Before any laparoscopic exploratory or corrective surgery is undertaken, serious injury to major blood vessels and other vital structures may occur during the puncturing of the abdominal wall for introduction of surgical instruments[1], [2], [3], [4]. Adherence to safety rules minimises risk of harm by the trochar (spike)[4a].
PRACTICE POINT In contrast with advanced laparoscopic techniques, attempts to demonstrate inadequacy of training or supervised experience are unlikely to succeed |
In general, prior introduction of a Verres needle and inflation of the abdomen with carbon dioxide is preferable but not foolproof. The Verres needle itself causes more frequent but less life-threatening injury.
As with other surgical procedures, standard technique requires the identification of anatomical landmarks which delineate safe and unsafe entry zones. The first puncture is the most dangerous because it must be undertaken blind: second and subsequent punctures are undertaken under the direct vision of a lighted laparoscope introduced at the first.
A formal scalpel incision[2], [5] is standard if anatomical distortion is expected - in patients who are thin, have adhesions or have undergone prior surgery, for instance. A blunt trochar can then be used to prepare for introduction of the laparoscope.
Given correct location, a sharp trochar should be introduced at right angles to the skin, not obliquely[4], [5]. The instrument is gently advanced until the operator feels the "give" when the peritoneum is penetrated. A cover protecting the sharp point is engaged before further advancement.
In Canada, the majority of major vessel injuries have resulted in Settlement.6
PRACTICE POINT The courts are recognising that the majority of serious trochar injuries arise from substandard surgical technique |
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