Initial closed trocar entry for laparoscopic surgery: Technique, umbilical cosmesis, and patient satisfaction

Abstract

Background/aims: Despite the benefits of laparoscopic surgery, which is being performed with increasing frequency, complications that do not occur during laparotomy are sometimes encountered. Such complications commonly occur during the initial trocar insertion, making this a procedural step of critical importance.

Methods: In 2002, we experienced, upon initial trocar insertion, a serious major vascular injury (MVI) that led to hemorrhagic shock, and we thus modified the conventional closed entry method to an approach that we have found to be safe. We began developing the method by first measuring, in a patient undergoing laparoscopic cystectomy, the distance between the inner surface of the abdominal wall and the anterior spine when the abdominal wall was lifted manually for trocar insertion and when it was lifted by other methods, and we determined which method provided the greatest distance. We then devised a new approach, summarized as follows: The umbilical ring is elevated with Kocher forceps. The umbilicus is everted, and the base is incised longitudinally. This allows penetration of the abdominal wall at its thinnest point, and it shortens the distance to the abdominal cavity. A bladeless trocar (Step trocar) is used to allow insertion of the Veress needle. We began applying the new entry technique in July 2002, and by December 2014, we had applied it to 9676 patients undergoing laparoscopic gynecology surgery.

Results: All entries were performed successfully, and no MVI occurred. The umbilical incision often resulted in an umbilical deformity, but in a questionnaire-based survey, patients generally reported satisfaction with the cosmetic outcome.

Conclusion: A current new approach provides safe outcome with a minor cosmetic problem.

Keywords: Closed laparoscopy; Laparoscopic myomectomy; Major vascular injury; Umbilical deformity.

Fig. 1

Conventional trocar insertion method and newly developed trocar insertion method. (A) When the conventional method is used, the skin is lifted manually, a Veress needle is inserted into the horizontal incision that has been made along the lower margin of the umbilical ring, and the abdomen is insufflated; (B) After removal of the Veress needle, the abdominal wall is pressed against from the left and right, and a “safety shielded trocar” is inserted. (C) When our new entry method is used, the umbilicus is lifted with Kocher forceps, and a Step Veress needle is inserted into the vertical incision that has been made at the base of the umbilicus; (D) After insufflation, the inner needle is removed, an 11-mm blunt-tip dilator is inserted to dilate the expandable sleeve, and the trocar is set in place.

Fig. 2

Preliminary study in which we measured distances from the abdominal wall to the anterior surface of the lumbar spine. We lifted the abdominal wall by 3 different methods: (A) by lifting the skin manually, (B) by pressing against the abdominal wall from the left and right after insufflation, (C) by lifting the umbilical ring with Kocher forceps. Measurements shown are taken from the external abdominal wall. (D, E, F) Corresponding measurements taken from the internal abdominal wall.

Fig. 3

Diagrams shown to patients 6 months after laparoscopic myomectomy for self-evaluation of the umbilical scar. Survey period: January 2013–December 2014; 61 respondents, with 1 failing to mark the level of satisfaction. Type A deformity: Scaring at the midline. Type B deformity: Umbilical protrusion. The skin within the umbilicus protrudes. Type C: Atypical deformity.

Fig. 4

Actual examples of each type of umbilical deformity. Type A: Healing creates a central scar. Type B: Healing creates a protuberance (omphaloproptosis). Note that the umbilicus is collapsed and the skin protrudes. Type C: Healing is atypical, often resulting in a radial bridge-like scar.

Fig. 5

Three-dimensional computed tomography image obtained from a patient who was 171 cm in height and weighed 57 kg (BMI = 19.4).