Risks of the minimal access approach for laparoscopic surgery: multivariate analysis of morbidity related to umbilical trocar insertion

The objective of this study was to determine the morbidity associated with trocar and needle insertion for laparoscopic surgery and to identify risk factors for complications. Data from a prospectively collected database of all laparoscopic operations performed at a major teaching hospital over a 4-year period were analyzed. In 203 patients closed laparoscopy (Veress needle plus blind trocar insertion) was used to establish the pneumoperitoneum. Open laparoscopy with a Hasson's trocar was performed in 200 patients. A total of 1206 operative trocars were inserted (mean +/- SD 2.99 +/- 0.4). Sixty-nine percutaneous punctures for cholangiography or liver biopsy were carried out. Of the 403 patients undergoing laparoscopic surgery, 20 (3%) had developed complications specifically related to the access to the abdominal cavity after a minimum follow-up of 3 months, abdominal wall hematoma being the most frequent (n = 8, 2.0%), followed by umbilical hernias (n = 6, 1.5%) and umbilical wound infection (n = 5; 1.2%). The rate of penetrating injuries was 0.2% (n = 1). Of 20 complications, 15 (75%) were related to the umbilical insertion site. Female sex and closed laparoscopy were associated with umbilical morbidity by univariate analysis. In a multivariate analysis, closed laparoscopy was the only factor associated with these complications (odds ratio = 6.0; p = 0.04). Age, gender, obesity, diabetes mellitus, previous abdominal surgery, and the specific procedure had no influence. In conclusion, gaining access to the peritoneal cavity for laparoscopic surgery may cause severe complications, most of which are related to the umbilical trocar. Although closed laparoscopy can be safely used, open laparoscopy is associated with a lower morbidity rate; therefore its utilization is recommended.