Saving Time During Laparoscopy Using a New, Wall Anchoring Trocar Device.

2010·0.06 MB·English

by  Tchartchian, Garri

S P
CIENTIFIC APER
Saving Time During Laparoscopy Using a New, Wall
Anchoring Trocar Device
Garri Tchartchian, MD, Joanna Dietzel, MD, Mark W. Surrey, PhD,
Rudy L. DeWilde, PhD, Bernd Bojahr, PhD
ABSTRACT stability of ports and have a time-sparing effect. Compar-
ing the 2 trocar groups with wall-anchoring properties
Objective: Safe and reliable access systems are crucial in (trocar with thread-fitted sleeve vs fixator (cid:1) trocar with
laparoscopy, and trocar dislodgement is still a common
plain sleeve), the mean operation time was lowest in the
and frustrating problem. Wall emphysema can occur be-
fixator group, and the time-saving effect was higher.
sides the risky prolongation of the surgical procedure.
Wall-anchoring components provide a better hold of the Key Words: Laparoscopy, Trocar, Dislodgement.
device. This comparative analysis assesses the frequency
ofdislodgementandatime-sparingeffectontheinterven-
tionof3differenttrocarsystems,includinganinnovation
in the field of access-providing systems.
Methods: Patients who underwent laparoscopy for vari- INTRODUCTION
ousgynecologicalindicationswereincludedandrandom-
ized consecutively into 3 groups according to the access This study addressed the timesaving effect of different
system used in the intervention: (A) trocar fitted with a trocar systems in gynecological laparoscopic interven-
spiral thread on the sleeve, (B) trocar with plain sleeve, tions.Thedislodgmentoftrocarsisaknownproblemand
(C) trocar as in B together with a fixator. This novelty is can lead to frequent interruption of an endoscopic inter-
installedonthetrocarbeforeinsertionandthensuturedto vention and to its prolongation.
theabdominalwall.Interventiontime,frequencyoftrocar
Laparoscopicaccesssystemshave2components:anouter
corrections, and the time loss through correction were
sleeveorportandremovableinnertrocarusedtofacilitate
registered. Standard statistical analyses were performed.
insertion.Theportremainsinplacetoallowinsufflation
Results: The cohort comprised 131 patients; 51 patients and passage of instruments. Regarding their mode of
were consecutively randomized into group A, 38 into insertion, the variety of available laparoscopic access
groupB,and42intogroupC.Meaninterventiontimewas systems can be classified into 2 categories: bluntly di-
different, shortest in C and highest in B. Frequency of lating-tip-trocarsandcuttingbladed-tip-trocars.Bladed-
interruption of the intervention due to adjustment of the tip-trocars incorporate a sharp plastic or metal blade that
device and time loss through adjustment was lowest in cutsthroughtissuelayersasforceisapplied.Dilating-tip-
group C (fixator (cid:1) plain sleeve) and highest in group B trocars bluntly separate and dilate tissue as force is ap-
(plain-sleeve) (0.47 vs 0.29, P(cid:2)0.05 and 2.13 minutes vs plied. The insertion of the trocar has to be easy, and
0.69 minutes, P(cid:2)0.05). nontraumatic to the underlying viscera; the defect size
should be as minimal as possible. Dilating-tip-trocars are
Conclusion: Wall-anchoring components lead to higher
designed to minimize the complications associated with
the insertion of the device into the abdominal wall, and
DepartmentofObstetricsandGynecology,Pius-Clinic,Oldenburg,Germany(Drs
they seem to have favorable effects on vascular and vis-
Tchartchian,DeWilde);DepartmentofNeurology,UniversityofGreifswald,Ger-
many(DrDietzel);SouthernCaliforniaReproductiveCenter,BeverlyHills,Califor- ceralinjury,abdominalwallhematoma,ortrocar-site-pain
nia USA (Dr Surrey); Clinic of Minimally Invasive Surgery, Evangelic Hospital compared with cutting-trocar systems.1-4 Dilating-tip tro-
Hubertus,Berlin,Germany(DrBojahr).
cars and bladed-tip trocars have been compared before,
Study performed at the Department of Obstetrics and Gynecology, Pius-Clinic, addressingthequestionofinjuryofviscera.5Management
Oldenburg,Germany.
of trocar-site hernia is another aspect of the various ap-
Addresscorrespondenceto:RudyL.DeWilde,Pius-HospitalOldenburg,Georg-
straße 12, 26121 Oldenburg, Germany, Telephone: (cid:1)49 441 229 1501, E-mail: proachesthataremadetooptimizetheattributesoftrocar
[email protected] systems.4,6
DOI:10.4293/108680810X12785289144034
For preventing the dislodgement of the port, attempts are
©2010byJSLS,JournaloftheSocietyofLaparoendoscopicSurgeons.Publishedby
theSocietyofLaparoendoscopicSurgeons,Inc. made by giving more structure to the port’s surface, like a
196 JSLS(2010)14:196–199
spiralthreadforscrewingtheportintotheabdominalwall, (C): fixator plus 5-mm plain sleeve trocar. (Inno-
orbysewingthedevicedirectlyontotheabdominalwall.7 vamed) bladed-tip trocar like in (B). The fixator is in-
stalled on the port before insertion. It consists of 3 parts:
Trocar designs have evolved in response to complication
atriangularperforatedplateoftransparentplastictohold
rates and surgical ergonomics. Displacement of surgical
the port. The port is fitted with a plastic nut. For a better
devices during laparoscopy can be more stressful for the
fit of the nut, differently sized rubber rings are provided
operating surgeon than during open surgery due to im-
and inserted through the hole of the plate that has a
pairedviewandmanualaccesstotheoperationfield.The
connection-threadtoscrewthepartstogether.Thenuton
physical and visual interface has been shown to increase
the trocar sleeve can be screwed to the plate with a
the workload of the surgeon.8 The trocar as access-pro-
correspondingscrewingtool.Theportisinsertedasusual,
viding device has to fulfil the demands of easy and min-
and the plate is sutured at 3 points over the insertion
imally traumatic handling, it has to remain reliably at-
point. The defect size is ca. 5mm after removal plus 3
tached to the insertion site throughout manipulation with
suture marks.
endoscopicalinstruments,andithastomaintainthevalve
function to preserve the insufflation of the abdomen. Patients who were scheduled for gynecological laparo-
Regarding their dislodgement behavior, we evaluated 3 scopic interventions in the Pius Hospital Oldenburg,
access systems in a comparative study: one dilating-tip Germany between November 2006 and July 2007 were
(A): the sleeve of this trocar is fitted with a spiral-thread; consecutively randomized into the trocar groups A-C
one bladed-tip (B): common working trocar with a plain after written, informed consent. For a subgroup analysis of
smooth sleeve; and third(C): an innovation in the field of thedistributionofmajororminorsurgicalinterventioninthe
access-providing systems, a trocar fixator that is used in groups, the type of intervention was registered in the com-
combination with (B). The objective of this device is to monmannerinto2groups: minor - adnexal interventions
prevent the trocar from overinsertion and secondly to singleorincombinationwithtreatmentofendometriosis,
stabilize it broadly based on the abdominal wall and by and/or adhesiolysis; major - interventions on the uterus,
being sutured at 3 points over the insertion point. This ie, laparoscopic-assisted supracervical hysterectomy and
combinationoftrocarpropertiesisanoveltytothefieldof myomectomy. Each intervention was logged by a nurse,
accesssystems.Theaimofthestudywastodeterminethe and time was measured with a stopwatch. Intervention
trocar system with the most favorable dislodgement be- time was measured from the moment of incision in the
haviour regarding the time-sparing effect. Tissue-anchor- umbilical area until the last suture. All interventions were
ingcomponentsofportstryingtoenhancethestabilityof performedbythesamesurgeon.Twotrocarsofeachtype
thesystemintheabdominalwallthroughouttheinterven- at a time were placed at conventional insertion sites for
tionhavenotbeeninvestigatedinastudybefore,though gynecological laparoscopic intervention in the lower ab-
the necessity of a better stability of the port system has domen; the optic-trocar was placed conventionally in the
been a matter of consideration, and suturing the port to umbilicalareaandwasnotregardedinthisstudy.All-over
the abdominal wall with a single wall-anchoring suture intervention time and the duration of interruption of the
and without additional devices has been previously de- intervention for correction of the trocars were registered.
scribed in a small series.5
StatisticalanalysiswasperformedwithSSPS16.Theover-
all difference between the groups was calculated with a
multivariate analysis, and Pearson’s correlation and re-
MATERIALS AND METHODS
gression analysis was used for calculating significances.
P(cid:2)0.05 was defined as significant.
Access Systems
(A): 5-mm thread-fitted trocar. (Aesculap) bluntly di-
RESULTS
lating-tip.Thesleeveisfittedwithaspiralthreadtoscrewthe
portintheabdominalwallandprovideabetterholdinthe See Table 1 for details of the 3 groups. Included in this
tissue.Defectsizeafterremovalca.7mm. analysis were 131 patients; 51 consecutive patients were
randomizedintothegroupA(thread-fittedsleeve),38into
(B): 5-mm plain sleeve trocar. (Storz) bladed-trocar- group B (plain sleeve), and 42 into group C (fixator plus
tip.Thetrocarsleevehasasmoothsurface.Defectsizeof plainsleevetrocar).Therewasasignificantoveralldiffer-
ca. 5mm after removal. ence in the parameters between the 3 groups. The mean
JSLS(2010)14:196–199 197
SavingTimeDuringLaparoscopyUsingaNew,WallAnchoringTrocarDevice,TchartchianGetal.
Table1.
ResultsforEachAccessSystem
GrpAThread-fittedSleeve GrpBPlainSleeve GrpCFixatorPlusPlainSleeve
Meanoperationtime(min)(range,10to310) 74.6 80.3 62.1P(cid:2)0.05
Meanno.ofcorrections(range,0to15) 0.96 4.63P(cid:2)0.05 1.10
Meantimelossthroughcorrection(min) 0.69 2.13P(cid:2)0.05 0.69
intervention time was significantly different in the 3 The value of the fixator in avoiding major vessel injury
groups, being shortest in group C with 62.1 minutes (fix- can only be evaluated in very large series of patients,
ator plus plain sleeve) and longest in the group B with because the frequency of major vessel lesions is rela-
80.3 minutes (plain sleeve trocar). The frequency of cor- tively low. Dislodgment of trocars is more likely to
rectionsofthedisplaceddevicewassignificantlylowerin occur in obese patients.5 The obesity state of the pa-
group C (fixator (cid:1) plain sleeve) and group A (thread- tients included in this study has not been assessed; in
fitted sleeve) and highest in group B (plain sleeve trocar) further comparative studies the obesity state of the
(C: 1.1 resp. A: 0.96 vs. B: 4.63, P(cid:2)0.05). The time loss patient should be registered, adjusting for this risk fac-
through adjustment was significantly shorter in group C tor for trocar dislodgement. Furthermore the patients’
(fixator (cid:1) plain sleeve trocar) and longest in group B responseandacceptanceoftheadditionalsuturemarks
(plain sleeve trocar) with 2.13 minutes vs 0.69 minutes that remain after the use of the fixator combination
(P(cid:2)0.05). In these 2 parameters, there was no significant have not yet been investigated.
difference between group A (thread-fitted trocar) and
group C (fixator (cid:1) plain sleeve trocar). Desufflation of the abdomen and subcutaneous emphy-
sema are some of the sequelae of dislodgement of port
The subgroup analysis of the types of interventions re-
systems,besidesthedisadvantagesduetoprolongationof
vealed no significant difference in the distribution of ma-
the surgical procedure. Since economical considerations
jor gynecological and minor gynecological interventions
in surgery typically comprise the minimization of inter-
in the 3 groups.
vention time, an evaluation of surgical devices regarding
Therewasaweakpositivecorrelationbetweenoperation theirtime-sparingmodificationscouldbeusefulforwork-
timeandfrequencyofcorrection(rsquare0.25),showing ing endoscopic surgeons.
the prolongation of the surgical procedure through cor-
recting of the device, overall and in the subgroups. The
weakest correlation here was found in the thread-fitted-
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