Laparoscopic Trocar Complications - Society of Laparoscopic & Robotic Surgeons

Laparoscopic Trocar Complications

Ronald A. Rhodes, M.D., FACS

There is no debate that laparoscopic surgery has had tremendous positive impact on patients and the healthcare system. Patients tend to have less pain, less morbidity and return to their daily activities more quickly. Thus, the number of laparoscopic procedures done each year continues to rise substantially. There are over 2 million laparoscopic cases performed annually in the U.S.1 Laparoscopic surgery, also known as minimal access surgery, is an approach to surgery whereby operations are performed with specialized instruments designed to be inserted through small incisions. In order to perform minimal access surgery, you must have access to the peritoneal cavity to establish pneumoperitoneum. The pneumoperitoneum is essential for improving visualization by moving the abdominal wall away from the viscera. This initial step in establishing pneumoperitoneum is done blindly with either a Veress needle or trocar. These two devices will be extensively discussed later in the chapter. The initial trocar insertion is the most dangerous aspect of trocar use and likely the most dangerous step in minimally invasive surgery.2 The risk associated with the blind initial access and establishing pneumoperitoneum is not found in open surgery. Despite the many technical advances in laparoscopic surgery equipment and the extensive experience of many surgeons, there is still a number of injuries and deaths each year from insertion of trocars and Veress needles. The creation of a pneumoperitoneum along with insertion of trocars remains the source of significant injuries to intraabdominal viscera and both intra and retroperitoneal vessels.3 The complications associated with trocars vary in severity and in the time of presentation. It is well established that over 50% of the trocar-related injuries to the bowel and vasculature are during the initial entry.4 Unfortunately, 30-50% of the bowel injuries and 15-50% of the vascular injuries are not diagnosed at the time of injury.4 This delay has contributed to mortality rates of 3-30% for bowel and vascular injuries.3,4 Since a large number of laparoscopic procedures are done in a nonhospital ambulatory setting, life threatening immediate complications may be compounded by the lack of resources.
There are also several non-life threatening complications including wound infection and incisional hernia that are important as well.

In this chapter, we will review all aspects of abdominal access with trocars and the Veress needle focusing on the complications of their use, both immediate and delayed, and how to recognize, treat, and most importantly prevent complications.

Understanding of abdominal wall anatomy and its relationship with the viscera and vessels below is crucial for safe placement of trocars. The umbilicus is the best site for insertion of the Veress needle or primary trocar because the skin is attached to the fascia and anterior peritoneum with minimal intervening muscle or fat. This is not the case above or below the umbilicus. This midline insertion is also avascular. Once one gets away from the midline, the major vessels that can be injured are the superior and inferior mesenteric arteries. These course just beneath the rectus abdominis muscles. Their usual location is in the mid portion of the rectus sheath running longitudinally. There are numerous small vessels that can be injured as trocars are passed through the abdominal wall. By transilluminating the abdominal wall, many of these can be seen and avoided.

The relation of the viscera and more importantly the retroperitoneal vasculature to the insertion site must also be considered. This is particularly most important in the very thin and very obese. The normal relationships between the abdominal wall and the vasculature are distorted. According to Anaise, in thin people, the distance between the abdominal wall and the retroperitoneal vessels may be less than 2 cm. Also, the distal aorta and right common iliac artery are particularly vulnerable to injury since the junction of these two vessels is directly below the umbilicus.5

Another consideration during the insertion is the potential for adhesions between the intraabdominal contents and the abdominal wall. The rate of abdominal wall adhesions varies according to patient’s history. According to Vilos et al. the rates of adhesions are 0%to 0.68% in those without any previous abdominal surgery, 0% to 15% in those with previous laparoscopy, 20% to 28% in those with previous laparotomy through a low transverse incision and 50% to 60% in those with a previous midline laparotomy.6 Passage of a Veress needle or trocar near or through adhesions may result in injury.

When performing a laparoscopic procedure, one must decide upon the method of trocar insertion that would be most appropriate for the patient and fit the surgeon’s skill set.
Simply stated, a trocar is a surgical instrument passed through the body wall that allows easy exchange of instruments during laparoscopic surgery. The initial trocar that is inserted is called the primary trocar and all others are secondary trocars. There are two broad categories to consider for insertion of the primary trocar. These are the percutaneous or the open method. In addition, if the percutaneous method is chosen, then one must decide whether or not to establish pneumoperiteum with a Veress needle prior to insertion of the primary trocar. The pneumoperitoneum is composed of carbon dioxide gas that is pumped into the patient controlling the rate of delivery and intraabdominal pressure. Establishing a pneumoperitoneum theoretically should decrease one’s risk of injury by establishing a “buffer zone” of air between the abdominal wall and viscera. In the percutaneous method, no matter whether or not pneumoperitoneum is used, the primary trocar is inserted through the abdominal wall blindly. The fact that there are various techniques for insertion confirms that none has proved to be totally efficacious or complication free.2

If one chooses to use pneumoperitoneum prior to insertion of the primary trocar, this is done by the use of a Veress needle. Anaise provides a nice description of the design and function of the needle. It is a blunt tipped, spring-loaded inner stylet with sharp outer needle. The stylet retracts during passage through the abdominal layers to allow penetration. Once the peritoneum is entered, the lack of resistance allows the blunt stylet to protrude. Theoretically, this should prevent perforation of intra-abdominal structures. Since the blunt tip does not lock once in the peritoneal cavity, it can again retract exposing the needle if it comes into contact with an intraabdominal structure.5

The technique for Veress needle insertion begins by placing the patient supine on the operating table with a nasogastric tube and Foley catheter. The key decision is then choosing the appropriate site for insertion. Most prefer the umbilical site as long as the patient is of average BMI and has no previous surgery or suspicion of periumbilical adhesions. If the patient has a BMI greater than 30, a history of midline incision or failed three attempts at passage of the Veress needle, an alternate site is recommended for insertion. The preferred site is Palmer’s point, which is 3 cm below the left costal margin in the midclavicular line.6 Other alternative sites such as trans-uterine and trans-culdesac have been described but should not be used due to a high risk of complications.7 One should palpate the abdominal wall feeling for the aortic pulsation prior to passing the needle.

The technique of Veress needle insertion involves an incision of appropriate size to pass the needle and a trocar as well if necessary. The Veress needle in then held securely and inserted through the abdominal wall taking care to control the force of the needle. The angle of insertion should be perpendicular to the skin in obese and average patients and angled 45 degrees toward the pelvis in thin patients.7 This comes from a study by Hurd et al that found that the distance between the umbilicus and the aortic bifurcation was 0.4 cm in normal weight patients (BMI <25 kg/m2), 2.4 cm in overweight patients (BMI 25- 30 kg/m2) and 2.9 cm in obese patients (BMI >30 kg/m2).6 Lifting the abdominal wall may improve safety by increasing the distance between the abdominal wall and the viscera. Lifting the abdominal wall by placing towel clips within 2 cm of the umbilicus has been shown to provide significant elevation of the peritoneum (6.8 cm above the viscera) that was maintained during insertion.6

There are many techniques described to confirm appropriate intraperitoneal placement of the Veress needle. Teoh has shown that the most effective way to confirm intraperitoneal placement of the Veress needle is initial gas pressure <10 mmHg. The other techniques, including the double click test, the aspiration test, and the saline drop test are not useful in confirming placement.8 There is danger in wiggling the needle back and forth once in place, as a puncture to a vessel or bowel loop made by the Veress needle can increase from 1.6 mm to 1 cm.6

Once intraperitoneal placement is confirmed, insufflation of CO2 is carried out by the use of a pump in which the rate of insufflation and pressure limits are adjusted by the surgeon’s preference up to what is deemed an adequate pneumoperitoneum. Various authors have studied this and an intraabdominal pressure of 10-15 mmHg seems most appropriate.6 Care should be taken to observe the patient’s vital signs during the insufflations. If there is any alteration in the patient’s hemodynamics or oxygen saturation, insufflation should stop immediately and the pneumoperitoneum should be released. This is usually secondary to inhibited venous return and increased intrathoracic pressure. However, this could be a sign of an air embolus. Once satisfactory pneumoperitoneum has been established, it is now time for insertion of the primary trocar. Some are advocating a temporary increase of the intraabdominal pressure to 20-30 mmHg just before the insertion of the primary trocar. The theoretical advantage to this is that the increased intraabdominal CO2 bubble causes increased resistance in the abdominal wall and a larger buffer zone making trocar insertion easier and safer.6 There have been reports that higher limits of insufflation can be tolerated without side effects on the patient’s hemodynamics. It has been found that the physiologic effect is similar to placing the patient in Trendelenburg position with an intra-abdominal pressure of 15 mmHg.6 These higher limits are used only for a short time during the insertion of the trocar and then the pressure is reset back to the baseline setting of 12-15 mmHg.

If unsuccessful in placing the Veress needle after three attempts, one should consider using Palmer’s point for the Veress needle insertion or convert to an open technique.7

The theoretical advantages of establishing a pneumoperitoneum with a Veress needle are increased distance between the abdominal wall and viscera/vessels and increased resistance of the abdominal wall. The drawbacks of establishing pneumoperitoneum include the risk of bowel or vascular injury, preperitoneal placement of the catheter, and gas embolus. The incidence of bowel and vascular injuries is 0.05 -0.5%3. Even though the incidence is quite low, a major vascular injury or unrecognized bowel injury carries a significant morbidity and a mortality rate of about 4% overall. This increases to a mortality rate of 21% for unrecognized bowel injuries.3 Preperitoneal placement of the needle allows for extraperitoneal insufflation of gas which leads to subcutaneous emphysema and increased distance between the skin and peritoneal cavity making eventual percutaneous placement much more difficult. This can lead to abandonment of the laparoscopic procedure.6 Gas embolus is rare but potentially fatal. It often occurs by accidental puncture of a vessel by the Veress needle and subsequent insufflation. Gas embolus is recognized by a sudden drop in end tidal CO2 and blood pressure.9

Once, the pneumoperitoneum is established, the primary trocar is inserted. There are various designs of trocars with their advantages and disadvantages. A trocar has 2 components to it. There is an inner, removable obturator and the outer port or cannula, which remains in place to allow instruments to pass through. There are two major designs that are found in the majority of trocars, cutting and dilating trocars. The cutting trocars have a metal or plastic blade that cuts through the tissue as force is applied. The dilating system uses a blunt, tapered tip that separates and dilates the tissue as it is inserted.11 The early trocars had sharp cutting tips which were easy to insert but had many complications such as vascular or visceral injury, abdominal wall hematoma, trocar site pain, and trocar site hernias.11 Retractable safety shields have not been proven to prevent insertion injuries. More recent focus has been on non-cutting trocars. These systems have shown improvement with less pain, less port site bleeding, shorter scars and increased patient satisfaction. The negative is that these trocars require much more application of force for insertion, which can potentially increase the rate of injury.11 The latest has been a hybrid type system of all features of separating, dilating, and cutting. The study by Shafer comparing the insertion forces, removal forces, and defect size shows that radially dilating trocars require the most insertion force with the cutting systems requiring the least. The defect sizes were larger with the bladed trocars compared to the dilating systems. This may be a factor in determining which trocar sites require fascial closure.11

In addition, Passerotti et al showed that a significant amount of force is necessary to pass through the thin peritoneal lining.12

Another approach is the percutaneous approach without first establishing a pneumoperitoneum. This is referred to as the direct entry technique. This was first described by Dingfelder in 1978.12 This is done with either via direct trocar insertion or optical trocar insertion. The difference between these two techniques is simply the type of trocar used. The trocar chosen for the optical entry has a central canal that will accomodate the laparoscope which is placed near the end of the trocar and locked into place for the insertion. The direct entry trocar without optical guidance does not have the camera in place for insertion. As the optical trocar is inserted, one can see the subcutaneous fat, fascia, preperitoneal fat, and lastly, the peritoneum give way. These trocars have a tapered end that allows the trocar to pass through the tissues. The technique involves holding the trocar in the palm of your hand and orienting the laparoscope parallel alongside your arm. Using controlled, careful, continuous force, the optical trocar is inserted in a twisting fashion until any opposing force disappears.12,13 These trocars are inserted in the umbilical site and oriented straight down without angulation.12 The infraumbilical midline is grasped with the nondominant hand and elevated to facilitate passage.2 Once the trocar insertion into the peritoneal cavity has been visually confirmed, the CO2 insufflation can begin to establish an appropriate pneumoperitoneum.

Direct trocar insertion can also be done without optical guidance. Accoding to Inan, the technique involves elevation of the abdominal wall between the umbilicus and pubis while inserting the primary trocar. The elevation helps to guide the tip toward the pelvis and pass through the fascia.13 The CO2 stopcock is left open to relieve the negative intraabdominal pressure once the peritoneum is entered. It is proposed that the viscera falls away from the parietal apposition prior to contact with the advancing sharp trocar.2 The proper positioning of the inserted trocar is then confirmed by inserting the camera and directly visualizing the abdominal cavity.12 After this visual confirmation, appropriate pneumoperitoneum can be established.

There are many advantages of the direct entry approach, with or without optical guidance. The first is that there is only one blind step as opposed to three blind steps when using the Veress needle technique. The three blind steps in Veress needle insertion are entrance of the Veress needle, insufflation through the needle, and trocar insertion. In the direct entry technique the blind stage number decreases to one.13 The second advantage is avoiding preperitoneal insufflation and subsequent subcutaneous emphysema by visualizing intraperitoneal placement prior to starting gas flow.2 Another advantage is the ease of elevating the abdominal wall because there has been no previous insufflation. Elevation of the abdominal wall does provide some counter force against the tip of the trocar.2 It has been shown that direct entry techniques do decrease operative time by decreasing the laparoscope insertion time from 5.9 minutes with the Veress needle approach to 2.2 minutes with the direct entry approach.2

Another technique is the open technique. This is also referred to as the Hasson technique. This was originally described by Hasson in 1971.14 In this entry method, a 2 cm periumbilical incision is made allowing exposure of the fascia. The fascia is then incised and the peritoneum below is grasped and opened. Care is taken to insure that there is no bowel attached. Two stay sutures are placed in the fascia around the opening. These sutures are used to secure the Hasson cannula that is placed into the peritoneal cavity to try to avoid leakage of the CO2 gas used for insufflation. The cannula is a cone shaped device that allows insufflation as well as passage of the laparoscope. At the conclusion of the procedure, the previously placed sutures are tied to close the fascial defect.

There are theoretical advantages to the Hasson technique, including avoidance of the blind puncture with a needle or trocar, certainty of establishing pneumoperitoneum, anatomic repair of the fascial incision, elimination of the risk of gas embolus, and reduction in vascular and bowel injuries related to the initial access.5,7

There have been many studies done comparing the safety of the open technique to the closed and direct entry techniques. There have been variable results. There has been no obvious advantage of one technique over another. One large metanalysis showed an incidence of vascular injury to be 0.44% in the closed cases compared to 0% in the open cases. They found a bowel injury rate of 0.7% to 0.5% respectively as well.7 Another large study compared the Veress/trocar, open and direct trocar techniques and found entry bowel injury rates of 0.04%, 0.11%, and 0.05% respectively. They had a rate of vascular injury of 0.04%, 0.01%, and 0% respectively.7

Once satisfactory placement of the primary trocar is confirmed, secondary trocars are inserted under direct visualization. The number, size and position of these trocars is dictated by the procedure being done. Through these sites the various instruments for the specific procedure can be inserted.

Once the procedure is concluded and the ports are removed, one must decide whether or not to perform fascial closure. The reason to closure the fascia is an attempt to prevent incisional hernia. Many recommend fascial closure of all port sites 10mm or more but this is not universally accepted practice.15,16

There are a couple of special circumstances that require further explanation. Those are abdominal access in the obese and in those with suspected adhesions. First, there are several problems with the other approaches in the obese patient. This includes the potential risk of misplaced ports with associated injury which is higher with Veress needle insertion.17 The open technique in the obese requires longer incisions leading to prolonged operating time and leakage of CO2.18 This led to looking at other techniques. There are multiple studies showing the optical trocar to be a safe and effective method of entry in the obese (³35 kg/m2).18,19

It has been found that 75-90% of patients who have had previous abdominal surgery have adhesions. More importantly, autopsy studies have shown that 10% of patients that have had no abdominal surgery show adhesions. Even scars away from the midline may result in umbilical adhesions.5 Therefore, any blind insertion around the umbilicus has potential risk for injury. Open technique as well as alternative site access such as Palmer’s point need to be strongly considered in those with suspected adhesions.

As previously stated, there are various complications that can occur as a result of trocar and/or Veress needle use. Those are divided into immediate and delayed complications. The immediate complications occur at the time of placement but may not be recognized at the time of the injury. As stated before, this can lead to increased morbidity and mortality. Immediate complications include vascular injury, bowel/visceral injury, subcutaneous emphysema, air embolus and inability to gain access to the peritoneal cavity. The bowel and vascular injuries are often due to placement of the primary trocar or Veress needle because they are done blindly. However, injuries can occur with secondary trocar insertion if the trocars are not properly visualized throughout their insertion.

Vascular injuries may involve retroperitoneal, intraperitoneal or abdominal wall vessels. Rates of major vascular injury during initial entry are between 0.05% and 0.5%.3 The sites of injury from most common to least common are iliac vein, greater omental vessels, inferior vena cava, aorta, pelvic and superior mesenteric veins and lumbar veins.17Injury to a major vessel is usually signified by visible bleeding and hemodynamic instability. If an injury is confirmed or highly suspected especially in the retroperitoneum, convert to an open procedure and explore the area in question. Depending upon the situation, consider calling for help from another surgeon and notify anesthesia of the potential for instability.

Since many laparoscopic procedures are done in an ambulatory, non-hospital environment, any surgeon performing laparoscopy needs to keep in mind a few basic principles of repair of a vascular injury according to Suarez.20

  • Once a potentially serious vascular injury is suspected, immediate conversion to an open procedure must be considered.
  • Direct compression of the bleeding site is the quickest and safest way to gain initial control of blood loss, especially with a venous injury.
  • If the patient exhibits unstable vital signs, adequate volume replacement, while controlling the blood loss, must take place prior to attempting repair of the injury.
  • If the bleeding site is difficult to see, early and wide exposure of the site and the surrounding structures must be obtained.
  • The vessel wall must be repaired with precise intima to intima apposition without tension.
  • Venous injuries may be best handled by ligation rather than suture repair if the patient is unstable.
  • If ligation of a vessel does not lead to ischemia, definitive repair may be postponed until the patient is stable and/or when the appropriate vascular surgeon is available.
  • In some circumstances of minor venous bleeding occur, hemostasis can be done by applying pressure, increasing the insufflation pressure, and a clip or suture closure.17

If there is any suspicion of a puncture of a major retroperitoneal vessel, including finding a retroperitoneal hematoma, it should be explored and the injury repaired. If not treated, these vessels will continue to bleed unnoticed until life-threatening changes have occurred.20

Abdominal wall vessels are much smaller and signified by bleeding along the trocar intraabdominally or externally alongside the skin incision. These can be controlled using multiple options. Routine injection of lidocaine with epinephrine may decrease skin edge bleeding. According to Vasquez-Frias, options for control of bleeding include using the trocar that the bleeding is coming through for direct pressure by rotating the tip against the bleeding site. A foley catheter can be passed into the port site, and after inflating the balloon, outward traction is applied to put pressure on the abdominal wall. Both intramural, such as with a Carter Thomason needle, and transmural suturing has been done. If transmural suturing is done, the sutures need to be removed early (around 24 hours) to prevent full thickness abdominal wall necrosis. One should also visualize all ports after trocar removal to ensure that there is no bleeding that was tamponaded by the trocar itself. This bleeding can often be stopped by cautery or pressure. Any significant bleeding that continues with these means requires enlarging the incision around the port site and direct ligation.21 Most bleeding will present during the procedure, but there can be delayed bleeding from the abdominal wall that presents in the post op period. In this circumstance, there is bruising and swelling of the abdominal wall and a drop in hemoglobin. These can usually be managed conservatively with observation. If the patient is unstable, exploration of the port site in question should be done. Bleeding from the smaller abdominal wall vessels can usually be avoided by not placing trocars or the Veress needle into the location of the epigastric vessels and by transilluminating the abdominal wall prior to inserting secondary trocars.

Bowel and visceral injuries from Veress needle insertion or trocar placement may or may not be seen at the time of the injury. The delayed presentation contributes to the morbidity and mortality of bowel injuries. The incidence of bowel injury is between 0.04% and 0.5%.3,18 More importantly, 30-50% of the bowel injuries are not diagnosed intraoperatively when they occur. This leads to a mortality rate of up to 30% for unrecognized bowel injury.3,6Bowel and visceral injuries occur by two mechanisms according to Bhoyrul. The injuries happen if the viscera is unusually close to the point of insertion and when the trocar penetrates too far into the abdominal cavity.22

If a bowel injury is recognized at the time of the injury, it needs to be repaired at that time. Careful visualization is necessary to delineate the extent of the injury. The surgeon has to then decide if he has the ability to repair the damage laparoscopically or convert to open. It varies depending on each individual surgeon’s skill set, equipment, and injury.
One should always err on the side of conversion to an open procedure it there is any question.

For visceral injuries, liver and spleen, management includes applying pressure, increasing the insufflation pressure and consideration of suturing and thrombin sealants for ongoing bleeding.17 Small bowel injuries are usually able to be controlled by laparoscopic suture repair or stapling.17 Colon injuries are somewhat more complicated. Injuries that are low risk for complications, such as those recognized right away, are best repaired by suturing with intravenous antibiotics and drainage. Injuries that are at higher risk for complications, such as those found in a delayed fashion, are best handled by open repair, washout, and proximal diversion.17

One must have a high level of suspicion for bowel injury in anyone who is not recovering in the usual timeframe from his or her laparoscopic procedure. If a bowel injury is confirmed or strongly suspected, surgical intervention is necessary after initial resuscitation. The procedure to be done is dictated by the structure that is injured, associated intraabdominal findings and associated patient factors.

Another immediate problem is subcutaneous emphysema. This usually presents as subcutaneous crepitance around the trocar site. However, it can be severe involving severe swelling of the head and neck area. This is due to malposition of the insufflation port allowing CO2 to track into the preperitoneal, retroperitoneal, or subcutaneous space. This can cause increased CO2 absorption leading to respiratory acidosis and hypercapnia. This is best prevented by keeping insufflation pressures around 12 mmHg and accurate port placement prior to insufflation. If the hypercapnea is severe, mechanical hyperventilation and possible cardiovascular support may be necessary.17

Air embolus is another immediate complication of trocar placement. This is summarized well by Suarez as follows. Air embolus may occur when the intra-abdominal pressure exceeds intravenous pressure and there is a communication with the venous system through a large vein. A large bolus of gas can cause cardiovascular collapse by interfering with right ventricular outflow. The physical findings are a machinery type heart murmur along with significant drops in blood pressure and oxygen saturation. If gas embolism is suspected, insufflation should be stopped and the peritoneal cavity vented.
The patient should be placed in the left lateral decubitus position and Trendelenburg (head down). In addition, a central line can be inserted into the right ventricle and gas bubbles may be aspirated.20

Another immediate complication is preperitoneal placement of the Veress needle or trocar, which causes an increase in the distance between the skin and peritoneum. This can make percutaneous insertion of a trocar quite difficult. This can also cause subcutaneous emphysema. This is best avoided by properly confirming intraperitoneal placement prior to insufflation.

There are times when satisfactory placement of a percutaneous trocar cannot be safely done. If unable to safely pass the trocar or Veress needle after three attempts in the periumbilical site, consider using Palmer’s point, which was previously described. One must convert to open technique if safe percutaneous access to the peritoneal cavity cannot be obtained.

There are also delayed complications regarding trocar insertion. These include trocar site infection, tumor implantation, endometriosis implantation and incisional hernia.

It has been accepted that the risk of postoperative wound infection in minimally invasive surgery is quite low and related to the case being performed and not necessarily the port insertion. The wound infection is signified by the usual findings of pain, erythema, and occasional wound drainage. The principles for treatment are antibiotics, local wound and drainage of pus if abscess is found. The ways to attempt to prevent these wound infections are prophylactic antibiotics for the specific procedure that is being done, placing any contaminated specimen inside a protective pouch prior to removing it from the skin and irrigation of the port sites prior to closure.

Implantation of tumor cells in port sites has been reported for all types of malignancy that are treated by minimally invasive surgery. The incidence is quite low, about 1% for colorectal23 and 2.3 % for gynecologic malignancies.24Poor surgical technique such as improper handling of the tissue is the most likely cause. There are other mechanisms investigated including hematogenous spread, aerosolization, and direct wound implantation. The timing of presentation is variable. Various preventative strategies including retrieval bags for specimens, wound protectors, intraperitoneal agents, port site excision, alternative insufflations strategies, and peritoneal wound closures have been tried.17,23,24

Endometriosis in port sites is quite rare. This can be found in patients with known endometriosis and those undergoing laparoscopic hysterectomy without evidence of endometriosis. The treatment is excision of the implant. Preventative measures include avoidance of implantation of fragments during morcellization.25-27

Incisional hernia is a problem that can be seen anytime in the post-operative period but usually delayed several months or years. The incidence of incision hernias in a trocar site is 21/100,000.15 The most prevalent feelings are that all fascial puncture sites that are 10 mm or more should undergo fascial closure.15,17 This is still controversial. There are multiple reports in the literature of 5 mm trocar sites that develop incisional hernias.15 Various other risk factors other than trocar size such as BMI, age, and duration of surgery have been found to contribute to the risk of incisional hernia. Usla et al found that age greater that 60, BMI greater than 25, and duration of procedure greater that 90 min increased the risk in laparoscopic cholecystectomy patients.16 There is no consensus on closure of port sites and the means to do this. Many feel that the new dilating trocars allow the fascia to be left alone. There are various devices being proposed for closure but none that have gained widespread acceptance.

Despite the recent advances in minimally invasive techniques, the new technologies and evidence-bases guidelines, no single technique or instrument has been proven to completely eliminate laparoscopic entry associated injury.2,7According to the Cochrane review by Duffy et al, there is no difference in complication rates when using the open or closed laparoscopic entry technique.25 Therefore, the decision on which method of laparoscopic entry to use comes down to each individual surgeon’s choice. Mahajan summarizes it by saying safe access depends on adhering to well recognized principles of trocar insertion, knowledge of abdominal anatomy, and recognition of the hazards imposed by previous surgery. Each surgeon needs to determine which technique fits their operating style best while considering the circumstance of the particular patient. Each surgeon should choose the method with which the surgeon is most comfortable and with which he or she has the most experience.2 If a complication is encountered, timely and thorough investigation and repair will limit patient morbidity and mortality.


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