Surgical Trocar Insertion Procedures and Complication Management

In laparoscopic surgery, the insertion of the surgical trocar is a critical step to ensure the smooth progress of the surgery. Proper operation can not only effectively establish the operation space but also reduce the occurrence of complications. This article will detail the insertion procedure of the surgical trocar and the methods for handling possible complications.

Surgical Trocar Insertion Steps

Insertion of the Observation Port

The surgical trocar insertion usually starts with the observation port. The specific steps are as follows:

• Preparation: After removing the Veress needle, hold the 10mm Trocar in the right hand, place the thenar on top of the cannula, and pinch the cannula with the index and middle fingers to protect the operating area.

• Puncture Action: Keep the Trocar perpendicular to the skin, avoid angling, and ensure the Trocar is operated along the central axis. Deviating from the central axis may damage the common iliac vessels. Use towel clamps to lift the abdominal wall skin on both sides, and advance the Trocar evenly, slowly, and rotationally into the abdominal cavity. Avoid violent operations. Once a hollow feeling is sensed, remove the core, advance 1-2cm further, connect the insufflation tube, and insert the laparoscope.

Insertion of the Operation Port

After successfully inserting the laparoscope through the observation port, the next step is to insert the operation port. The specific steps are as follows:

• Transillumination Test: Use the laparoscope for transillumination testing to ensure the insertion positions of the operation port and auxiliary ports avoid abdominal wall blood vessels and nerves. Confirm the safety of the puncture path through the transillumination test.

  
  

• Insertion Principle: The operation and auxiliary ports should be as close as possible to both sides of the observation port. According to the principle of equidivision of the triangle, the angle between the operating arms is ideally a right angle. The axis of the observation mirror exactly bisects the angle between the two operating arms, facilitating direction control on the 2D image, thus improving operation accuracy.

Complications and Management of Surgical Trocar Insertion

Vascular or Organ Injury

Inserting the surgical trocar can cause vascular or organ injury due to the "blind puncture" of the observation port. Methods to handle such complications are similar to those in establishing pneumoperitoneum:

• Preventive Measures

Conduct a thorough anatomical assessment before puncture and use transillumination tests to check the puncture path, ensuring important structures are avoided.

• Management Measures

In case of injury, immediate repair should be performed, including vascular ligation or organ suturing, with conversion to open surgery if necessary.

Abdominal Wall Vascular Injury

Abdominal wall vascular injury is usually caused by puncture directions not perpendicular to the abdominal wall or vascular injury due to thick abdominal walls. Specific management measures include:

• Preventive Measures

Ensure the puncture direction is perpendicular to the abdominal wall and use transillumination tests to avoid abdominal wall blood vessels. For patients with a thick abdominal wall, be particularly familiar with the course of abdominal wall blood vessels, especially the course of the abdominal wall arteries.

• Management Measures

External Compression: In case of bleeding, direct external pressure can be applied for at least 5 minutes. Avoid frequent lifting to prevent exacerbating the bleeding.

Identify Bleeding Point: If external compression cannot stop the bleeding, the surgical trocar should be removed, the bleeding point identified, and hemostasis performed by ligation, suturing, or electrocautery techniques.

Internal Compression: A Foley catheter can be inserted into the abdominal cavity through the puncture hole. After inflating, the catheter is pulled tightly outward for compression hemostasis.

Abdominal Wall Suturing: Hemostasis is performed by suturing the abdominal wall at the bleeding artery, usually guided by a laparoscope, using an abdominal wall stapler.