Reduced-Force Closed Trocar Entry Technique: Analysis of Trocar Insertion Force Using a Mechanical Force Gauge.

2011·0.26 MB·English

by  Fanning, James

S P
CIENTIFIC APER
Reduced-Force Closed Trocar Entry Technique:
Analysis of Trocar Insertion Force Using a
Mechanical Force Gauge
James Fanning, DO, Manish Shah, MD, Bradford Fenton, MD, PhD
ABSTRACT INTRODUCTION
BackgroundandObjectives:Trocarinsertioninjuryhas Advancedlaparoscopicproceduresareincreasinglybeing
a high morbidity, mortality, and cost. The purpose of this used as an alternative for laparotomy in gynecological
study was to compare standard trocar entry with our surgery. A metaanalysis of 27 prospective randomized
reduced-forceclosedtrocarentrytechniquebymeasuring trials has proven the benefits of laparoscopic compared
trocar insertion force using a mechanical force gauge. withabdominalgynecologicsurgery:decreasedpain,de-
creased surgical-site infections (decreased relative risk
Methods: In the operating room, the force gauge was
80%),decreasedhospitalstay(2daysless),quickerreturn
insertedintoasterilegloveandconnectedtotheproximal
toactivity(2weekssooner),anddecreasedpostoperative
portion of the trocar to measure insertion force. Through
adhesions (decreased by 60%).1
one incision, we used a standard closed trocar entry,
while through the other incision, we used our reduced-
Initial access into the abdomen is a major challenge of
forceclosedtrocarentrytechnique.Aftermakingtheskin
laparoscopy, because it can result in injury to the gastro-
incisionandbeforetrocarentry,wespreadanddilatedthe
intestinal tract, urinary tract, and blood vessels. Trocar
skin, subcutaneous tissue, fascia, and muscle with a he- insertioninjuryoccursin(cid:2)1%ofcaseswith50%ofthese
mostat.
complications occurring during initial trocar insertion.2
Results: Twenty-five patients entered the trial and none Because of the rarity of trocar insertion injury (1%), there
were excluded. Median trocar insertion force was 3.3lb arenoprospectiverandomizedstudiestoprovethesafest
(range, 1.6 to 5.4) with our reduced-force trocar entry method of trocar insertion.2
technique versus 6.5lb (range, 2.0 to 14.0) with the stan-
dard trocar entry (P(cid:1).001). No complications occurred Veress needle-pneumoperitoneum-closed trocar entry is
themostcommonlaparoscopicentrytechnique.2Follow-
with the reduced-force trocar entry technique.
ingaskinincision,theVeressneedleisinsertedandgasis
Conclusion: Our reduced-force trocar entry technique insufflated into the abdomen. A trocar is then introduced
decreasestrocarinsertionforceby50%,requiresnoaddi- intotheabdominalcavity.Wehavedevelopedareduced-
tional instruments or cost and is fast and safe. Reduced- force closed trocar entry technique by spreading and di-
entryforcepressuremaydecreasetheriskoftrocarinser- lating the skin, subcutaneous tissue, fascia, and muscle
tion injury. with a hemostat after making the skin incision and before
Veress needle and trocar entry (Figures 1 and 2). This
Key Words: Laparoscopy, Reduced force, Trocar entry.
technique requires no additional instruments or cost, and
takesonlyafewsecondstoperform.Webelievethatthis
technique reduces the force of entry into the abdomen,
which possibly could decrease injury associated with tro-
car insertion.
Thepurposeofthisstudywastocomparestandardtrocar
DepartmentofObstetricsandGynecology,PennsylvaniaStateUniversity,MiltonS. entry with our reduced-force trocar entry technique by
HersheyMedicalCentre,Hershey,PennsylvaniaUSA(allauthors).
measuring trocar insertion force with a mechanical force
Address correspondence to: James Fanning, DO, Professor, Chief, Division of
gauge.
GynecologicOncology,DepartmentofObstetricsandGynecology,Pennsylvania
StateUniversity,MiltonS.HersheyMedicalCenter,500UniversityDrive–Room
C-3620,Hershey,PA17033.USA.Telephone:[phone],Fax:[phone],
E-mail:[email protected] MATERIALS AND METHODS
DOI:10.4293/108680811X13022985131219
Female patients undergoing advanced gynecologic lapa-
©2011byJSLS,JournaloftheSocietyofLaparoendoscopicSurgeons.Publishedby
theSocietyofLaparoendoscopicSurgeons,Inc. roscopicproceduresthroughourstandardfour5-mmtro-
JSLS(2011)15:59–61 59
Reduced-ForceClosedTrocarEntryTechnique:AnalysisofTrocarInsertionForceUsingaMechanicalForceGauge,FanningJetal.
Pressure was recorded by using a Wagner Force Dial,
model FDK 10 (Wagner Instruments, Greenwich, CT),
whichisaccurateto0.1lb.Intheoperatingroom,theforce
gauge was inserted into a sterile glove. The force gauge
was connected to the proximal portion of the trocar to
measure the pressure of trocar insertion force. The same
type of trocar was used in all cases: a 5-mm disposable,
shielded, bladed design (Applied Medical, Rancho Santa,
CA). We routinely perform our laparoscopic surgery
throughfour5-mmtrocars.3–5Twoof4trocarsareparallel
to each other in the right and left lower quadrants. Using
apen,wemarkedthe2incisionlocationshavingthesame
size (7mm) and same location (1 in the right and 1 in the
leftlowerquadrant).Theexactlocationdependedonthe
individual surgery. As per our standard, no trocar inser-
tionsarethroughapriorsurgicalscar.Throughoneofthe
incisions, we used a standard trocar entry while through
theotherincisionweusedourreduced-forcetrocarentry
Figure1.Reduced-forcetrocarentrytechnique.
technique.Aftermakingtheskinincisionandpriortotrocar
entry, we spread and dilated the skin, subcutaneous tissue,
fasciaandmusclewithahemostat(Figures1and2).Suc-
cessful dilation can be felt manually and was verified
laparoscopically by an assistant. The trocar was then in-
serted.Becauseofthedilation,thetrocarroutinelyfollows
the same insertion path. We alternated the side (right vs.
left) of the reduced-force trocar entry technique every
other patient. All trocar insertions were performed by the
samesurgeon,usingtheright(dominant)handandstand-
ing on the trocar side of the patient. Pressure readings
duringinsertionwereblinded,becausetheWagnerForce
Dialwasinsideasurgicalglove.Standardtrocarentryand
reduced-force trocar entry technique were not observed
laparoscopically(thesurgeonperformingthetrocarinser-
tion did not look at the monitor during insertion) in an
effort to mimic initial trocar insertion.
Insertionforcewascomparedusinga2-tailedttest.Sam-
Figure 2. Reduced-force trocar entry technique–laparoscopic plesizecalculationusingaPvalueof0.05andapowerof
view–tipsofhemostatvisibleabovetheperitoneum.
0.8requiredasamplesizeof12patientsusedastheirown
controls to detect a 30% difference in force.
carapproach3–6wereeligible.IRBapprovalandinformed
consent were obtained. RESULTS
Allpatientsreceivedapreoperativebowelprepwith45cc Twenty-five patients entered the trial and none were ex-
ofmagnesiumcitrateorally,asingledoseofpreoperative cluded. Median age was 56 years (range 41 to 80), and
prophylactic antibiotics if indicated, and external pneu- median BMI was 33kg/m2 (range, 24 to 51). Of the pa-
matic cuffs. All procedures were performed with the pa- tients, 80% had medical comorbidities, 48% had prior
tient under general endotracheal anesthesia with muscle abdominal surgery, and 80% were Caucasian.
relaxation. An orogastric tube was inserted and removed
at the end of surgery. The patient was positioned in the Median operative time was 2.0 hours (range, 1.1 to 3.5),
dorsolithotomy position with legs in Allen stirrups. and median blood loss was 150cc (range, 50 to 500).
60 JSLS(2011)15:59–61
Mediantrocarinsertionforcewas3.3lb(range,1.6to5.4) no complications with the reduced-force trocar entry
with our reduced-force trocar entry technique versus technique, which is predictable since the hemostat re-
6.5lb (range, 2.0 to 14.1) with standard trocar entry mains above the peritoneum.
(P(cid:1).001).
CONCLUSION
There were no port-site hematomas or other complica-
tionswiththereduced-forcetrocarentrytechnique,and We have developed a reduced-force trocar entry tech-
there was no problem with inadvertent port with- nique that decreases insertion force pressure (cid:3)50%, re-
drawal. Although not prospectively evaluated, no pa- quires no additional instruments or cost and is fast and
tient reported increased pain at the dilated port site. safe. Because reduced-entry force pressure may decrease
the risk of trocar insertion injury, we recommend the use
of our reduced-force trocar entry technique.
DISCUSSION
Advancedlaparoscopicproceduresareincreasinglybeing References:
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