Blunt hasson trocar injury: long intra-abdominal trocar and lean patient--a dangerous combination

Injury at the time of trocar placement with the Hasson approach is rare. The cone of the Hasson cannula is wedged into the skin for an air seal, and, using fascial sutures, fastened under tension to flanges of the cannula. The shorter the fascial securing suture, the greater the tension and the more secure the air seal. Flanges for securing the fascial suture were attached to the external cannula in early Hasson cannula models. With these, much of the trocar needs to be intra-abdominal in order to shorten the suture. For lean patients, with very little distance between the anterior and posterior abdominal walls, the force required to fasten the sutures to the flanges may allow an intra-abdominal trocar to damage intervening organs. Later versions of the cannula had the flanges attached to the cone, allowing for short suture without need for intra-abdominal cannula. These models avoid the possibility of such injury. An unusually lean patient underwent laparoscopic cholecystectomy using an older Hasson cannula with flanges for the fascial securing suture attached to the cannula. Postoperative changes in vital signs and hemoglobin led to a diagnosis of intra-abdominal bleeding, and laparotomy revealed a transsected branch of the middle colic artery. Earlier Hasson cannulas, where the flanges are attached to the cannula, should be replaced with those with flanges attached to the cone.