Five-year experience with a bladed optical trocar

Five-year experience with a bladed optical trocar
in an uninsufflated abdomen in bariatric surgery
Timothy Lapham MD
Michael Tarnoff MD FACS
Julie Kim MD FACS
Scott Shikora MD FACS
Division of Minimally Invasive
and Bariatric Surgery
Department of Surgery
Tufts-New England Medical Center
Boston, MA
Background: Trocar insertion with direct visualization
through a small incision (direct trocar insertion) has been
the bariatric surgery gold standard for minimally invasive
peritioneal access. Despite its widespread acceptance,
this technique can be time consuming and often leads to
an inadequate pneumoperitoneum seal, especially in the
morbidly obese. The Veress needle has been considered
a safe method of closed access to the peritoneal cavity
but more recently has been shown to be associated
with an increased risk of bowel and vascular injuries.
1 2 3
Optical trocars allow entry into the abdomen with direct
visualization of the layers of the abdomen. Traditionally,
these trocars have been used after insufflation has been
achieved with the verees needle. We present our five year
bariatric surgery experience with use of a bladed optical
trocar in an uninsufflated abdomen.
Technique: The VISIPORT™ (US Surgical, Norwalk, CT) is
Results: 1,623 of 1,626 (99.8%) entries were uneventful.
a single use Optical Obturator that includes a blunt clear
Three injuries (0.2%) and no deaths (0%) occurred. Two
window at the distal end along with a crescent-shaped
of the three injuries required conversion to laparotomy
knife blade and a pistol grip handle with a trigger at the
and repair of lateral retroperitoneal bleeding. The other
proximal end, and an opening to accommodate a 10mm
patient had self-limited retroperitoneal bleeding that
0° laparoscope. When the trigger is pulled, the blade
was managed laparoscopically. All injuries occurred with
extends approximately 1mm and immediately retracts.
placement of the trocar in an off-midline location. No
This action permits a controlled, sharp dissection of the
injuries occurred with midline placement. There was no
tissue layers. The laparoscope permits visualization as
long-term morbidity and no mortalities associated with
the obturator passes through the abdominal or thoracic
the injuries.
body wall.
Conclusion: Use of the VisiportTM without prior
It is essential to assure that the image is in clear focus
insufflation is safe in the morbidly obese population. It
prior to use. With midline deployment, the subcutaneous
appears to be safest in the midline, where the layers of
fat, the linea alba, the peritoneal fat and the peritoneum
the abdominal wall are easily recognized. Alternate site
can be clearly and reliably visualized layer by layer
entry requires extra caution because the anatomic layers
(see images below). The combination of slow steady
are less predictable and harder to recognize. The most
gentle pressure with firing of the blade only through
important aspects of safe insertion in any location are
these recognizable abdominal wall layers are essential
slow and steady gentle pressure with firing of the blade
components of safe entry.
only through recognizable layers of the abdominal wall
layer.
Methods: From July 30, 2001 until August 30, 2006,
laparoscopic access for all bariatric surgery at a single
center was gained using the 5 mm/12 mm Visiport device
without prior insufflation. Three attending surgeons
and five laparoscopic bariatric fellows used the device
References
1
Schafer M, Lauper M, Krahenbuhl L. Trocar and Veress
for a total of 1,626 cases, including 1,233 laparoscopic
needle injuries during laparoscopy. Surg Endosc 2001;
gastric bypass procedures (LGBP) and 393 laparoscopic
15(3):275-80.
adjustable gastric band placements (LAGB). The LGBP
2
McKernan JB, Champion JK. Access techniques:
entry point was midline, except in cases where alternate
Veress needle—initial blind trocar insertion versus
site access was desired due to prior surgery. All LAGB
open laparoscopy with the Hasson trocar. Endosc
had an off-midline Visiport insertion.
Surg All Technol 1995. 3(1):35-8.
3
Agresta F, DeSimone P, Ciardo LF, Bedin N. Direct
trocar insertion vs. Veress needle in nonobese patients
undergoing laparoscopic procedures: a randomized
prospective single-center study. Surg Endosc 2004.
18(12):1778-81.
Subcutaneous Fat
Cutting of the Fascia
Michael Tarnoff, MD, FACS and Scott Shikora, MD, FACS are consultants and receive consulting fees from Covidien.
Reprinted with permission of Tufts-New England Medical Center.
Cutting of the Peritoneum