THE SAFETY OF LAPAROSCOPY PERFORMED BY DIRECT TROCAR INSERTION AND CARBON-DIOXIDE INSUFFLATION UNDER VISION

The records of 6,173 laparoscopies performed by specialist gynaecologi sts in the course of routine gynaecological care using the technique o f direct insertion of the umbilical trocar and insufflation of carbon dioxide under vision were reviewed to ascertain the incidence of serio us complications, A review of the published literature on laparoscopy methodology was also undertaken to complement the data obtained from t his study, The nature of the records precluded accurate assessment of both indications and minor complications. There were 4 perforating bow el injuries (0.06%) requiring laparotomy (2 small intestine, 2 large i ntestine), There were no cases of major vascular injury or gas embolus necessitating surgical or resuscitative measures, On 3 of the 4 occas ions where bowel injury occurred the patients had undergone prior abdo minal surgery and had midline vertical subumbilical incisions, Review of the published literature demonstrated bowel or vessel perforation r ates (requiring laparotomy or resuscitation) of 1 in 1,000 regardless of whether the method of gaining peritoneal access was open (Hasson) t echnique, Verres needle insufflation, or direct trocar, Direct trocar insertion may reduce the risk of ens embolism by insufflating only aft er intraperitoneal replacement has been confirmed, moreover it allows immediate recognition and rapid treatment of major blood vessel lacera tion, both of which have been identified as bring crucial in reducing laparoscopy associated mortality, When compared to other available met hods of gaining peritoneal access for laparoscopy, direct trocar inser tion followed by insufflation of carbon dioxide under vision can be pe rformed with the same degree of safety for the patient. It is simply w rong to deduce from the available data that one particular technique o f gaining peritoneal access is superior to another. Each have their in dividual advantages and disadvantages and similar morbidity when perfo rmed by experienced operators with appropriate indications. In light o f this observation, each alternative should be considered by the indiv idual surgeon to assess which would best suit his or her operating tec hnique and the particular circumstance of each patient. Indeed prefere nce should be given to the method with which the surgeon is most comfo rtable or with which he or she has the most experience.