Comparison of closed and open methods of pneumoperitonium in laparoscopic cholecystectomy. Randomized trial comparing a radially expandable needle system with cutting trocars. Efficacy of establishment of pneumoperitoneum with the Veress needle, Hasson trocar, and modified blunt trocar (TrocDoc): a randomized study. Blind versus open approach to laparoscopic cholecystectomy: a randomized study. Randomized, prospective, single-blind trial of a new parallel technique of Veress pneumoperitoneum needle insertion versus the conventional closed method. Direct trocar insertion vs Veress needle in nonobese patients undergoing laparoscopic procedures: a randomized prospective single-center study. Is it necessary to lift the abdominal wall when preparing a pneumoperitoneum? A randomized study. Cardiovascular and respiratory changes and convalescence in laparoscopic colonic surgery: comparison between carbon dioxide pneumoperitoneum and gasless laparoscopy. Laparoscopy. Gasless vs. CO2 pneumoperitoneum. A prospective randomized trial comparing pneumoperitoneum and U-shaped retractor elevation for laparoscopic cholecystectomy. Radially expanding trocar: a less painful alternative for laparoscopic surgery. Laparoscopic surgery in gynecology: randomized prospective study comparing pneumoperitoneum and abdominal wall suspension. A randomized, prospective study comparing the use of the missile trocar and the pyramidal trocar for laparoscopy access. Randomized clinical trial comparing radially expanding trocars with conventional cutting trocars for the effects on pain after laparoscopic cholecystectomy. Direct trocar insertion vs. Verres needle use for laparoscopic sterilization. Different pain scores in single transumbilical incision laparoscopic cholecystectomy versus classic laparoscopic cholecystectomy: a randomized controlled trial. Prospective randomized comparison of cutting and dilating disposable trocars for access during laparoscopic renal surgery. Abdominal access in gynaecological laparoscopy: a comparison between direct optical and blind closed access by Verres needle. Prospective study comparing the bladeless optical access trocar versus Hasson open trocar for the establishment of pneumoperitoneum in laparoscopic renal procedures. A randomized comparison of Verres needle and direct trocar insertion for laparoscopy. Fixity of ports to the abdominal wall during laparoscopic surgery: a randomized comparison of cutting versus blunt trocars. Direct trocar versus veress needle entry for laparoscopy: a randomized clinical trial. A randomized prospective study of radially expanding trocars in laparoscopic surgery. Transfundal insertion of a Veress needle in laparoscopy of obese subjects: a practical alternative. Randomized double-masked comparison of radially expanding access device and conventional cutting tip trocar in laparoscopy.
Pneumoperitonium is the first step in laparoscopic surgery including cholecystectomy. Two commonly used methods to create pneumoperitonium are closed and open technique. Both have advantages and disadvantages. The current study was designed to compare these two techniques in terms of safety and time required to complete the procedure.
                This was a randomized controlled prospective study conducted at Department of Surgery, Ayub Hospital Complex Abbottabad, from 1st June 2007 to 31st May 2008. Randomization was done into two groups randomly using sealed envelopes containing the questionnaire. Seventy envelopes were kept in the cupboard, containing 35 proformas for group A and 35 for group B. An envelope was randomly fetched and opened upon selection of the patient after taking the informed consent. Pneumoperitonium was created by closed technique in group A, and by open technique in group B. Time required for successful pneumoperitonium was calculated in each group. Failure to induce pneumoperitonium was determined for each technique. Time required to close the wounds at completion, total operating time and injuries sustained during induction of pneumoperitonium were compared in both techniques.
                Out of the total 70 patients included in study, 35 were in group A and 35 in group B. Mean time required for successful pneumoperitonium was 9.17 minutes in group A and 8.11 minutes in group B. Total operating time ranged from 55 minutes to 130 minutes in group A and from 45 minutes to 110 minutes in group B. Mean of total operating time was 78.34 and 67 minutes in group A and B respectively. Mean time needed to close the wound was 9.88 minutes in group A and 4.97 minutes in group B. Failure of technique was noted in three patients in group A while no failure was experienced in group B. In two cases in group A minor complications during creation of pneumoperitonium were observed while in group B no complication occurred. No patient died in the study.
                We concluded from this study that open technique of pneumoperitonium was, less time consuming and safer than the closed technique. Sharp trocar insertion for laparoscopic procedures carries with it increased risk for vascular and visceral complications and incisional hernia. In a trial, which randomized 87 patients to treatment with either sharp trocars or a radially expanding needle system with blunt dilator, results showed that with the latter system there was statistically improved patient assessment of pain, a lower complications rate, and shorter procedure time. In the group of patients randomized to treatment with conventional trocars, there were a total of six instrument-related adverse events (6/42): four cases (five incidences) of abdominal wall injuries and one small bowel perforation caused by a Veress needle. Of the 45 patients randomized to the blunt dilator/cannula treatment, there was one adverse event (1/45) that was unrelated to the blunt dilator/cannula system: Veress needle injury to abdominal vasculature. The radially expanding access system demonstrates statistically improved patient postoperative comfort and improved patient safety. To compare three techniques of establishment of pneumoperitoneum for efficacy: the Veress needle/first trocar, the Hasson trocar, and a newly developed modified blunt trocar, the TrocDoc.
                Between June and December 1999, 62 patients eligible for laparoscopic surgery were randomized. The effectiveness of installation of the pneumoperitoneum using the three techniques was assessed by time-motion analysis. Primary efficacy measures were total time and number of actions required to establish the pneumoperitoneum. Secondary efficacy measures were procedure-related complications, wound complications, and occurrence of CO2 leakage.
                Two patients were withdrawn from inclusion. The three groups were comparable for age and body mass index. Total time was shortest using the TrocDoc rather than the Veress needle/first trocar and the Hasson trocar (respectively, 138 +/- 58 v 237 +/- 56 v 350 +/- 103 seconds), and the number of actions was lowest for the Veress needle/first trocar combination: 22 +/- 7 v 32 +/- 12 (TrocDoc) v 53 +/- 17 (Hasson). There was no morbidity related to the installation of pneumoperitoneum nor trocar wound complications. Gas leakage occurred in five of the Hasson introductions.
                Establishment of the pneumoperitoneum is more efficient using the TrocDoc compared with the Veress needle/first trocar and the Hasson trocar. The TrocDoc might replace the two alternatives because of its efficacy and open method of introduction. Intraabdominal structures may be damaged during blind introduction of the first trocar for laparoscopic operations. In this study, 150 patients with gallbladder lithiasis who underwent laparoscopy were randomly assigned to two groups, a blind (V group) or an open (H group), in order to compare the results and the rate of complications. No mortality was observed. Major complications occurred in 3/75 (4%) patients of the V group and in 1/75 (1.3%) patient of the H group (p < 0.05). Minor complications occurred in 5/75 (6.7%) patients of either group. The achievement of pneumoperitoneum required 4.5+/-0.4 min in the V group and 3.2+/-0.2 min in the H group (p < 0.05). The open laparoscopic technique is safer and faster than the blind approach; therefore, it is proposed that this approach be routinely used in all laparoscopic procedures. To evaluate the safety and effectiveness of a new closed parallel technique of Veress needle insertion and to compare this method with the conventional closed approach.
                Sequential, randomized, prospective, single-blind clinical trial.
                University hospital.
                Women undergoing elective diagnostic and/or operative laparoscopy. Subjects (n = 200) were assigned randomly to undergo the conventional closed method (group 1; n = 100) or the new parallel technique (group 2; n = 100) of Veress needle insertion.
                Randomization of the patients was performed in the operating room. The investigator performed both diagnostic and operative laparoscopy in both study groups.
                Safety and effectiveness of the needle insertion technique.
                There were no significant differences in demographics between the groups, or in the time required for Veress needle insertion to establish pneumoperitoneum. There were no nonlethal major or minor intraoperative complications associated with either laparoscopic approach.
                There is no significant disadvantage to the parallel technique of Veress pneumoperitoneum needle insertion compared with the conventional closed approach. This new technique avoids the anatomic location of large vessels during insertion and may serve as a safeguard to decrease the potential for lethal laceration of a major vessel. Nonobese patients undergoing laparoscopic procedures present a dilemma as to the correct mode of entry into the abdominal cavity because the Veress needle (VN) technique seems to be associated with a high risk of vascular and visceral injuries. Direct trocar insertion (DTI) has been reported as an alternative to the VN for creation of the pneumoperitoneum.
                An open comparative randomized prospective study was conducted on the feasibility and safety of DTI vs the VN technique in nonobese patients of any age category referred for urgent or scheduled laparoscopic procedures. Exclusion criteria were obesity (defined as a body mass index [BMI] > 27 kg/m(2)), major abdominal distension, and two or more previous abdominal operations. The study endpoints were the feasibility and safety of the DTI and VN techniques. Results were evaluated on an intention-to-treat basis. Statistical analysis was carried out with the t-test for independent samples, the chi-square tests, and the Fisher's exact tests, as appropriate. The level of significance was 0.01.
                Since January 2002, a total of 598 nonobese patients have been entered into the current trial; 46% (mean BMI 21.6 A+/- 4.4 kg/m(2)) were randomly allocated to DTI, whereas 54% (BMI 21.1 A+/- 5.3 kg/m(2)) were allocated to the VN techniques. Demographic features and type of procedures were similar for the two groups. DTI was feasible in 100% of patients vs 98.7% in the VN group (p = NS). Minor complications were nil in the DTI group and 5.9% in the VN group (p < 0.01). The latter group consisted of 11 cases (3.4%) of subcutaneous emphysema and eight cases (2.5%) of extraperitoneal insufflation. Major complications were nil in the DTI group and 1.3% among VN patients (p = NS). These latter cases consisted of two (0.3%) hepatic lesions managed laparoscopically; one (0.3%) misdiagnosed ileal perforation requiring reintervention, and one (0.3%) mesenteric laceration treated conservatively.
                In thin and very thin patients of any age category with no more than one previous abdominal operation, DTI is a safe alternative to the VN technique and is associated with fewer minor complications. In terms of major complications, there is no difference between the two techniques. Either technique of access is acceptable Thin and very thin patients undergoing laparoscopy, on condition that the basic principles of laparoscopic surgery are complied with. In order to create a pneumoperitoneum with the Veress needle, it is generally advocated that the abdominal wall should be lifted. Lifting is aimed at increasing the distance between the abdominal wall and the intraabdominal structures. This study was conducted to compare lifting (L) and nonlifting (NL) of the abdominal wall.
                All patients scheduled for laparoscopic surgery without previous abdominal surgery or morbid obesity were included in the study group. The number of attempts needed for proper positioning of the needle was assessed.
                A total of 150 patients were randomized. There were no complications. The number of attempts needed for correct positioning of the Veress needle was significantly higher in the L group than in the NL group (31 of 75 vs nine of 75, p < 0.001). The body mass index (BMI) of patients in whom peritoneal entry needed more than one puncture was significantly higher than the BMI of patients with immediate proper placement (28.3 vs 24.7 kg/m(2), p < 0.05).
                Abdominal wall lifting is not necessary. Gasless laparoscopy produces smaller cardiopulmonary and systemic changes than carbon dioxide (CO2) laparoscopy during colonic surgery.
                Prospective randomized trial.
                Department of Surgery in a university hospital.
                Twenty-two patients scheduled for laparoscopic colonic resection; 5 patients were excluded because of conversion to open surgery (N = 17).
                Patients were randomized to either gasless (n = 9) or conventional CO2 (n = 8) surgery.
                Intraoperative assessment of hemodynamic factors and pulmonary function, and postoperative assessment of pain, pulmonary function, convalescence, and various injury factors were done several times until 30 days after surgery. Surgical complications were noted.
                Descending aorta blood flow after 30 minutes (P=.03) and heart rate after 150 minutes were higher in the CO2 group (P=.009). Central venous pressure, PaCO2 inspiration pressure, and end tidal CO2 level were significantly higher in the CO2 group (P = .05, .03, .04, and .01, respectively). Patients in the CO2 group had less pain during mobilization and coughing (P = .008 and .006, respectively), and were significantly more fatigued (P = .04). No other important differences were observed in intraoperative hemodynamic factors, postoperative convalescence, immunocompetence, or pulmonary function.
                No clinically important differences in cardiovascular and systemic response were observed between patients undergoing CO2 or gasless laparoscopy for colonic disease. To compare gasless laparoscopy with conventional laparoscopy using CO2 pneumoperitoneum.
                Women undergoing bilateral laparoscopic tubal coagulation (LTC) were randomly assigned to one of two laparoscopy procedures: (1) a gasless laparoscopy system consisting of an intraabdominal fan retractor and electrically powered mechanical arm, and (2) standard CO2 pneumoperitoneum laparoscopy. The two laparoscopic procedures were compared on the basis of intraoperative visualization, operation duration, procedural difficulty, ventilatory parameters, hemodynamic stability, and postoperative pain and nausea.
                Significant disadvantages for the surgeon (increased technical difficulty, poorer visualization, longer operative times) and patient (greater postoperative pain and nausea) were seen with the gasless system. Because of these findings, the study was prematurely terminated after only 18 patients had participated. Intraoperative ventilatory and hemodynamic parameters were more stable in the gasless laparoscopy groups; however, the differences were not clinically significant in this population of healthy patients.
                The markedly increased technical difficulty and absence of clear clinical benefits for the healthy patient led to the conclusion that laparoscopy with CO2 pneumoperitoneum is preferable for routine LTC and most laparoscopic procedures in the pelvis. Gasless laparoscopy may be of benefit for the fragile patient with a compromised cardiovascular system who may suffer complications from hypercarbenemia. Between April and August 1991, 83 Japanese patients with symptomatic gallstones underwent laparoscopic cholecystectomy in our clinics. A prospective randomized trial was carried out to examine the safety, efficacy, and complications of the two techniques, pneumoperitoneum vs an elevating method using a U-shaped retractor. Forty-two patients were randomly allocated to the pneumoperitoneum (P) group and 41 to the U-shaped retractor (U) group. These two groups were well matched with respect to age, sex, etiology, and the severity of the chronic cholecystitis. Laparoscopic resection was successful for 88.1% (37/42) in the P group and 100% (41/41) in the U group. In patients with a severe fibrotic gallbladder, the rate of success was significantly higher (P < 0.05) in the U group (100%, 6/6) than in the P group (11.8%, 1/6). In the moderately inflamed group, the operation time (mean +/- SD) was significantly (P < 0.01) less in the U group (58.7 +/- 22.7) than in the P group (87.3 +/- 18.3). With the U-shaped retractor the usual surgical instruments can be used, and a rapid and safer laparoscopic cholecystectomy can be carried out. We prefer this approach to a pneumoperitoneum for patients with an inflamed gallbladder as hospital stay and pain are minimal. One advantage of minimal-access surgery is that it produces less pain. A radially expanding trocar has been claimed to reduce pain further. We aimed to evaluate this claim.
                This was a randomized controlled single-blind clinical trial. Fifty-four patients who underwent laparoscopic cholecystectomy at the Department of Surgery, United Christian Hospital, Hong Kong, between July 1997 and September 1998 were randomized into either the study group or the control group. The radially expanding 10-mm trocar was used for the epigastric port in the study group. The conventional 10-mm metal trocar was used similarly in the control group. The operation was otherwise performed with a standardized technique. Another conventional 10-mm metal trocar was used for the subumbilical port for all patients. Pain was measured using a visual analog scale. Pain scores for the epigastric port and subumbilical port were documented for 3 days after the surgery.
                There was no difference in age, sex, diagnoses, operating time, or conversion rate. There was consistently no difference in the pain experienced in the subumbilical wound, whereas pain at the epigastric wound was consistently less with the radially expanding trocar (p < 0.05).
                The radially expanding trocar produces less early postoperative pain than the conventional metal trocar. To compare laparoscopic surgery using insufflation of carbon dioxide gas with laparoscopic surgery using abdominal wall retractor in gynecology. Setting: University hospital.
                Prospective randomized study.
                Fifty-one patients were assigned to the gasless laparoscopy group, and 52 patients were assigned to the laparoscopy group with pneumoperitoneum. Patients presented with ovarian cyst, endometriosis, acute salpingitis, hydrosalpinx and extra-uterine pregnancy.
                No severe complications were noted. One conversion to laparotomy was performed in each group. Eight gasless laparoscopic procedures were converted into laparoscopy with pneumoperitoneum; difficulties appeared in patients with adhesions following laparotomy and in cases of unsatisfactory exposure of the pelvis. No differences appeared between the two groups in terms of complications, quality of the operative sequelae, and duration of hospitalization.
                Gasless surgery is a recent technique and progress in modifying the equipment is necessary to reduce conversions. The missile trocar was developed for smooth abdominal penetration of the primary port. It contains a longitudinal tunnel connecting the abdominal cavity with the outside.
                To evaluate the efficacy of the missile trocar compared with the traditional method using the Veress needle.
                The times required to enter the abdominal cavity and the difficulty of the procedure were compared with the traditional Veress needle. A blind technique was used on 100 consecutive patients in a randomized fashion.
                The missile trocar technique took 2.7 +/- 1.6 minutes to perform compared with 3.9 +/- 1.3 min in the Veress needle group (p = 0.001), and the difficulty of the procedure was 2.1 +/- 1.9 cm (p = 0.433) rated from 10-cm scale. No carbon dioxide leakage or serious complications occurred in any patient.
                The results of the present study indicate that a long-tip missile trocar technique may be used safely when the technique is fully understood. This procedure is a relatively quick alternative approach for laparoscopy. Trocar incisions are important sources of pain the first days after laparoscopic cholecystectomy. Radially expanding trocars may cause less pain than conventional cutting trocars.
                In a patient- and observer-blinded trial, 80 patients were randomized to undergo laparoscopic cholecystectomy using either radially expanding trocars (radial group) or conventional cutting trocars (cutting group). Two 10-mm and two 5-mm trocars were used in both treatment groups. All the patients received standardized anesthetic and analgesic treatment. The primary outcome was incisional pain. Pain was registered during mobilization using a visual analog scale (VAS) and a verbal rating scale (VRS) before and 6 h after the operation, and at postoperative days 1 and 2. The needs for a fascial incision to retract the gallbladder, active surgical hemostasis, and supplementary requirements of opioids during the hospital stay were registered. In addition, 2 days after the operation, the incidence and severity of suggilations at the trocar incisions were measured.
                Data from 77 patients were available for statistical analysis. In the radial group, 23 patients needed fascial incision for gallbladder retraction compared with 11 patients in the cutting group (p = 0.006). No significant intergroup differences in VAS or VRS pain scores or any other variable were found.
                The use of radially expanding trocars has no effect on incisional pain after laparoscopic cholecystectomy. A randomized, prospective trial was designed to compare direct trocar insertion with prior peritoneal insufflation with a Verres needle for laparoscopic tubal sterilization. Direct trocar insertion resulted in fewer instrument insertions (21.8% vs. 7.8%) and use of smaller volumes of CO2 (2.67 vs. 2.32 L). Direct trocar use resulted in a decrease in operating time from 9 minutes, 40 seconds in the needle group to 7 minutes, 30 seconds in the trocar group. Minor omental injuries occurred in a small percentage of each group, while serious complications occurred once in each group. The attempt to further reduce operative trauma in laparoscopic cholecystectomy has led to new techniques such as natural orifice transluminal endoscopic surgery (NOTES) and single-incision laparoscopic surgery (SILS). These new techniques are considered to be painless procedures, but no published studies investigate the possibility of different pain scores in these new techniques versus classic laparoscopic cholecystectomy. In this randomized control study, we investigated pain scores in SILS cholecystectomy versus classic laparoscopic cholecystectomy.
                Forty patients (34 women and 6 men) were randomly assigned to two groups. In group A (n = 20) four-port classic laparoscopic cholecystectomy was performed. Patients in group B (n = 20) underwent SILS cholecystectomy. In all patients, preincisional local infiltration of ropivacaine around the trocar wounds was performed. Infusion of ropivacaine solution in the right subdiaphragmatic area at the beginning of the procedure plus normal saline infusion in the same area at the end of the procedure was performed in all patients as well. Shoulder tip and abdominal pain were registered at 2, 6, 12, 24, 48, and 72 h postoperatively using visual analog scale (VAS).
                Significantly lower pain scores were observed in the SILS group versus the classic laparoscopic cholecystectomy group after the first 12 h for abdominal pain, and after the first 6 h for shoulder pain. Total pain after the first 24 h was nonexistent in the SILS group. Also, requests for analgesics were significantly less in the SILS group, while no difference was observed in incidence of nausea and vomiting between the two groups.
                SILS cholecystectomy, as well as the invisible scar, has significantly lower abdominal and shoulder pain scores, especially after the first 24 h postoperatively, when this pain is nonexistent. (Registration Clinical Trial number: NTC00872287, www.clinicaltrials.gov ). Traditional trocar tip design for laparoscopic access incorporates cutting blades to penetrate the body wall. More recently, trocars applying tissue dilation have been used that create a smaller defect, seldom requiring fascial wound closure. Four 12-mm commercially available single-use trocar designs were evaluated for postoperative pain.
                The 4-trocar types included 2 cutting (single or pyramidal bladed) and 2 dilating trocars (radially or axially dilating) type. Fifty-six patients undergoing transperitoneal laparoscopic renal surgery were randomized and blinded to one of the 4 trocar types. In each case, trocars were placed in a standard "diamond" configuration: three 12-mm study trocars and a lateral 5-mm trocar that served as a reference point for normalizing patients' pain scores. Postoperative pain based on a visual analog scale and complications were assessed.
                No statistically significant difference existed in pain scores between different trocar types or trocar sites at 3-hour, 24-hour, and 1-week postoperative assessment time points. Eight (4.8%) minor complications occurred: bleeding in 7 (4.2%) and 1 (0.6%) wound infection. The radially dilating trocar had more device malfunction (P<0.05) than did the others.
                All 4 disposable trocars, muscle cutting or dilating type, were safe and yielded similar postoperative pain scores with or without the fascial wound closure after renal laparoscopy. Complications associated with initial abdominal entry are a prime concern for laparoscopic surgeons. In order to minimize first access-related complications in laparoscopy, several techniques and technologies have been introduced in the past years. This investigation compares two laparoscopic access techniques.
                194 women underwent laparoscopic surgery for simple ovarian cysts: 93 were assigned to direct optical access (DOA) abdominal entry (group I), and 101 women to classical closed method by Verres needle, pneumoperitoneum and trocar entry (group II). The following parameters were compared: time required for entry into abdomen, occurrence of vascular and/or bowel injury, blood loss. The results were analyzed using SAS software. p-value<0.05 was considered as significant.
                No statistically significant differences were observed in the occurrence of blood loss and minor vascular injury between the two techniques, as well as minor bowel injuries; time for of abdominal entry, instead, were significantly reduced in the DOA group.
                The results of the preliminary comparison between the DOA and the Verres methods, commonly used by gynecologists, suggests that the visual entry system confers a statistical advantage over closed entry technique with Verres needle, in terms of time saving and due to the minor vascular and bowel injuries, thus enabling a safe and expeditious, visually-guided, entry for surgeons.
                2009 Elsevier Ireland Ltd. All rights reserved. To present a single centre prospective randomized study on the use of the bladeless Optiview system (Ethicon Endosurgery, Cincinnati, OH) to create the pneumoperitoneum in laparoscopic renal procedures reporting the results with regards safety, efficacy and complications and comparing it with the Hasson open technique.
                Sixty patients were randomly recruited, 27 to the open and 33 to the bladeless group at the Bristol Urological Institute, UK. Time to insertion, time to closure and any intraoperative and postoperative complication related to trocar insertion was recorded.
                All procedures were performed for renal pathology. BMI values were similar in both groups. The mean time to insertion of the 12 mm Hasson and Bladeless trocars were 443 and 125 seconds, respectively (p < 0.0001). The incision in the bladeless group was only closed when the defect exceeded 12 mm (38%) or extended for specimen removal (23%), resulting in a mean time to closure of 203 seconds. In the Hasson group, entry into the abdominal cavity could not be confirmed in two patients (7.4%) due to multiple adhesions. In the Bladeless group, there was one failed placement (3%) requiring conversion to the Hasson technique and two injuries to intraabdominal structures (peritoneal minor bruising, liver injury requiring conversion to open procedure, 6%), There was one incidence of gas leakage (3%). There were no reports of port site herniation at a mean follow up of 9 months.
                Direct placement of a bladeless trocar under direct vision in a desufflated abdomen can reduce port placement time when compared to the Hasson technique. The benefits are maximised by using the bladeless trocar for procedures not requiring intact specimen removal. However, despite visualisation of tissue layers, this port cannot prevent serious intra abdominal injuries that can occur in a higher percentage of cases in comparison to the Hasson technique. Two hundred and fifty-two women scheduled to undergo laparoscopy were randomly assigned to a Verres needle or direct insertion group. The groups were similar with respect to incidence of obesity, prior surgical treatment, indication for operation and level of training of the surgeon performing the procedure. There were no major complications associated with either technique. Minor complications (preperitoneal insufflation, failed entry or more than three attempts necessary to enter the peritoneal cavity with the trocar) were significantly more frequent (p < 0.05) in the Verres needle technique group. One hundred and thirteen of these patients underwent sterilization procedures. The mean times for performance of the laparoscopic procedure using the direct insertion and Verres needle techniques was 15.3 and 19.6 minutes, respectively. The time saved using the direct insertion technique is explained by a significant (p < 0.01) reduction in the mean laparoscope insertion time, which was 2.2 minutes and 5.9 minutes for the direct insertion and Verres needle techniques, respectively. We prefer the direct insertion technique for trocar placement because it has fewer minor complications and requires less operating time. Dislodgement of ports from the abdominal wall is a common problem during laparoscopic surgery. The aim of this study was to evaluate port stability using either cutting or blunt-tipped trocars.
                Patients undergoing laparoscopic surgery were randomized to have the secondary ports inserted using either cutting or blunt-tipped trocars. The fixity of ports to the abdominal wall was evaluated at the start and completion of surgery by measuring the total traction force required to displace the ports. Similarly, the friction forces required to displace instruments within the ports were measured.
                Thirty patients were randomized into two groups (15 patients in each group), and a total of 114 ports (cutting, n = 51; blunt, n = 63) were evaluated. The groups were comparable in age, gender, body mass index, and operating time. The total traction forces needed to displace the 5-mm and 10-mm ports were significantly lower when cutting trocars were used at both the beginning (2.6 vs. 11.8 N, p < 0.001, and 6.3 vs. 15.5 N, p = 0.014, respectively) and completion of surgery (1.3 vs. 6.7 N, p < 0.001, and 1.1 vs. 12.0 N, p = 0.001, respectively). The declines in the total traction forces from the start to the completion of surgery were significant for the 5-mm and 10-mm cutting-trocar ports (p = 0.031 and p = 0.043, respectively) but not for the blunt-trocar ports (p = 0.088 and p = 0.152, respectively). While no significant differences between the instruments' friction forces and the traction forces of the cutting-trocar ports were observed, the former were significantly lower than the traction force needed to displace the blunt-trocar ports. This explains the significantly greater frequency of spontaneous port dislodgements when cutting ports were employed (25.5% vs. 1.6%, p < 0.001). Port-site bleeding was encountered only in patients (n = 2, 13%) where cutting trocars were used.
                Port fixity to the abdominal wall during laparoscopic surgery declines with time. The insertion of ports using a blunt-tipped trocar is associated with significantly greater stability and fixity of the port to the abdominal wall. The use of blunt-tipped trocars is recommended for routine practice in laparoscopic surgery. To compare direct trocar (DT) to Veress needle (VN) entry for the creation of pneumoperitoneum during laparoscopy with regard to the duration of the procedure, volume of gas used, ease of performance, and frequency of complications.
                A randomized clinical trial. Subjects and
                One thousand patients scheduled to undergo diagnostic laparoscopy were recruited for the study. They were randomly allocated to either DT entry (group A, n = 500) or VN (group B, n = 500) for pneumoperitoneum. The laparoscopic procedures were performed by the same surgeon.
                The duration of the procedure, volume of gas consumption, ease of performance and frequency of complications were analyzed.
                Patients in the 2 groups had similar demographic characteristics. The mean duration of the procedure was significantly shorter in group A (2.2 +/- 0.7 min, 95% CI 2.14-2.26) than in group B (8.2 +/- 1.4 min, 95% CI 8.08-8.32; p < 0.0001). The mean gas consumption was significantly less in group A (2.6 +/- 0.9 liters, 95% CI 2.52-2.68) than in group B (8.4 +/- 2.6 liters, 95% CI 8.17-8.63; p < 0.0001). No major complications in both groups were encountered. Minor complications were significantly less in group A (0.4%, 95% CI 0.77-3.23) than in group B (14%, 95% CI 10.96-17.04; p < 0.0001).
                DT entry is a safe alternative to the VN entry technique for the creation of pneumoperitoneum. Such an approach has further advantages such as less cost and instrumentation and rapid creation of pneumoperitoneum.
                Copyright (c) 2010 S. Karger AG, Basel. Trocar injury is one of the most serious and potentially preventable complications of laparoscopic surgery. Use of a blunt rather than a cutting trocar could be expected to lessen the likelihood of this injury. Therefore complications related to laparoscopic port design were studied by comparing conventional cutting trocars with radially expanding (blunt) trocars. A multicenter, prospective, randomized clinical trial was conducted in 250 adult patients undergoing elective laparoscopic procedures at tertiary care centers and community hospitals. The patients were randomly assigned to one of two groups: group C, conventional cutting trocars; or group S, radially expanding trocars. Sixteen surgeons performed 244 elective laparoscopic procedures; six patients were removed from the study. One hundred nineteen patients were assigned to group S and 125 to group C. The groups were similar with regard to age, sex, and type of procedure. The following data were collected: intraoperative complications related to the trocars, abdominal wall bleeding, visceral or vascular injury, other complications, fascial closure, procedure time, trocar site assessment at 4 and 24 hours postoperatively, and visual analog pain scores at 4, 8, 12, and 24 hours postoperatively. Fascial defects from 10 mm or larger trocars in group C were closed; the fascial defects in group S were not closed. The trocar sites were checked for incisional hernias at late follow-up. Mean operating time was not different between the two groups (group S, 92 +/- 73 minutes; group C, 100 +/- 74 minutes). There were no episodes of intraoperative cannula site bleeding in group S compared with 16 episodes in 13 patients (P < 0.001) in group C. Postoperative wound complications were fewer in group S (13 vs. 23; P < 0.05). Although the pain scores were generally lower in group S, the differences were not significant. Only 3% of the patients in group S had fascial defects of 10 mm or greater that had to be closed. Within a follow-up period of 6 to 18 months, there have been no incisional hernias in either group. This study shows that radially expanding trocars are safe and effective, and less likely than conventional trocars to result in intraoperative or postoperative complications. The defects created by the radially expanding trocars do not have to be routinely closed. Because induction of artificial pneumoperitoneum through the infra-umbilical route is associated with complications in laparoscopic procedures, especially in obese patients, we performed a prospective randomized study comparing the conventional infra-umbilical route with a transfundal route, in which the Veress needle is inserted into the peritoneal cavity through the uterine fundus. One hundred obese subjects (body mass index >/=25 kg/m(2)) scheduled for laparoscopic sterilization were randomized into two groups. In the infra-umbilical group pneumoperitoneum was achieved at a ratio (punctures/pneumoperitoneum) of 56/49 (1.14). There was one failure in this group. In the transfundal group the ratio was 53/51 (1.04). There was no clinically significant bleeding in either of the groups; nor were there any major complications. One subject in whom the infra-umbilical route failed was moved to the transfundal group. This subject also underwent dilatation and curettage at the time of laparoscopy. Postoperatively she contracted chlamydial pelvic inflammatory disease. No other infections were detected postoperatively in either of the groups. In conclusion, the transfundal route of inducing artificial pneumoperitoneum proved to be easy, safe and effective. To compare postoperative wound pain associated with the radially expanding access device and the conventional disposable cutting-tip trocar.
                Our randomized, double-masked, self-controlled study involved 34 women scheduled for laparoscopic adnexal surgery. In each, a 10-mm radially expanding access device was inserted laterally on one side of the lower abdomen and a size-matched disposable cutting-tip trocar was placed on the other side, using random assignment. Postoperative pain for each studied wound and patient satisfaction toward the wounds were assessed using a visual analog scale. Any bleeding complication associated with insertion of the trocar was also recorded.
                The radially expanding access device was associated with significant reduction in severity (median 1.4 versus 5.0, P <.001) and duration (median 11 versus 21 days, P <.001) of postoperative wound pain, shorter wound scars (14 versus 17 mm, P <.001), a lower incidence of wound induration (0 versus 9, P <.01), and a higher patient satisfaction (median 9.7 versus 6.2, P <.001). There were four inferior epigastric artery injuries, all at the conventional trocar wound.
                The radially expanding access device was associated with less postoperative wound pain and more patient satisfaction than the conventional cutting-tip trocar.
An open-entry technique is associated with a significant reduction in failed entry when compared to a closed-entry technique, with no difference in the incidence of visceral or vascular injury. 
Significant benefits were noted with the use of a direct-entry technique when compared to the Veress Needle. The use of the Veress Needle was associated with an increased incidence of failed entry, extraperitoneal insufflation and omental injury; direct-trocar entry is therefore a safer closed-entry technique.
The low rate of reported complications associated with laparoscopic entry and the small number of participants within the included studies may account for the lack of significant difference in terms of major vascular and visceral injury between entry techniques. Results should be interpreted with caution for outcomes where only single studies were included.