RISKS OF THE MINIMAL ACCESS APPROACH FOR LAPAROSCOPIC SURGERY - MULTIVARIATE-ANALYSIS OF MORBIDITY RELATED TO UMBILICAL TROCAR INSERTION

The objective of this study was to determine the morbidity associated with trocar and needle insertion for laparoscopic surgery and to ident ify risk factors for complications. Data from a prospectively collecte d database of all laparoscopic operations performed at a major teachin g hospital over a 4-year period were analyzed. In 203 patients closed laparoscopy (Veress needle plus blind trocar insertion) was used to es tablish the pneumoperitoneum. Open laparoscopy with a Hasson's trocar was performed in 200 patients. A total of 1206 operative trocars were inserted (mean +/- SD 2.99 +/- 0.4). Sixty-nine percutaneous punctures for cholangiography or liver biopsy were carried out. Of the 403 pati ents undergoing laparoscopic surgery, 20 (5%) had developed complicati ons specifically related to the access to the abdominal cavity after a minimum follow-up of 3 months, abdominal wall hematoma being the most frequent (n = 8, 2.0%), followed by umbilical hernias (n = 6, 1.5%) a nd umbilical wound infection (n = 5; 1.2%). The rate of penetrating in juries was 0.2% (n = 1). Of 20 complications, 15 (75%) were related to the umbilical insertion site. Female sex and closed laparoscopy were associated with umbilical morbidity by univariate analysis. In a multi variate analysis, closed laparoscopy was the only factor associated wi th these complications (odds ratio = 6.0; p = 0.04). Age, gender, obes ity, diabetes mellitus, previous abdominal surgery, and the specific p rocedure had no influence. In conclusion, gaining access to the perito neal cavity for laparoscopic surgery may cause severe complications, m ost of which are related to the umbilical trocar. Although closed lapa roscopy can be safely used, open laparoscopy is associated with a lowe r morbidity rate; therefore its utilization is recommended.