The barrier-free trocar technique in three laparoscopic standard procedures.

BACKGROUND: Numerous technical and surgical innovations took place in laparoscopic surgery in the recent past. It is debatable whether single-access surgery or natural orifice surgery (NOS) will establish for several standard procedures. Most of the NOS-procedures are controversial and single-access surgery still has to prove its equality in controlled trials. In the intention to reduce the ingress incisons and to facilitate instrumentation, we decided to test the barrier-free AirSeal(®)-trocar in clinical practice.
MATERIALS AND METHODS: Laparoscopically we performed a cholecystectomy, gastric wedge-resection and a fundoplication using the barrier-free AirSeal(®) 12-mm-trocar. This trocar works without any mechanical barrier so that via this trocar the use of two instruments is possible.
RESULTS: All three operations were successful.
CONCLUSION: Laparoscopic standard procedures are feasible using this barrier-free trocar without a higher degree of difficulty. Because of the facilitated instrumentation, it is possible to work more efficiently and to maintain the focus on the surgical field.

INTRODUCTION

The benefit of laparoscopic surgery is a reduction of morbidity by reducing the risk of surgical site infection, incisional hernias, or adhesions, the latter especially in paediatric surgery.[1-3] Besides the reduced morbidity, postoperative pain and hospital stay duration are reduced in laparoscopic surgery and patients return to normal activities earlier.[45] Furthermore the aspect of cosmesis becomes more important in these days. These facts led to an extensive search for less invasive surgical approaches. Single-access surgery is already wide-spread regarding several standard procedures like cholecystectomy. There has yet been no confirmation of the equality of single-access surgery in randomized controlled trials.[6] The same applies to natural orifice surgery (NOS)-procedures. Some hybrid-NOS-procedures like transvaginal cholecystectomy exclude male patients from the potential advantages of NOS.

Our own studies about transvaginal surgery revealed different complications than those of conventional laparoscopic surgery.[7] These considerations and the intention to reduce the ingress incions and to facilitate instrumentation such as extracorporeal knot tying led to the decision to test the barrier-free trocar (AirSeal®, SurgiQuest®, USA) in clinical practice.

This trocar has already been used as a 21 mm-single port in an experimental model of sigmoidectomy with survival in mini-pigs.[8] We applied a 12-mm version of this trocar.

The objective of this study was to investigate the feasibility and safety of the use of a 12-mm AirSeal®-trocar in clinical practice of three standard procedures of laparoscopic surgery. It was not our goal to perform a single-access procedure.

MATERIALS AND METHODS

Trocar Description

Single-use product contents: 12-mm trocar, obturator, pressure tube with filter system by SurgiQuest®. The AirSeal®-trocar has received FDA 510(k) approval and has been cleared to market in the United States. It has received a CE mark on the basis of examination under the requirements of council directive 93/42/EEC.

Inside the AirSeal®-trocar in the position of the mechanic valves in conventional trocars at the end of small high pressure nozzles a vortex of carbon dioxide creates an air-seal. This vortex is preserved by a dynamic-pressure-system (DPS)-insufflation engine (SurgiQuest®). The operating instrument and the simultaneously traversing camera are automatically encased with vortexes. Therefore instrument changes, camera cleaning, etc. are possible without destabilization of the capnoperitoneum. The insufflation engine preserves the capnoperitoneum and keeps clear sight via the filtering and exchange of carbon dioxide (SmokeEvac system). The DPS is based on a real-time pressure sensing-system.

The trocar can be inserted using the supplied obturator with a prismatic top without knifes. Inside this obturator a 5-mm camera can be placed for the insertion process under visual control [Figure 1].

Figure 1

AirSeal® devices

Case 1

A 59-year-old female patient with a BMI of 25.6 was suffering from symptomatical cholecystolithiasis. We performed a cholecystectomy using a two-trocar-technique instead of using three or four trocars. The AirSeal®-trocar was inserted first subumbilical with the supplied obturator. After building up the capnoperitoneum a 5-mm trocar was inserted in the epigastrium. The left hand instrument and the 5-mm camera were operated via the AirSeal®-trocar. The right hand instrument was operated via the epigastric 5-mm trocar. This allowed us to safely prepare the triangle of calot. All structures were identified as usual. The cystic duct and the cystic artery were clipped with a 5-mm Ligamax™ (Ethicon Endo-surgery, LLC, USA) multiple titanium-clip applier. The gall bladder was removed in an extraction-bag (Unimax Medical Systems, Inc., Taiwan) via the subumbilical incision. The total operation time was 64 min.

Case 2

A 49-year-old woman with a BMI of 27.3 was complaining of recurrent epigastric pain since 2 years. The preoperative esophagogastroscopy revealed a intramural gastric tumour. The computed tomography of the abdomen and the endosonography described a 24 × 10 mm2 tumour of the gastric wall without any signs of malignancy. The location given by all three investigations has been the angle area of the antrum in the lesser gastric curvature. After interdisciplinary discussion, we decided to perform a laparoscopic wedge-resection under the suspicion of a gastrointestinal stroma tumour (GIST).[9]

The patient was placed in a french position. Part of the supraumbilical scar that resulted from a previous operation via upper abdomen laparotomy with hepatic cysts was used for the first incision. Next the fascia was prepared and the peritoneum was opened in a open technique. After that the AirSeal®-trocar without the obturator was inserted under visual control and the capnoperitoneum was built up. A 5-mm trocar was placed in the epigastrium and a further 5-mm trocar in the left upper abdomen. After adhesiolysis the tumour was not detectable. In the following intraoperative gastroscopy the tumour was detected in the corpus area of the lesser gastric curvature. This area was now prepared and then the camera was placed in the trocar in the left abdomen, the tumour was grasped via the trocar in the epigastrium and the EndoGIA™ (Covidien, Ireland) inserted via the AirSeal®-trocar. The tumour was resected completely with two 60/3.5 mm magazines. Through the first supraumbilical inzision the specimen was removed in a extraction-bag. Completing the operation we performed a leak test. The total operation time was 105 min.

Case 3

A 46-year-old, obese woman with a BMI of 43.4 was suffering from a gastroesophageal reflux disease and a hiatal hernia (40 mm diameter). We performed a 360°-Nissen-fundoplication plus hiatal hernia repair with three trocars. The patient was placed in a french position. The AirSeal®-trocar was inserted first subumbilical with the supplied blunt obturator. After building up the capnoperitoneum, a 5-mm trocar was inserted in the epigastrium and a second 5 mm trocar in the left upper abdomen analogous to Case 2. Because of lateral tension between the liver retractor and the 5-mm camera (both in the AirSeal®-trocar) we changed the instrument operating in the left hand from the epigastrium to the AirSeal®-trocar and placed the 5-mm liver retractor in the epigastrium. A posterior hiatoplastic was performed to repair the large hiatal hernia prior to the 360°-fundoplication. The total operation time was 70 min.

RESULTS

The postoperative course was uncomplicated and the patient left the hospital after a normal stay of 2 days.

The complete resection of ectopic pancreatic tissue (20 × 15 × 10 mm3) was confirmed histologically. No further therapy was indicated. The course was uncomplicated and the patient was discharged on postoperative day 7.

The postoperative course was uncomplicated. The patient mentioned that her heartburn sensations ceased postoperatively. Discharge was on postoperative day 4.

DISCUSSION

Concerning the duration of the three operations two statements seem appropriate. First, performing the cholecystectomy we were using this technology for the first time. Preoperative instructions as well as some intraoperative instructions were necessary. Second, the setup of the unexpected gastroscopy during Case 2 resulted in a much longer than expected operation.

The possibility of a third 5-mm instrument (grasper, liver retractor, Babcock forceps) operating simultaneously via the AirSeal®-trocar was very helpful for the adhesiolysis in Case 2 and for the steps of preparation of Cases 2 and 3 where expectably the left hepatic lobe covers the operative site [Figures 2 and 3]. Therefore we usually use four trocars to perform a laparoscopic fundoplication and most of the gastric wedge-resections. Using the AirSeal®-trocar one trocar and hence one incision less were necessary for both operations.

Figure 2

Grasper and the 5-mm camera via the AirSeal trocar

Figure 3

Internal view: grasper and camera via the AirSeal® trocar (fundoplication). r/l = Right/left crus of diaphragm; *right hand instrument (left upper abdomen cases 2 and 3)

During the fundoplication extracorporal knot tying was easily performed through the AirSeal®-trocar. With regard to the hybrid-NOS procedure of transvaginal cholecystectomy, which is performed with one subumbilical abdominal trocar, a cholecystectomy using the AirSeal®-trocar requires only two abdominal trocars and is independently of gender applicable.

The agility of the operating instrument in the AirSeal®-trocar proved to be greater. There is less traction than in conventional trocars resulting in a better tactile control.

The SmokEvac-system allowed us to have a clear sight of the operative site, hence it greatly facilitated the course of the presented procedures. It is expected to be enormously helpful in procedures where more tissue is resected, e.g. laparoscopic sigmoidectomy with the usage of ultrasonic devices. The approximate carbon dioxide consumption was 100 l/ h.

Due to the DPS the capnoperitoneum proved to be more stable than with a conventional insufflator. During instrument changes and extracorporal knot tying no disturbing losses of the capnoperitoneum occurred. All instruments including the 12-mm endostapler can be used without any extra valve-manipulation of the trocar, which allows for significant saving of time and maintaining of focus on the surgical field.

A further benefit is that after the removal of tissue particles, gauze or haemostatic sponge usage no valve-dysfunction will disturb the operation.

On a less positive note, the operating noise of the insufflator and the higher carbon dioxide consumption were perceived as unfavourable. Concerning this we have to mention that the older DPS 1000 system has been used during this study and it is expected that improvements of the new generation of insufflators will overcome this problem. The charge of the single-use devices will be most crucial for the use of this technology.

To summarise, the application of the AirSeal®-trocar allows us to reduce the number of ingress incisions in a feasible and safe way in the clinical practice of laparoscopic standard procedures and facilitates simultaneous as well as consecutive use of multiple instruments.