Direct Trocar Entry in Laparoscopic Surgeries: A Retrospective Study

Parag G. Patel1*,Chikhalia DP1,Rupal Patel1,Shailesh Jadav1,Aditi M Dave1

1Department of Laparoscopy Endoscopy Surgery, Trimurti Hospital, Junagadh, Gujarat, India

*Corresponding Author:Parag G. Patel, Department of Laparoscopy Endoscopy Surgery, Trimurti Hospital, Junagadh, Gujarat, India; TEL:2852631731; FAX:2852631731;

Citation: Parag G. Patel, Chikhalia DP, Rupal Patel, Shailesh Jadav,Aditi M Dave, et al. (2017) Direct Trocar Entry in Laparoscopic Surgeries: A Retrospective Study. Gastroenterol Hepatol J 1:109.

Copyright:© Parag G. Patel 2017, et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited

Received date:: January 16 ,2017; Accepted date:February 01, 2017;Published date:February 06, 2017


Background: Laparoscopy is still in its budding state especially in the rural areas of Gujarat state of India. It’s a very skillful procedure which reduces not only the operating time but also the overall stay of patients & enables faster recovery. There are various modes of entry into the abdomen while operating Laparoscopically.

Laparoscopic entry is a blind procedure and it often represents a problem for all the related complications. In the last three decades, rapid advances in laparoscopic surgery have made it an invaluable part of general surgery, but there remains no clear consensus on an optimal method of entry into the peritoneal cavity.

Objective: The aim of this paper is to focus on the evolution of blind non – visual direct trocar method of entry into the peritoneal cavity in laparoscopic surgery.

Methods: A retrospective review was performed in all Surgical cases operated at Trimurti hospitals from 2006 - 2016 by retrieval from Medical record department.

Study also focused on age, gender, BMI, co-morbid conditions, whether the surgery was Emergency or planned, socio-economic status, general built, previous Surgical history, females who earlier underwent any Lap TL, patients who were posted for adhesionolysis & type of technique (open/closed).

Results: We studied in 10250 patients operated Laparoscopically, out of which in 25 cases open technique was used

Rest – direct trocar entry (trocar used: standard metallic Karl Storz, 5mm in paediatric). Age Group: under 10 yrs -920 cases, 9180 – in 18- 65 age group, 125 cases – in age 65 yrs & above. Gender: Males: 44.5% Female 55.5%. Analysis was performed using the Microsoft Excel and Graphical representation of the values in form of bar diagram & pie diagram. (Figure 1,2)

Body Mass Index

21-25: 20%, 26-30: 30%, 31-35: 30%, > 35:10% (Figure 1-3) In Patients with BMI > 35, direct trocar entry was difficult to negotiate. It required experience hand & good skill for this, since abdominal fat in higher BMI people made the direct entry difficult. Lesser the belly fat, it was easier to negotiate the trocar.

Figure 1
Figure 1:Laparoscopy Surgeries From 01/01/2012 – 31/03/2016.
Figure 2
Figure 2:Gender – Age Distribution in Laparoscopy Surgeries in Year 2014- 2015.
Figure 3

Emergency or Planned Surgery

Figure 4

Figure 4 There was no correlation in the ease of trocar entry & type of operation, but in cases of Emergency Surgeries in which acute peritonitis, haemoperitoneum occurred, was associated with dilated bowel loops, care should be taken while insertion not to injure them, which again requires great skill & Surgical expertise.

Co- Morbid Conditions: Diabetes Mellitus & Hypertension did not directly affect the method of entry but they were found to be associated with higher BMI

Socio-Economic Status: We considered the socio-economic status of the patient & their activity levels.

We found that lower socio economic class of people belonged to the group doing more of labor work, esp. males and they were found to have good abdominal muscle strength & tone (which actually hinders direct trocar entry) but at the same time low belly fat content made it easy to maneuver. But in the females of this class, due to repeated child births & lax abdominal wall it was easier to negotiate trocar.

Whereas, in people with higher socio economic class, they were found to be doing sedentary work, & thus higher BMI.

Figure 5
Figure 5

Previous Surgical History: Previous history of midline laparotomies were the most difficult cases for direct trocar entry due to midline adhesions.

Similarly, other surgeries like previous Lap TL, Appendicectomies, LSCS, Hysterectomy, other miscellaneous surgeries contributed towards difficult direct trocar entry if Adhesions were present at the midline. they contibuted to 10 % of the cohort.

In patients of previous h/o peritonitis + haemoperitoneum, and also seeing the location of previous scar, we presumed that they might be having dense adhesions, hence open technique was performed in such patients, number : 25 – HASSEN’S TECHNIQUE

Some major omental adhesions were found but they were away from the trocar entry point, so in other such cases closed non-visual blind direct trocar entry was used.

LAP. TL was found in 153 of these patients with previous surgeries which amounts to 15 % of the total cohort.

Figure 6
Figure 3

Site of Entry:

  • • Supraumbilical
  • • Intraumbilical
  • • Infraumbilical Pfenential


  • • Initially we were using 11 no. Knife, open the skin & subcut upto the sheath (so that trocar entry would be easie)
  • • Lift the abdomen & insert the trocar with cork screw movement


  • • No significant injury to blood vessel or mesentery
  • • Only one case of enteral injury in patient of koch’s abdomen as small bowel were adherent to ant abdominal wall in cuckoon abdomen
  • • While creating skin incision with 11 no. Knife, injured small mesenteric vessel, repaired laparoscopically with suturing of small bowel
  • • Then we started using 15 no. knife, with that no complaints till date



LAPAROSCOPY (GR: LAPARO- ABDOMEN, SCOPEIN-TO EXAMINE) is the art of examining abdominal cavity & its contents [1]. It requires insertion of cannula through the abdominal wall, distention of abdominal cavity with gas (pneumoperitoneum), visualization & examination of abdomen contents with an illuminated telescope [2-8]. With the advent of videocameras & other ancillary instruments, laparoscopy rapidly advanced from being a diagnostic procedure to one used in fallopian tubal occlusion to sterilization & eventually in performing numerous surgical procedures in all surgical disciplines for variety of indications [9-14].


Access into the abdomen is the one challenge of laparoscopy that is particular to the insertion of surgical instruments through small incisions. Laparoscopy is currently widely used in the practice of medicine, for both diagnostic and therapeutic purposes [15]. The minimally invasive approach has become the method of choice for treating most benign abdominal diseases that require surgery. However, it is obvious that laparoscopic procedures are not risk free. Laparoscopic entry is a blind procedure, and it represents a problem for all the related complications [16-21].

Complications arising from laparoscopic surgery are rare and commonly occur when attempting to gain access to the peritoneal cavity [22]. Creation of the pneumoperitoneum is the first and most critical step of a laparoscopic procedure because that access is associated with injuries to the gastrointestinal tract and major blood vessels and at least 50% of these major complications occurs prior to commencement of the intended surgery.


History of Laparoscopic Access Techniques

Georg Kelling (1866-1945): – German surgeon – The first person to create the pneumopeitoneum – He performed this procedure on dogs

Jacobeus – Sweden – Performed the first laparoscopy in a human

Janos Veres (1903-1979): – Hungarian – Who has been primarly used the needle for the creation of a pneumothorax

History of Laparoscopic Access Techniques

Raol Palmer (1904-1945):
  • • French gynecologist
  • • Introduced the most popular method of the closed laparoscopic entry in 1947
  • • Use of the Veress needle to induce CO2 pneumoperitoneum for laparoscopy
  • • Published on its safety in the first 250 patients
Harrith M. Hasson:
  • • An American who described the open access laparoscopy in 1970 Dingfelder:
  • • Who developed the direct laparoscopic trocar insertion technique in 1978

Laparoscopy Entry Systems

1. Blind Non-Visual Entry
Insufflated –
• Closed conventional trocar entry
• Radially expanding trocar entry
Non-insufflated –
• Direct sharp trocar entry
2. Visual entry –
Optical trocar (Optiview, Visiport)
Open Technique –
Hassan trocar entry

Note: The First Laparoscopy in Human Was Performed by Jacobeus of Sweden in 1910.
Finding a safe entry technique is a priority not only for the life of the patients but also for the increasing rate. In the last three decades, rapid advances in laparoscopic surgery have made it an invaluable part of general surgery, but there remains no clear consensus as an on optimal method of entry into the peritoneal cavity.

Patients with previous abdominal surgery are more prone to visceral injury caused by the Verres needle [23-27]. This is due to peritoneal adhesions, which typically grow where the incision of the parietal peritoneum was made.

Note: Autopsy studies have found adhesions in 74% to 95% of patients with previous abdominal surgery. Midline incisions greatly increase the risk of adhesions in the umbilical region. Even incisions made away from the umbilicus may lead to adhesion formation in the periumbilical region. On the other hand, insertion of the Verres needle into the left hypochondrium has been reported as safe, with reduced risk of iatrogenic injury [28-33]. The stomach is immediately below the anterior abdominal wall at the site where the left hypochondrium puncture is made. If the stomach is accidentally perforated, its contents will not necessarily leak [34-36]. This is due to the protection provided by the three layers of gastric muscle, which tend to close the puncture.

Note: A stomach perforation is easy to diagnose upon initial inspection of the peritoneal cavity and can be repaired by laparoscopic suture.

Specific measures for the correct insertion and for the reduction of the risk of injury of obese and thin patients have to be improved [37]. The Verres needle insertion at 45° from the umbilicus means that needle has to traverse a distance of 12–16 cm, which increases the risk of extraperitoneal insufflation.

Note: Major vascular injuries caused by the insertion of the Verres needle into the abdominal midline occur even in the hands of experienced surgeons.

Schäfer et al. [35] analyzed 26 major vascular injuries and reported that only four of them (15%) had been caused by inexperienced surgeons (surgeons who had performed fewer than 50 laparoscopic procedures) [38]. The other 22 injuries (85%) had been caused either by experienced surgeons (those who had performed between 51 and 100 procedures) or very experienced surgeons (over 100 procedures performed).

OPEN TECHNIQUE – Hassan trocar entry

Open laparoscopy is a technique which allows placement of a laparoscopic camera port, in a controlled manner, by sharply opening the layers of the abdominal wall.

History of Procedure

Open laparoscopy was first developed by Dr. Harrith Hasson of Chicago, IL, who published the description of this technique in the American Journal of Obstetrics and Gynecology in 1971 [5]. In the past 38 years, this technique of open laparoscopy has become widely accepted and is constantly being modified to improve its practice. A survey published in 1998 [13] revealed that approximately 30% of surgeons use Hasson open entry technique to perform laparoscopy, 40% perform closed laparoscopy with Veress needle insufflation, and the remaining 30% utilize direct trocar insertion without prior insufflation. Dr. Hasson, in 2000, [29] published 29 years of his personal experiences in the use and development of open laparoscopy (4). During that time, he performed 5,284 procedures and found this entry technique to be safe, effective, and reproducible. There were only 27 complications in this group of patients, the majority being wound infections and hematomas [39-42]. There was only one case of bowel perforation as a consequence of port entry.

Direct Trocar Entry

Laparoscopic entry is initiated with only one blind step (trocar) instead of three (veress needle, insufflation, trocar). The direct entry method is faster than any other method of entry.

The technique begins with infra umbilical skin incision wide enough to accommodate the diameter of sharp trocar/cannula system. The anterior abdominal wall must be adequately elevated by hand, and the trocar is directly inserted into the cavity, aiming towards the pelvic hollow. Alternatively, the abdomen is elevated by pulling onto the towel clips placed 3cms on either side of umbilicus, & the trocar is inserted at a 90-degree angle. On removal of sharp trocar, the laparoscope is inserted to confirm the presence of omentum or bowel in the visual field.

Figure 7
Figure 7

Changes in Cardiovascular Status Due to Rapid Insufflation of Co2 Gas

In addition, analysis of intraperitoneal pressure and volume of gas insufflated at different time points during insufflation is essential to prevent gas insufflation into sites other than the peritoneal cavity. It has been established that intraperitoneal pressure levels and the total volume of gas insufflated into the peritoneal cavity at given time points can be predicted, provided that the tip of the Verres needle is in fact in the peritoneal cavity during insufflations.

No vascular injury was reported in a study investigating 3,041 patients submitted to blind insertion of the first trocar through a midline incision at the umbilicus under intraperitoneal pressure of 25-30 mmHg. This corroborates the hypothesis that elevated intraperitoneal pressure protects the intraabdominal structures from injury caused by the first trocar. No injury caused by blind insertion of the first trocar was reported in a study involving 1,150 patients submitted to laparoscopy under intraperitoneal pressure of 25 mmHg.

Note: No clinical complications have been shown to arise from transitory elevation of intraperitoneal pressure on rapid gas insufflations.

However, it is known that extremely high levels of intraperitoneal pressure for longer periods of time can cause physiological and structural changes, directly related to the tension levels caused by the high pressure. Therefore, most authors have proposed that intraperitoneal pressure remains at 12 mmHg and never above 15 mmHg during laparoscopic procedures.


Veress needle insertion, direct trocar insertion and open technique are different methods of establishing pneumoperitoneum to perform a successful laparoscopic procedure.

From this retrospective study, we conducted we infer that

• direct trocar insertion is a safe method to create pneumoperitoneum.
• 10250 Laparoscopic operations were evaluated.
• In this study, we have seen that the complication rate while performing pneumoperitoneum by direct trocar entrance was negligible (only one case out of 10250).
• Direct trocar entrance also reduces the operation time. In laparoscopic surgeries, the direct trocar entrance method is a more reliable and less time consuming method.

Note: Trocar and needle injuries are rare complications of laparoscopy.


  1. R Varma, JK Gupta (2008) “Laparoscopic entry techniques: clinical guideline, national survey, and medicolegal ramifications”.  Surgical Endoscopy and Other Interventional Techniques 22: 2686-2697.
  2. Krishnakumar S, Tambe P (2009) Entry complications in laparoscopic surgery.  J Gynecol Endosc Surg 1: 4-11. [crossref] 
  3. DC Wherry, MR Marohn, MP Malanoski, SP Hetz, NM Rieh, et al. (1996) “An external audit of laparoscopic cholecystectomy in the steady state performed in medical treatment facilities of the Department of Defense”. Annals of Surgery 224: 145-154.
  4. Patel DN, Parikh MN, Nanavati MS, Jussawalla MJ (1985) Complications of laparoscopy. Asia Oceania J Obstet Gynaecol 11: 87-91. [crossref] 
  5. Hasson HM (1971) A modified instrument and method for laparoscopy. Am J Obstet Gynecol 110: 886-887. [crossref] 
  6. Chandler JG, Corson SL, Way LW (2001) Three spectra of laparoscopic entry access injuries.  J Am Coll Surg 192: 478-490. [crossref] 
  7. HB Peterson, JR Greenspan, HW Ory (1982) “Death following puncture of the aorta during laparoscopic sterilization”.  Obstetrics and Gynecology 59: 133-134.
  8. GC Roviaro, F Varoli, L Saguatti, C Vergani, M Maciocco, et al. (2002) “Major vascular injuries in laparoscopic surgery: still of interest?”  Surgical Endoscopy and Other Interventional Techniques 16: 1192-1196.
  9. Vellinga TT, De Alwis S, Suzuki Y, Einarsson JI (2009) Laparoscopic entry: the modified alwis method and more.  Rev Obstet Gynecol 2: 193-198. [crossref] 
  10. D Polyzos, N Papadopoulos, L Chapman, et al. (2007) “Where is the aorta? Is it worth palpating the aorta prior to laparoscopy?”  Acta Obstetricia et Gynecologica Scandinavica 86: 235-239.
  11. MP Milad, MF Terkildsen (2002) “The spinal needle test effectively measures abdominal wall thickness before cannula placement at laparoscopy”.  Journal of the American Association of Gynecologic Laparoscopists 9: 514-518.
  12. WH Hurd, RO Bude, JOL DeLancey, JM Gauvin, AM Aisen, et al. (1991) “Abdominal wall characterization with magnetic resonance imaging and computed tomography: the effect of obesity on the laparoscopic approach”.  Journal of Reproductive Medicine for the Obstetrician and Gynecologist 36: 473- 476.
  13. F Nezhat, AI Brill, CH Nezhat, A Nezhat, DS Seidman, et al. (1998) “Laparoscopic appraisal of the anatomic relationship of the umbilicus to the aortic bifurcation”.  Journal of the American Association of Gynecologic Laparoscopists 5: 135-140.
  14. MR Cohen, B Scoccia (1991) “Double laparoscopy: an alternative two-stage procedure to minimize bowel and blood vessel injury”.  Journal of Gynecologic Surgery 7: 203-206.
  15. FF Tu, GM Lamvu, KE Hartmann, JF Steege (2005) “Preoperative ultrasound to predict infraumbilical adhesions: a study of diagnostic accuracy”.  American Journal of Obstetrics and Gynecology 192: 74-79.
  16. I Kodama, LA Loiacono, B Sigel, et al. (1992) “Ultrasonic detection of viscera slide as an indicator of abdominal wall adhesions”.  Journal of Clinical Ultrasound 20: 375-380.
  17. C Nezhat, J Cho, V Morozov, P Yeung (2009) “Preoperative periumbilical ultrasound-guided saline infusion (PUGSI) as a tool in predicting obliterating subumbilical adhesions in laparoscopy”.  Fertility and Sterility 91: 2714-2719.
  18. SG Levrant, E Bieber, R Barnes (1994) “Risk of anterior abdominal wall adhesions Increase whith number and type of previous laparotomy”.  Journal of the American Association of Gynecologic Laparoscopists 1: S19.
  19. A Rohatgi, AL Widdison (2004) “Left subcostal closed (Veress needle) approach is a safe method for creating a pneumoperitoneum”.  Journal of Laparoendoscopic and Advanced Surgical Techniques A 14: 278-280.
  20. Afifi Y, Raza A, Balogun M, Khan KS, Holders R (2011) New nomogram for safe laparoscopic entry to reduce vascular injury.  J Obstet Gynaecol 31: 69-72. [crossref] 
  21. Hanney RM, Alle KM, Cregan PC (1995) Major vascular injury and laparoscopy. Aust N Z J Surg 65: 533-535. [crossref] 
  22. M Ito, Y Asano, A Horiguchi, et al. (2010) “Cholecystectomy using single-incision laparoscopic surgery with a new SILS port”.  Journal of Hepato-Biliary-Pancreatic Sciences 17: 688-691.
  23. RM Hanney, HL Carmalt, N Merrett, N Tait (1999) “Use of the hasson cannula producing major vascular injury at laparoscopy”.  Surgical Endoscopy 13: 1238-1240.
  24. M Larobina, P Nottle (2005) “Complete evidence regarding major vascular injuries during laparoscopic access”.  Surgical Laparoscopy, Endoscopy and Percutaneous Techniques, 15: 119-123.
  25. J Penfield (1994) “Critical decisions in 22 years of outpatient laparoscopy”.  Journal of the American Association of Gynecologic Laparoscopists 1: S28–S29.
  26. A String, E Berber, A Foroutani, JR Macho, JM Pearl, et al. (2001) “Use of the optical access trocar for safe and rapid entry in various laparoscopic procedures”.  Surgical Endoscopy 15: 570-573.
  27. C Compeau, NT McLeod, A Ternamian (2011) “Laparoscopic entry: a review of Canadian general surgical practice”.  Canadian Journal of Surgery 54: 315-320.
  28. JB Long, DL Giles, JL Cornella, PM Magtibay, RMC Kho, et al. (2008) “Open laparoscopic access technique: review of 2010 patients”.  Journal of the Society of Laparoendoscopic Surgeons 12: 372-375.
  29. HM Hasson (1999) “Open laparoscopy as a method of access in laparoscopic surgery”.  Gynaecological Endoscopy 8: 353-362.
  30. Antevil JL, Bhoyrul S, Brunson ME, Vierra MA, Swadia ND (2005) Safe and rapid laparoscopic access--a new approach.  World J Surg 29: 800-803. [crossref] 
  31. P Lal, A Vindal, R Sharma, J Chander, VK Ramteke, et al. (2012) “Safety of open technique for first-trocar placement in laparoscopic surgery: a series of 6,000 cases”.  Surgical Endoscopy 26: 182-188.
  32. J Mayol, J Garcia-Aguilar, E Ortiz-Oshiro, JA De-Diego Carmona, JA Fernandez-Represa, et al. (1997) “Risks of the minimal access approach for laparoscopic surgery: multivariate analysis of morbidity related to umbilical trocar insertion”.  World Journal of Surgery 21: 529-533.
  33. Palmer R (1974) Safety in laparoscopy.  J Reprod Med 13: 1-5. [crossref] 
  34. D Molloy, PD Kaloo, M Cooper, TV Nguyen (2002) “Laparoscoic entry a literature review and analysis of techniques and complications of primary port entry”.  Australian and New Zealand Journal of Obstetrics and Gynaecology 42: 246-254.
  35. Schäfer M, Lauper M, Krähenbühl L (2001) Trocar and Veress needle injuries during laparoscopy.  Surg Endosc 15: 275-280. [crossref] 
  36. JLMC Azevedo, OC Azevedo, AA Sorbello, et al. (2009) “Intraperitoneal pressure and volume of gas injected as effective parameters of the correct position of the veress needle during creation of pneumoperitoneum”.  Journal of Laparoendoscopic and Advanced Surgical Techniques 19: 731-734.
  37. Reich H, Ribeiro SC, Rasmussen C, Rosenberg J, Vidali A (1999) High-pressure trocar insertion technique.  JSLS 3: 45-48. [crossref] 
  38. J Tsaltas, S Pearce, A Lawrence, A Meads, J Mezzatesta, et al. (2004) “Safer laparoscopic trocar entry: it's all about pressure”.  Australian and New Zealand Journal of Obstetrics and Gynaecology 44: 349-350.
  39. OHM Hypólito, JLMC Azevedo, FMS De Lima Alvarenga Caldeira, et al. (2010) “Creation of pneumoperitoneum: noninvasive monitoring of clinical effects of elevated intraperitoneal pressure for the insertion of the first trocar”.  Surgical Endoscopy and Other Interventional Techniques 24: 1663-1669.
  40. JLMC Azevedo, OC Azevedo, SA Miyahira, et al. (2009) “Injuries caused by Veress needle insertion for creation of pneumoperitoneum: a systematic literature review”.  Surgical Endoscopy and Other Interventional Techniques 23: 1428-1432.
  41. OC de Azevedo, JLMC Azevedo, AA Sorbello, GPS Miguel, JL Wilson, et al. (2006) “Evaluation of tests performed to confirm the position of the Veress needle for creation of pneumoperitoneum in selected patients: a prospective clinical trial”.  Acta Cirurgica Brasileira 21: 385-391.
  42. Hasson HM (1971) A modified instrument and method for laparoscopy. Am J Obstet Gynecol 110: 886-887. [crossref]