Operative Technique |

Safety and Efficacy of Initial Trocar Placement in Morbidly Obese Patients

Atul K. Madan, MD; Suraj Menachery, MD
Arch Surg. 2006;141(3):300-303. doi:10.1001/archsurg.141.3.300.
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Hypothesis  The use of a nonbladed trocar with an optical view is a safe and effective method for initial trocar placement for laparoscopic bariatric surgery.

Design  Retrospective review of consecutive patients.

Setting  University-associated hospital.

Patients  All patients who underwent laparoscopic bariatric surgery from December 2002 to November 2003.

Intervention  Initial trocar placement.

Main Outcome Measures  Injury and bleeding during initial trocar placement, trocar placement time, and insufflation time. Trocar placement time was defined as the time to place the trocar into the peritoneal cavity (including infiltration of local anesthesia and incision). Insufflation time was defined as time to insufflate the abdomen to a pressure of 10 to 15 mm Hg (including time to place tubing on trocar).

Results  There were 228 patients who had no evidence of any bowel or vessel injury during initial trocar placement. In the last 50 patients, average body mass index (calculated as weight in kilograms divided by the square of height in meters) was 47 (range, 35-63). Average trocar placement time was 25 seconds (range, 10-60 seconds), and average insufflation time was 16 seconds (range, 5-25 seconds). In almost all cases, appropriate pneumoperitoneum was established in less than a minute. No correlation was seen between times and body mass index (trocar, P = .56; insufflation, P = .95) or waist-hip circumference (trocar, P = .74; insufflation, P=.48).

Conclusions  Initial trocar placement using a nonbladed trocar with an optical view without prior abdominal insufflation is safe and effective in morbidly obese patients. This method can be applied even in the super obese.

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Figure 1.

The trocar was placed through the incision, visualizing the subcutaneous fat layer.

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Figure 2.

Constant pressure was applied in the subcutaneous fat layer until the anterior fascia (arrow) was noted.

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Figure 3.

A small amount of rotating clockwise and counterclockwise allowed easy passage through the posterior fascia layer (arrow) and anterior muscle layer (arrowhead).

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Figure 4.

Passing the peritoneum (arrow) and the anterior muscle layer (arrowhead).

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Figure 5.

The omentum (arrow) is visualized past the peritoneum (arrowhead).

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