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2/1/2012

Avoiding Trocar Injuries Associated with Laparoscopic Surgery

Up to half of major intraoperative complications associated with laparoscopy, including major vascular injury, occur at the time of surgical entry. Half of all bowel injuries occur during entry, with the small intestine at highest risk. Insertion of the Veress needle (VN) and primary trocar for initial entry account for 40% of complications and the majority of fatalities.

Assuming initial peri-umbilical entry, in non-obese women, the VN or trocar should be inserted at 45 degrees from the horizontal plane of a patient’s spine. At this angle, the abdominal wall thickness varies from 2 to 3 cm and distance to the major vessels averages 6 to 10 cm. In obese patients, the needle or trocar can be placed close to 90 degrees from the horizontal plane. At this angle, the distance to the vessels averages 13 cm. When placing midline trocar, they should remain true to midline to avoid injury to lateral structures. Increasing abdominal girth could result in wide lateral excursions.

The VN should be open when inserted. The surgeon can feel or listen for two clicks (the double click test) as the VN is placed through the anterior abdominal wall (click #1 = anterior rectus sheath, click #2 = the peritoneum). The needle should be freely movable at a fulcrum located within the anterior abdominal wall (waggle test). A drop of saline can be placed in the open needle hub and the abdominal wall lifted (hanging drop test). If the drop is drawn into the needle, it suggests that the tip is within the abdominal cavity.

Many surgeons prefer to insert the primary trocar after insufflation of the abdomen to 25 to 30 mm Hg. This stiffens the anterior abdominal, preventing the umbilicus from being depressed toward the major vessels.

Open laparoscopy avoids blind placement by incising the periumbilical fascia and peritoneum and advancing a blunt trocar directly into the peritoneal cavity. Intra-umbilical incision leverages the shortest access point to the peritoneal cavity where the parietal peritoneum and fascia are tethered. Although open technique reduces the risk of major vascular injury, small bowel injuries can occur especially in the setting of intra-peritoneal adhesions.

In direct trocar insertion, the primary trocar is placed without prior insufflation and may avoid injuries associated with VN placement, but not decrease overall risk of injury.

Alternatively, left upper quadrant insertion at Palmer’s Point can be used. This point is located 3 cm below the middle of the left costal margin. The VN is inserted perpendicular to the patient’s skin and abdominal cavity with care to avoid lateral incursions into the abdominal wall. A small diameter scope can be placed, and other trocars then placed under direct visualization. Palmer’s Point can also be used with direct trocar entry. This is especially helpful in patients who have had prior abdominal surgery.

The literature suggests the highest likelihood of minor complications, repeated entry attempts, and failed entry with VN insertion. However, no entry approach is without risk of major injury and surgeon experience and preference should be considered. For insertion of secondary ports, transillumination can help to identify superficial vessels, but they are difficult to see in the obese patient. The inguinal ring can be identified by tracing the round ligament into the pelvic sidewall and the inferior epigastric arteries visualized arising from the inguinal ring and coursing lateral to the medial umbilical ligament. When laparoscopic landmarks are not visible, secondary trocars should be placed 5 cm superior to the mid-pubic symphysis and 8 cm lateral to the midline to avoid the epigastric vessels. This location is often directly over the external iliac vessels and can be further laterally situated in obese patients or carbon dioxide inflated abdomen, so care should be taken to control the direction, depth, and speed during insertion. The trocar should be placed as close as possible to perpendicular to the abdominal wall and peritoneum. A more oblique insertion can make entry into the peritoneal cavity more difficult as the distance from insertion site to peritoneal cavity increases. Once the trocar sleeve is through the peritoneum, the sheath can be further advanced under direct observation, preventing injury to the underlying structures.

Prior to incision of the skin and trocar insertion, injection of local anesthetic using a 1.5-inch needle along the projected trocar insertion allows identification of where the needle will enter the peritoneum and provides perioperative anesthesia.

Further Reading:

Burnett, T.L., Garza-Cavazos, A., Groesch, K., et al. Location of the Deep Epigastric Vessels in the Resting and Insufflated Abdomen. J Minim Invasive Gynecol. 2016 Jul-Aug;23(5):798-803. doi: 10.1016/j.jmig.2016.04.002. Epub 2016 Apr 19. Makai G, Isaacson K. Complications of gynecologic laparoscopy. Clin Obstet Gynecol. 2009;52:401-11.

Pickett SD, Rodewald KJ, Billow MR, et al. Avoiding major vessel injury during laparoscopic instrument insertion. Obstet Gynecol Clin North Am. 2010 Sep;37(3):387-97. doi: 10.1016/j.ogc.2010.05.002.

Initial Approval February 2012; Revised January 2017; Reaffirmed November 2019; Revised July 2021, Revised January 2023. Minor Revision November 2024.

 

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