I read with interest the 2 recent articles on laparoscopic surgery: “Avoiding vascular injury at laparoscopy,” by Michael Baggish, MD (October 2004), and “Laparoscopic surgery in the obese: Safe techniques,” by James K. Robinson III, MD, and Keith B. Isaacson, MD (March 2005).
Although complications from the use of optical-access trocars have been briefly described, I believe primary trocar insertion under direct visualization (video) is safer than “blind” or “open” techniques. Using an optical-access primary trocar, an experienced laparoscopist can clearly identify the subcutaneous tissue, fascia, and peritoneum, allowing for a more controlled and “thrustless” insertion into the peritoneal cavity. Even when extensive intraperitoneal adhesions are present, peritoneal windows can be identified by direct visualization.
Of course, the ability to recognize tissues traversed by the laparoscope is key to minimizing primary trocar injuries. “Seeing where you are going” may not prevent injuries if the physician cannot interpret what he or she is seeing. Fortunately, the technique can be mastered with little training. I have been using it for 15 years without any primary trocar-related injuries.
Moshe R. Peress, MD
Boca Raton, Fla
Dr. Baggish responds:
Contrary to Dr. Peress’ assertion, these devices are not safer than blind or open techniques, as the various layers are poorly defined.1
In 2002, Sharp et al reported 37 major vascular injuries with these devices involving the aorta, vena cava, and iliac vessels.2
In addition, 18 bowel perforations, 3 liver lacerations, and a stomach perforation were cited. Four of the patients died as a result of these complications.
The optical-access trocar has not proved to be a safer device.
- Narendren M, Baggish MS. Mean distance between primary trocar insertion site and major retroperitoneal vessels during routine laparoscopy. J Gynecol Surg. 2002;18:121-127.
- Sharp HT, Dodson MK, Draper ML, et al. Complications associated with optical access laparoscopic trocars. Obstet Gynecol. 2002;99:553-555.
Drs. Robinson and Isaacson respond:
Our review of peritoneal access in obese patients did not specifically mention the use of optical-access trocars. However, our approach to primary intraperitoneal access for all our patients, obese or not, does involve an optical trocar. While our experience and intuition support Dr. Peress’ assessment that optical trocars are less dangerous than nonoptical ones, there have been numerous reports of injury utilizing these “safer” trocars,1-3 and we are unaware of any good comparative data that support our bias.