional V.

A Modified Open Primary Laparoscopic Surgery Port Placement through Umbilical Tube

Background:

A safe, reliable technique for primary trocar introduction is important for laparoscopic surgery. In resource-constrained settings where there is paucity of needed equipment and cost is prohibitive, a method utilizing fewer instruments will be useful.

Aim:

This study aims to describe a method of primary trocar introduction that utilizes any available port.

Methods:

A supra- or infra-umbilical incision is made into an everted tubular umbilicus. The linear alba is incised and the resultant opening bluntly developed, after which any available port is inserted using the trocar as a guide. The trocar is withdrawn while the sleeve is pushed in.

Results:

One hundred and three successful insertions were affected in 107 patients with age range of 1–75 years, with no significant gas leaks.

Conclusion:

This modified open approach is a simple and reliable way of primary port insertion. Access is gained easily in different age groups and umbilicus types.

Programmable Multistable Mechanisms for Safe Surgical Puncturing

We present novel medical devices for safe surgical puncturing, in particular a cannula for the treatment of retinal vein occlusion (RVO). This passive mechanical device has an adjustable stroke and exerts a puncturing force independent of operator applied displacement. The innovative feature of this tool is that puncturing stroke is decoupled from operator input thereby minimizing the possibility of overpuncturing. This is achieved using our concept of stability programming, where the user modifies the mechanism strain energy as opposed to imposing direct displacement which is the case for standard bistable mechanisms. Ultra-fast laser three-dimensional (3D) printing is used to manufacture the needle in glass. A microfluidic channel is integrated into the needle tip for drug injection. Numerical simulations and experimental measurements validate the mechanical stability behavior of the puncture mechanism and characterize its puncturing stroke and force.

Laparoscopic entry techniques

BACKGROUND

Laparoscopy is a common procedure in many surgical specialties. Complications arising from laparoscopy are often related to initial entry into the abdomen. Life-threatening complications include injury to viscera (e.g. bowel, bladder) or to vasculature (e.g. major abdominal and anterior abdominal wall vessels). No clear consensus has been reached as to the optimal method of laparoscopic entry into the peritoneal cavity.

OBJECTIVES

To evaluate the benefits and risks of different laparoscopic entry techniques in gynaecological and non-gynaecological surgery.

SEARCH METHODS

We searched the Cochrane Gynaecology and Fertility (CGF) Group trials register, CENTRAL, MEDLINE, Embase, PsycINFO, and trials registers in January 2018. We also checked the references of articles retrieved.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) that compared one laparoscopic entry technique versus another. Primary outcomes were major complications including mortality, vascular injury of major vessels and abdominal wall vessels, visceral injury of bladder or bowel, gas embolism, solid organ injury, and failed entry (inability to access the peritoneal cavity). Secondary outcomes were extraperitoneal insufflation, trocar site bleeding, trocar site infection, incisional hernia, omentum injury, and uterine bleeding.

DATA COLLECTION AND ANALYSIS

Two review authors independently selected studies, assessed risk of bias, and extracted data. We expressed findings as Peto odds ratios (Peto ORs) with 95% confidence intervals (CIs). We assessed statistical heterogeneity using the I² statistic. We assessed the overall quality of evidence for the main comparisons using GRADE methods.

MAIN RESULTS

The review included 57 RCTs including four multi-arm trials, with a total of 9865 participants, and evaluated 25 different laparoscopic entry techniques. Most studies selected low-risk patients, and many studies excluded patients with high body mass index (BMI) and previous abdominal surgery. Researchers did not find evidence of differences in major vascular or visceral complications, as would be anticipated given that event rates were very low and sample sizes were far too small to identify plausible differences in rare but serious adverse events.Open-entry versus closed-entryTen RCTs investigating Veress needle entry reported vascular injury as an outcome. There was a total of 1086 participants and 10 events of vascular injury were reported. Four RCTs looking at open entry technique reported vascular injury as an outcome. There was a total of 376 participants and 0 events of vascular injury were reported. This was not a direct comparison. In the direct comparison of Veress needle and Open-entry technique, there was insufficient evidence to determine whether there was a difference in rates of vascular injury (Peto OR 0.14, 95% CI 0.00 to 6.82; 4 RCTs; n = 915; I² = N/A, very low-quality evidence). Evidence was insufficient to show whether there were differences between groups for visceral injury (Peto OR 0.61, 95% CI 0.06 to 6.08; 4 RCTs; n = 915: I² = 0%; very low-quality evidence), or failed entry (Peto OR 0.45, 95% CI 0.14 to 1.42; 3 RCTs; n = 865; I² = 63%; very low-quality evidence). Two studies reported mortality with no events in either group. No studies reported gas embolism or solid organ injury.Direct trocar versus Veress needle entryTrial results show a reduction in failed entry into the abdomen with the use of a direct trocar in comparison with Veress needle entry (OR 0.24, 95% CI 0.17 to 0.34; 8 RCTs; N = 3185; I² = 45%; moderate-quality evidence). Evidence was insufficient to show whether there were differences between groups in rates of vascular injury (Peto OR 0.59, 95% CI 0.18 to 1.96; 6 RCTs; n = 1603; I² = 75%; very low-quality evidence), visceral injury (Peto OR 2.02, 95% CI 0.21 to 19.42; 5 RCTs; n = 1519; I² = 25%; very low-quality evidence), or solid organ injury (Peto OR 0.58, 95% Cl 0.06 to 5.65; 3 RCTs; n = 1079; I² = 61%; very low-quality evidence). Four studies reported mortality with no events in either group. Two studies reported gas embolism, with no events in either group.Direct vision entry versus Veress needle entryEvidence was insufficient to show whether there were differences between groups in rates of vascular injury (Peto OR 0.39, 95% CI 0.05 to 2.85; 1 RCT; n = 186; very low-quality evidence) or visceral injury (Peto OR 0.15, 95% CI 0.01 to 2.34; 2 RCTs; n = 380; I² = N/A; very low-quality evidence). Trials did not report our other primary outcomes.Direct vision entry versus open entryEvidence was insufficient to show whether there were differences between groups in rates of visceral injury (Peto OR 0.13, 95% CI 0.00 to 6.50; 2 RCTs; n = 392; I² = N/A; very low-quality evidence), solid organ injury (Peto OR 6.16, 95% CI 0.12 to 316.67; 1 RCT; n = 60; very low-quality evidence), or failed entry (Peto OR 0.40, 95% CI 0.04 to 4.09; 1 RCT; n = 60; very low-quality evidence). Two studies reported vascular injury with no events in either arm. Trials did not report our other primary outcomes.Radially expanding (STEP) trocars versus non-expanding trocarsEvidence was insufficient to show whether there were differences between groups in rates of vascular injury (Peto OR 0.24, 95% Cl 0.05 to 1.21; 2 RCTs; n = 331; I² = 0%; very low-quality evidence), visceral injury (Peto OR 0.13, 95% CI 0.00 to 6.37; 2 RCTs; n = 331; very low-quality evidence), or solid organ injury (Peto OR 1.05, 95% CI 0.07 to 16.91; 1 RCT; n = 244; very low-quality evidence). Trials did not report our other primary outcomes.Other studies compared a wide variety of other laparoscopic entry techniques, but all evidence was of very low quality and evidence was insufficient to support the use of one technique over another.

AUTHORS' CONCLUSIONS

Overall, evidence was insufficient to support the use of one laparoscopic entry technique over another. Researchers noted an advantage of direct trocar entry over Veress needle entry for failed entry. Most evidence was of very low quality; the main limitations were imprecision (due to small sample sizes and very low event rates) and risk of bias associated with poor reporting of study methods.

Comparison of two methods of laparoscopic trocar insertion (Hasson and Visiport) in terms of speed and complication in urologic surgery

BACKGROUND

Nowadays, diverse approaches have been existed for laparoscopic procedures. The most common laparoscopic entry methods included close and direct entry laparoscopy and open (Hasson) laparoscopy. There is no evidence regarding the superiority in safety and initial speed for the use of open and optical laparoscopic entry. Therefore, the sight of current study was to evaluate comparative survey of two methods of laparoscopic trocar insertion (Hasson and VisiportTM) in terms of speed and complications in urologic surgery.

METHODS

This expertized base clinical trial study was conducted on 100 patients who underwent urological laparoscopy in Alzahra Hospital, Isfahan, Iran. These patients were randomly divided to two groups (n = 50). One group underwent open laparoscopy and another group Visiport optical trocar. Speed and Complications of urologic surgery was extracted from medical records. Independent T test was used for doing of analysis.

RESULTS

The mean age of patients in Hasson and Visiport laparoscopic group was 41.4 ± 11.2 and 41.6 ± 15 years old, respectively (p = 0.91). The mean time for initial trocar placement in patients who underwent Visiport trocar system and Hasson laparoscopic technique was 37.7 ± 15.59 and 95.4 ± 31.75 seconds. There was gratifying difference between two techniques of laparoscopic trocar insertion (Hasson and Visiport) in terms of speed (p = 0.000). In addition, complications were observed in 8% of patients who underwent Visiport trocar system. However, no complications were observed in Hasson laparoscopy group.

CONCLUSION

Visiport optical trocar technique is faster for initial trocar placement than open laparoscopy. However it is associated with complications compared to open laparoscopy. Therefore, there is evidence of benefit in terms of speed for initial trocar placement and harm based on complications in Visiport trocar system.

Design of a Handheld Trocar Insertion Device for Laparoscopic Surgery to Avoid Overshooting

Overshooting trocar insertion in Iaparoscopic surgery has been extensively cited as a major cause of surgical injury. The complexity and extensive insertion force required of the current handheld insertion method increases the risk of overshooting and is difficult for novice and female operators. Hence, we developed a trocar insertion device to make the procedure easier and safer. The device is designed so it is easy to handle and assemble. It used negative pressure and pneumatic cylinders to lift the abdominal wall and two motors to drive the trocar insertion. In addition, we interpreted the characteristics of the insertion force and developed an algorithm to detect whether the trocar is properly inserted. By monitoring changes in the insertion force with this device, the trocar insertion can be stopped automatically and immediately. The development of this device has realized the automation of trocar insertion. It reduces the demand on operators and improves the safety of the procedure.

OneShot-M: A New Device for Close Laparoscopy Pneumoperitoneum

INTRODUCTION

The induction of pneumoperitoneum is the first and most critical phase of laparoscopy, due to the significant risk of serious vascular and visceral complications. The closed technique for the creation of pneumoperitoneum could lead to several surgical complications. The present study aimed to overcome the complications associated with the insertion of Veress needle, improving its use, and facilitating the rapid creation of pneumoperitoneum.

METHODS

Thirty large white female pigs were enrolled in our study. A common plunger was modified in order to allow the passage of a 15-cm long Veress needle. This method was applied to 26 laparoscopic procedures (26 pigs) of several specialist branches.

RESULTS

OneShot-M close laparoscopy pneumoperitoneum creation device allowed us to obtain pneumoperitoneum quickly in all attempts, without any intraoperative and postoperative complications related to the use of the Veress needle.

CONCLUSION

The use of the proposed device showed an induction time as quick as the standard laparoscopic closed abdominal entry. The patented device is cheap and allows a safe abdominal entry. In addition, abdominal entry is much faster than the classic open technique.