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INDICATIONS

  1. Top of page
  2. INDICATIONS
  3. METHODS
  4. COMPARISON WITH OTHER METHODS
  5. ADVANTAGES AND DISADVANTAGES
  6. REFERENCES

Recently, a novel technique for laparoscopic access was developed using a blunt-tip, latex-free, radial dilating trocar (VersaStep®, US Surgical, Norwalk, CT). This technique is effective, requires minimal incision and dissection, creates a gas-tight fascial seal, and provides 5-mm and 12-mm access. Traditionally, 5-mm ports using standard cutting trocars do not require fascial closure, although larger ports are generally closed to decrease the risk of hernia formation. For 12-mm access using the dilating trocar, there is no need for fascial closure, potentially saving time and decreasing the incidence of hernia formation. This pertains especially to obese patients, where closing the fascia is difficult and may be incomplete. We herein report our experience using the 12-mm radial dilating port for laparoscopic access.

METHODS

  1. Top of page
  2. INDICATIONS
  3. METHODS
  4. COMPARISON WITH OTHER METHODS
  5. ADVANTAGES AND DISADVANTAGES
  6. REFERENCES

The dilating trocar system (VersaStep) consists of an expandable mesh sleeve, a Veress needle, a blunt-tipped fascial dilator, and the laparoscopic port (Fig. 1). After standard preparation and positioning, pneumoperitoneum is achieved with either the Veress needle, open technique, or after placing a hand-port device. When the Veress needle is used, pneumoperitoneum is established, the Veress needle removed, the expandable mesh sleeve back-loaded over the Veress needle, and the combination re-introduced into the inflated peritoneum. Minimal dissection of the subcutaneous tissues is required. After removing the Veress needle, the blunt-tipped fascial dilator back-loaded with the laparoscopic port is then passed through the mesh sleeve lumen. While the subordinate hand provides counter-traction on the mesh sleeve, the dominant hand advances the dilator which radially dilates the fascia (Fig. 2). A constant pressure and twisting motion is best for introducing the blunt-tip obturator and trocar. After inserting the 12-mm trocar (Fig. 3), the obturator is removed and its depth adjusted under laparoscopic vision. The dilated fascia and crossed-hatch mesh sheath provide a gas-tight fascial seal, and enable stability and minimize slipping in the fascia. We have found stay sutures to be unnecessary. Additional ports may be placed using the same technique under direct laparoscopic vision. At the end of the procedure, the ports are simply removed and the skin closed, as no fascial sutures are used.

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Figure 1. Components of the radial dilating system (from left to right): laparoscopic port, blunt-tipped obturator, Veress needle, and expandable mesh sleeve. The pen and scissors (top) are for size comparison only.

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Figure 2. Technique of port insertion. Counter-traction is applied to the sleeve while the dominant hand inserts the port.

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Figure 3. The 12-mm dilating port after insertion.

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We used the 12-mm radial dilating port in 46 patients (12 women, 34 men; mean age of 54.5 years, range 19–83) from August 2000 to June 2002. We do not report our use of 5-mm ports, as these ports generally do not require fascial closure. Nine of the patients were described as obese (body mass index> 30 kg/m2). These patients were undergoing a variety of genitourinary laparoscopic procedures (Table 1); 112 of the 12-mm ports were placed in a variety of locations, including the upper and lower abdomen, midline, pelvis, flank, and suprapubic through the bladder for cuff excision during nephroureterectomy (Table 1). The ports were not sutured to the skin and the fascia was not closed for any of the 12-mm port sites.

Table 1.  Laparoscopic procedures undertaken, and the port sites used
Procedure/siteN
Hand-assisted laparoscopic nephrectomy34
Hand-assisted nephroureterectomy  4
Renal cyst decortication  3
Pelvic lymph node dissection  1
Laparoscopic prostatectomy  1
Laparoscopic pyeloplasty  1
Laparoscopic orchidopexy  1
Removal of retroperitoneal mass  1
Port sites
Upper quadrant23
Lower quadrant52
Upper midline24
Lower midline  2
Pelvis  7
Umbilicus  3
Bladder  1

During surgery, all attempts to place the radial dilating ports were successful and without incident. There were no cases of inadvertent port removal, vascular or visceral trocar injury, gas leak, or loss of pneumoperitoneum. There were no cases of intraoperative port-site bleeding. Patients were examined at routine follow-up appointments, and none were lost to follow-up. After surgery there were no cases of wound haematoma, wound infection, port-site hernia, or delayed bleeding. With a mean (range) follow-up of 8.8 (3–20.5) months there were no incidents of port-site hernia formation, based on physical examination.

COMPARISON WITH OTHER METHODS

  1. Top of page
  2. INDICATIONS
  3. METHODS
  4. COMPARISON WITH OTHER METHODS
  5. ADVANTAGES AND DISADVANTAGES
  6. REFERENCES

Trocar insertion remains the most dangerous technical aspect of laparoscopy [1]. Access-related complications during laparoscopic surgery include complications of placement (vascular and visceral injury, abdominal wall haematoma), procedural (gas leak and loss of pneumoperitoneum), and postoperative (wound infection, port-site hernia formation) [1–4]. The overall incidence of complications was recently reported to be 0.2–0.27%[5,6]. Alternative techniques such as the open ‘Hasson’ technique [7], disposable trocars with safety shields [8], blunt-tip trocars, and direct-view trocars [9] have been introduced, although no entry technique or device is absolutely safe [4].

ADVANTAGES AND DISADVANTAGES

  1. Top of page
  2. INDICATIONS
  3. METHODS
  4. COMPARISON WITH OTHER METHODS
  5. ADVANTAGES AND DISADVANTAGES
  6. REFERENCES

The radial dilating port system, first described in 1996 [10], appears to have several advantages over traditional cutting-tip trocars. The efficacy and safety has been reported in adult general surgery [11,12], genitourinary [13], obstetric cases [14–16] and paediatric surgical cases [17,18]. A summary of reports describing the outcomes of using the radial dilating ports is listed in Table 2, with a list of randomized, prospective studies comparing the radial dilating ports with traditional cutting ports.

Table 2.  Reports on the use of the radial dilating ports, and randomized, prospective studies comparing the dilating port (DP) with traditional cutting ports
StudyNo. of patientsComplications/comments
Paediatric
[ 17 ]  14None
[ 18 ]  50One minor CO2 leak
Adult
[ 13 ]  62One liver puncture (treated conservatively)
[ 12 ]  70None
[ 16 ] 212None
Current  46None
Comparisons
[ 14 ]  Less pain in epigastric site with DP; same amount of pain in umbilical site
[ 11 ]  DPs cause less bleeding (0% vs 16%) and wound complications (13% vs 23%)
No hernias reported in either group
[ 15 ]  Pain severity and duration less with DP, shorter wound scars (14 vs 17 mm), less wound induration (0% vs 9%). Four inferior epigastric artery injuries, all with the conventional trocar
[ 24 ]  DPs cause less pain, lower complication rate, shorter procedure

Traditional cutting trocars often require significant downward force to penetrate the abdominal wall during insertion, which increases the risk of vascular and visceral injury. In contrast, the radial dilating port is placed while applying counter-traction with the subordinate hand as the fascia is being dilated, which allows excellent control of axial force. We had no significant difficulty achieving access with the radial dilating ports in any case, although wetting the sheath may aid in insertion (personal experience). The port provides a blunt dilating tip, which in contrast to a cutting tip, may decrease the incidence of intra-abdominal vascular and visceral injury, and abdominal wall bleeding. The tamponade effect of the dilating port may also contribute to a decreased risk of port-site bleeding [11,12,15,18]. In several reports using the radial dilating ports there were no documented cases of port-site bleeding [11–18], and we had no cases of port-site bleeding or abdominal wall haematomas in any of the present patients.

During surgery the radial dilating ports provide a gas-tight seal with no need to place purse-string sutures. Once inserted, the crossed-hatch mesh does not slide out easily, eliminating the need to screw the port into the abdominal wall or place bolstering sutures [18]. In comparison, traditional trocars may allow gas leaks or require bolstering sutures to maintain the seal between the flange and the fascia [3]. We had no difficulty in placing or using the ports in obese patients.

Herniation of omentum [19] and bowel [20] are well-documented postoperative risks of laparoscopy. Factors include the use of ports of ≥ 10 mm, the use of ‘fascial screws’ to secure the port, and a longer procedure [21]. Alternative techniques to close the fascia, e.g. the Grice suture needle (Ideas for Medicine, Clearwater, FL) [22] and the Carter-Thomason needle-point suture passer (Advanced Surgical Education, San Clemente, CA) [23] have not eliminated this risk. Using the radial dilating ports, Bhoyrul et al.[10] reported the fascial defects to be half as wide as that of standard ports and reported no cases of hernia formation, although closure of all fascial defects> 10 mm was recommended, which occurred in 3% of the patients [11]. The risk of hernia formation using the radial dilating port has been shown to be almost nil even without fascial closure [11–18,24], although Bhoyrul et al.[11] recommended closing all fascial defects of> 10 mm. We similarly have had no port-site hernias from any of the 112 12-mm port sites; this may be especially important in obese patients, where the fascia may be difficult to locate and to properly close.

Pain after surgery appears to be equal to [11] or less than that of traditional trocars, probably because of the lack of a fascial incision [14,15,24]. Lam et al.[14] reported decreased pain from epigastric wounds but not subumbilical wounds. A randomized, double-blinded comparison showed that decreased pain severity and duration might lead to greater patient satisfaction [15]. The time to place the radial dilating trocars is similar to that required for traditional ports [11] but the overall operative duration might be less as these ports do not require closure.

In conclusion, radial dilating fascial ports circumferentially dilate rather than incise the fascia. The use of a blunt-tipped trocar probably decreases the incidence of initial access injuries. The use of the 12-mm radial dilating ports appears to be safe and does not require fascial closure.

REFERENCES

  1. Top of page
  2. INDICATIONS
  3. METHODS
  4. COMPARISON WITH OTHER METHODS
  5. ADVANTAGES AND DISADVANTAGES
  6. REFERENCES
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    Liu CD, McFadden DW. Laparoscopic port sites do not require fascial closure when nonbladed trocars are used. Am Surg 2000; 66: 8534
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    Yim ST, Tuen PM. A randomized double-masked comparison of radial expanding access device and conventional cutting tip trocar in laparoscopy. Obstet Gynecol 2001; 97: 4358
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    Galen DI, Jacobson A, Weckstein LN, Kaplan RA, DeNevi KL. Reduction of cannula-related laparoscopic complications using a radial expanding access device. J Am Assoc Gynecol Lap 1999; 6: 7984
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    Cuellar DC, Kavoussi PK, Baker LA, Docimo SG. Open laparoscopic access using a radial dilating trocar. experience and indications in 50 consecutive cases. J Endourol 2000; 14: 7556
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    Bloom DA, Ehrlich RM. Omental evisceration through small laparoscopic port sites. J Endourol 1993; 7: 312
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    Boike GM, Miler CE, Spirtos NM et al. Incisional bowel herniations after operative laparoscopy. A series of nineteen cases and review of the literature. Am J Obstet Gynecol 1995; 172: 172633
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    Stringer NH, Levy ES, Kezmoh MP et al. New closure technique for lateral operative laparoscopic trocar sites. A report of 80 closures. Surg Endoscopy 1995; 9: 83840
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    Carter JE. A new technique of fascial closure for laparoscopic incisions. J Laparoendoscop Surg 1994; 4: 1438
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    Nordestgaard AG, Kenton B, Osborne RW, Jr Buttorff JD. Major vascular injuries during laparoscopic procedures. Am J Surg 1995; 169: 5435
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