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While the debate over shielded vs. unshielded trocars goes on among surgeons and day surgery program managers, there are other options to the use of trocar entry to establish a primary insertion site for laparoscopic surgery. The four most common alternatives are:
While this procedure is just as "blind" as a primary trocar insertion, the smaller needle requires less force for entry, says C. Randle Voyles, MD, a general surgeon at Mississippi Surgery Center in Jackson. Even if punctures or lacerations occur, they are generally smaller and less severe than trocar injuries, he adds. A disadvantage to this procedure is that the needle cannot accommodate an endoscope, so position cannot be verified before insufflation, says Voyles. This lack of verification can increase the risk of a gas embolism and death in the rare case of insertion into a blood vessel, he says.
This is not a blind procedure because surgeons are looking directly at the area through which the trocar is penetrating. The blunt trocar minimizes the risk to vessels and results in a lower incidence of punctures or lacerations, Voyles says. The disadvantage is a potentially longer healing period for patients. Surgeons also must be careful to suture the opening well to prevent gas from leaking out of the cavity around the cannula, he adds.
With this approach, the Veress needle or blunt trocar is placed within the sleeve and inserted into the abdomen. The needle or trocar is removed, and a cannula is placed into the sleeve. Advantages of the sleeve include the capability of inserting a laparoscope prior to insufflation and the radial expansion of muscle fibers that produce small tears rather than the larger punctures of traditional trocars.1
Some of the optical trocars incorporate a cutting device that can be used on a previously distended cavity. An advantage of the optical trocar is the surgeon’s view of the actual penetration, says Vangie Paschall-Dennis, RN, CNOR, laser endoscopy coordinator for Promina Gwinnett Health System in Lawrenceville, GA.
1. Galen DI, Jacobson A, Weckstein, LN, et al. Reduction of cannula-related laparoscopic complications using a radially expanding access device. J Am Assoc Gynecol Laparosc 1999; 6:79-84.