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The trend toward safer, bladeless trocars continues, with more physicians opting for non-bladed options that provide a better view of the surgical site, and in many cases help achieve safer entry to the abdomen. Let's look at how common types of trocars are impacting the safety and visualization of site access for your laparoscopic surgeons.
Initial entry
With small plastic "wings" at the end of the obturator, most optical view trocars are generally considered non-bladed trocars, and have given surgeons the gift of sight as they enter the abdomen. With optical access trocars, surgeons insert a laparoscopic camera in the trocar's hollow obturator, which enables them to see where the advancing obturator's tip is heading. During insertion, surgeons can see the trocar working its way through layers of tissue and into the abdominal cavity, which minimizes the risk for organ injury.
These trocars can be placed with or without insufflation, and are ideal for initial entry. After the first trocar is inserted, the laparoscopic camera can be used inside the abdominal cavity to help guide the insertion of additional trocars. Some optical view trocars now on the market also include a feature that lets surgeons connect insufflation gas to the obturator, which helps dissect multiple layers of tissue.
Initially developed for laparo-scopy in patients who have previously undergone laparotomy, Hasson trocars continue to allow greatly improved access to the surgery site. These non-bladed trocars are inserted using the direct-cut method, which is one of the safest entry methods available. By dissecting tissue layers, the Hasson trocar ensures safe entry into the abdomen, and stays in place with sutures attached to the abdominal wall.
Balloon trocars are newer than Hasson trocars and also provide a high degree of safety because the surgeon can directly visualize access to the abdomen. Balloon trocars can be difficult to place off the midline, but can be placed almost anywhere in the abdomen. And with the balloon anchoring the trocar in the abdomen, sutures aren't necessary in the fascia.
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COSTLY CHALLENGE: Lens Smudging Still Problematic |
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Laparoscope lenses often get smudged as they pass through trocar valves. It's a persistent problem that continues to hamper the safety and efficiency with which abdominal procedures are performed. Some access systems are designed to prevent smudging and fogging, but smudging is a significant and time-consuming challenge for abdominal surgeons, says Guy Voeller, MD, FACS, professor of surgery at the University of Tennessee Health Science Center in Memphis. "In an average hour-long case, you probably have to wipe off the scope at least 10 or 20 times," says Dr. Voeller. "A minute in the operating room here in Memphis costs about $88. If you added up the time spent wiping off the scope during a case, it would cost a fortune." Beyond lost time and money, frequent smudging naturally compromises the surgeon's visualization of the surgical site. To combat the issue, Dr. Voeller recommends coating laparoscopic lenses with anti-fogging solutions to help provide clearer visualization of the surgical cavity, and using scope warming devices to help reduce fogging and smudging. "Those are some of the common things that you can do," says Dr. Voeller. "And right now, that's about all you can do." Whether disposable or reusable, bladed or non-bladed, trocars still need development in some key areas, says David Renton, MD, MPH, an assistant professor of surgery at Ohio State University Medical Center in Columbus, Ohio. "Some trocar systems are designed to prevent smudging and fogging by using an insufflator to create an air barrier, eliminating the need for a valve to preserve intra-abdominal pressure," says Dr. Renton. "How truly "smudgeless' many of these trocar systems are remains to be seen, however." — Mark McGraw |
Secondary ports
Dilating trocars are a safe option that actually spread tissue as opposed to slicing through it, which naturally causes less damage to the abdominal wall. Used as either an initial or secondary trocar, dilating trocars are beneficial because they create small fascial defects, and in most cases require little force to insert. Inserting a needle surrounded by an expandable sheath creates a small hole, which typically doesn't require closing.
Newer dilating trocars have emerged that offer features for greater security and control. For example, advanced features include a directional tip that helps surgeons navigate through tissue during insertion, and a retracting tissue-dilating shield that promotes a small fascial defect and may help limit tissue trauma.
Non-optiview trocars are similar to dilating trocars in terms of safety benefits. Both essentially push the tissue aside as the obturator moves ahead. Considered "non-bladed," these trocars still cut some of the issue, but are less sharp in comparison to traditional bladed trocars. Used as secondary ports, non-optiview trocars are typically a less costly option than optical trocars, and can be used in most any position.
Offering no visualization to the surgeon, bladed trocars should always be used as a secondary trocar. Surgeons' use of bladed trocars has waned significantly in recent years, due to the risk of injuries such as punctures to iliac arteries or the abdominal wall.
Bladed trocars still have a place in the hands of the right surgeon who needs to make a comparatively large hole in the abdominal wall. For example, some surgeons performing Roux-en-Y gastric bypass find it easier to place a circular stapler through the abdominal wall in an incision site made by a 15mm bladed trocar.
Each brand of trocar has significant safety benefits, and provides increased visualization and site access, but the decision on which trocar your surgeons ultimately opt for should be based largely on what they're most comfortable using.
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