A PROSPECTIVE STUDY TO

EVALUATE THE OUTCOME OF

VERESS ASSISTED OPEN TROCAR
INSERTION TECHNIQUE

• Principal investigator : Dr. Harshil D. Kacha (First year resident)

• Co principal investigator : Dr. A.M.Rajyaguru (Associate professor and Unit
Head)
• Site : PDU Medical college and Civil Hospital Rajkot
INTRODUCTION

Laparoscopy is widely used for different surgical procedures.

Access to the peritoneal cavity and creation of pneumoperitoneum is
the first and foremost important step.
Gaining access to peritoneum is associated with injuries to the
gastrointestinal tract and major blood vessels, and at least 50% of
these major complications occur prior to commencement of the
intended surgery.
Among the different methods of primary access in laparoscopy,
the popular ones being the Veress needle and Hasson’s technique. The
Veress needle technique is still being used by many surgeons as an
gold standard technique.

STANDARD TECHNIQUES

 OPEN TECHNIQUE

o Open technique involves skin and subcutaneous layer incision up

to cutting down the peritoneum.
o Once in the peritoneal cavity, a blunt trocar is placed under direct
visualization.
o Gas insufflation is provided and the laparoscope is inserted.

 CLOSED TECHNIQUE

o Closed technique starts with the insertion of a Veress needle into

the peritoneal cavity, after a small incision of the skin.
 o The needle is pushed in until it gives a double click, ensuring that
it is in the intraperitoneal space.
o Once into peritoneal cavity, gas insufflation is provided. After the
incision of the skin, the first trocar is placed through the abdominal
wall up to cutting down muscular layers and the peritoneum with
blunt manoeuvres.

 OPEN VERESS ASSISTED TECHNIQUE :

o The Open Veress Assisted technique allows a safe first trocar

insertion, in a previously tested abdominal wall site, after the creation
of pneumoperitoneum using Veress needle in the upper left quadrant.

o After a small incision of the skin with a scalpel, a Veress needle is

placed in the left hypochondrium two or three cm below the costal
margin, laterally to the rectus abdominis muscles.

o A gas tube is connected to the needle and CO2 insufflation starts with
high flow.

o When intra-abdominal pressure reaches 12 mmHg, the insertion site

of the first trocar is checked with the aspiration with the needle of a
10 mL syringe containing 3 mL of saline is introduced
perpendicularly into the abdominal cavity with simultaneous suction
manoeuvres.

o This hydro-pneumatic test can detect a free intra-peritoneal area when

CO2 backs into the syringe, whereas evidence of resistance, blood or
stools show a no safe zone.

o In the chosen area, a 10-mm full-thickness incision of abdominal wall

including the peritoneum is performed. The gas leakage confirms
 access so that the first trocar can be inserted into the abdominal cavity
without any effort, avoiding potential vascular or visceral injuries.

o The procedure ends with the check of Veress needle position by optics
and its removal.

o This method differs from the closed technique for a full-thickness

incision of the abdominal wall at the first trocar site, avoiding the
blind application of potentially dangerous insertion-related forces.

o Compared with the open technique, Open Veress Assisted technique

laparoscopic entry provides a smaller muscular fascia incision
because there is no need for layer-by-layer abdominal wall dissection.
This could prevent trocar site incisional hernia development.

o Open Veress Assisted technique is also applicable to obese patients.

o Furthermore, it is advantageous in previously operated patients

because of the risk of adhesions under the midline laparotomy scar
and in the operations that need to place optical trocar outside the
umbilicus.

AIMS AND OBJECTIVES

To evaluate complications of veress assisted first trocar insertion,

it’s efficacy and safety.

COMPLICATIONS :
 o Abdominal wall emphysema
o Omental injury
o Small bowel injury
o Mesenteric vascular injury
o Seroma, Hematoma
o Port site hernia

METHODOLOGY :

150 patients admitted in surgery department of Civil Hospital

Rajkot and undergoing laparoscopic surgeries for various indications
were selected according to inclusion and exclusion criteria.
Abdominal entry for various Laproscopic surgery will be done by
insertion of port using Veress needle assisted open trocar insertion
technique via inserting a veress needle over left hypochondrium two or
three cm below the costal margin, laterally to the rectus abdominis
muscles. Following which other abdominal trocars are inserted and
further surgical procedure commences.
Each patient followed up at 3 months for development of seroma,
hematoma and at 6 month for port site incisional hernia in further follow
ups.
Conclusion to be reached after statistical analysis of data collected
at the end of study duration.

STUDY DETAILS

 STUDY DESIGN : Prospective study

  STUDY PERIOD : 2 years

 TARGET POPULATION : All patients undergoing laproscopic

surgeries at PDU Medical College and Civil Hospital Rajkot

 SAMPLE SIZE : 150 patients

INCLUSION CRITERIAS :
Patients undergoing laproscopic surgeries in surgery
department of PDUMC Rajkot.
Patients above 18 years of age.

EXCLUSION CRITERIAS :

o Pregnant patients.
o Patients <18 yrs of age.
o Patients not giving consent for laparoscopy.

REFERENCES :
1. Ahmad G, Baker J, Finnerty J, Phillips K, Watson A.
Laparoscopic entry techniques. Cochrane Database Syst
Rev. 2019;1:CD006583.
2. Van der Voort M, Heijnsdijk EA, Gouma DJ. Bowel injury
as a complication of laparoscopy. Br J Surg. 2004;91:1253–
8.
3. Hasson HM. A modified instrument and method for
laparoscopy. Am J Obstet Gynecol. 1971;110:886–7.