The safety of laparoscopy performed by direct trocar insertion and carbon dioxide insufflation under vision

The records of 6,173 laparoscopies performed by specialist gynaecologists in the course of routine gynaecological care using the technique of direct insertion of the umbilical trocar and insufflation of carbon dioxide under vision were reviewed to ascertain the incidence of serious complications. A review of the published literature on laparoscopy methodology was also undertaken to complement the data obtained from this study. The nature of the records precluded accurate assessment of both indications and minor complications. There were 4 perforating bowel injuries (0.06%) requiring laparotomy (s small intestine, 2 large intestine). There were no cases of major vascular injury or gas embolus necessitating surgical or resuscitative measures. On 3 of the 4 occasions where bowel injury occurred the patients had undergone prior abdominal surgery and had midline vertical subumbilical incisions. Review of the published literature demonstrated bowel or vessel perforation rates (requiring laparotomy or resuscitation) of 1 in 1,000 regardless of whether the method of gaining peritoneal access was open (Hasson) technique, Verres needle insufflation, or direct trocar. Direct trocar insertion may reduce the risk of gas embolism by insufflating only after intraperitoneal replacement has been confirmed, moreover it allows immediate recognition and rapid treatment of major blood vessel laceration, both of which have been identified as being crucial in reducing laparoscopy associated mortality. When compared to other available methods of gaining peritoneal access for laparoscopy, direct trocar insertion followed by insufflation of carbon dioxide under vision can be performed with the same degree of safety for the patient. It is simply wrong to deduce from the available data that one particular technique of gaining peritoneal access is superior to another. Each have their individual advantages and disadvantages and similar morbidity when performed by experienced operators with appropriate indications. In light of this observation, each alternative should be considered by the individual surgeon to assess which would best suit his or her operating technique and the particular circumstance of each patient. Indeed preference should be given to the method with which the surgeon is most comfortable or with which he or she has the most experience.