Comparative Study of Veress Needle and Visiport in Creating Pneumoperitoneum in Laparoscopic Surgery

INTRODUCTION

In minimal access surgery, the technique of first entry in the human body with the telescope and instruments is called the access technique.³ It is important to know that 20% of laparoscopic complications are caused at the time of initial access. Developing access skill is one of the important achievements for the surgeons practicing minimal access surgery. First entry access in laparoscopy is of two types: closed and open access.

In the closed technique, a Veress needle is commonly used by minimal access surgeons worldwide but it is a blind technique. Nowadays, an entry technique with optical trocars is used for visual guided access into the abdomen. Here we are analyzing the merits and demerits of two entry techniques and the incidence of complications in both techniques. Comparison is between the blind technique by using the Veress needle and the undervision technique by using Visiport.

MATERIALS AND METHODS

OBSERVATION AND RESULTS

The average age of the subjects in the Veress needle group was 33.1 ± 12.8 years and that of the Visiport group was 35.4 ± 10.6 years. Both group were comparable according to age.

36.0% of the Veress needle group and 60.7% of the Visiport group were female.

100.0% of the Veress needle group and 98.7% of the Visiport group have no vascular injury.

98.0% of the Veress needle group and 99.3% of the Visiport group have no visceral injury.

96.7% of the Veress needle group and 100% of the Visiport group have no preparational insufflation.

0.7% of the Veress needle group and none of the Visiport group have failure of technique.

0.7% of the Veress needle group and 0.7% of the Visiport group have port site.

Average time required to induce pneumoperitoneum among the Veress needle group was 3.1 ± 0.7 minutes and that of the Visiport group was 2.1 ± 0.4 minutes. The observed difference was statistically significant (p < 0.05). Time required to induce pneumoperitoneum among the Veress needle group was significantly greater than the Visiport group.

Average duration of hospital stay among the Veress needle group was 83.5 ± 36.1 hours and that of the Visiport group was 62.8 ± 34.3 hours. The observed difference was statistically significant (p < 0.05). Duration of hospital stay among the Veress needle group was significantly greater than the Visiport group.

Average duration of surgery among the Veress needle group was 56.7 ± 17.2 minutes and that of the Visiport group was 59.6 ± 26.0 minutes. The observed difference was not statistically significant (p %3E; 0.05). Duration of surgery among the Veress needle group was significantly greater than the Visiport group.

DISCUSSION

Ever since the first laparoscopy performed by Jacobeus of Sweden in 1925, different techniques, technologists, and evidence-based guidelines have been introduced to eliminate the risk associated with laparoscopic entry, whatever be the method adopted for first port entry into the abdomen.⁴

From studies, it has been proved that in 50% of laparoscopic surgeries, major complications occur prior to the commencement of surgery and a delay in diagnosis of visceral injury will lead to increased morbidity and mortality.⁴

Regardless of the methods used, gaining access to the abdomen and initiating pneumoperitoneum remains a source of morbidity and mortality with most common complications being visceral and vascular injuries. Over the last three decades, rapid advances have made laparoscopic surgery a well-established entity. However, laparoscopy being relatively new, there are controversies regarding the best method of creating pneumoperitoneum.⁵

To establish pneumoperitoneum, access to the peritoneal cavity can be gained through different ways that include Veress/trocar (blind technique), the open technique (Hassons method), direct trocar insertion, disposable shielded trocars, radially expanding trocars, and the visual entry system.⁶ Related to this present study, we have reviewed and compared 37 similar studies related to different access techniques in creating pneumoperitoneum in various laparoscopic surgeries.

Laparoscopic surgery will only continue to expand in terms of procedures, which can be performed using technology. Regardless of the procedure, the first step being induction of pneumoperitoneum; all surgeons need to achieve competence in the technique.⁷

In our study, 150 cases of Veress needle and 150 cases of Visiport were compared and analyzed. This included appendicectomy, cholecystectomy, laparoscopic inguinal and ventral hernia repair, laparoscopic sleeve gastrectomy, laparoscopic mini gastric bypass and diagnostic laparoscopy, and laparoscopic closure of perforated duodenal ulcer.

In this study, there were two vascular injuries, both of them happened to the same surgeon who created pneumoperitoneum through the optiview trocar while attempting to do mini gastric bypass. Those two cases were converted to open and vascular surgeon was called in and repaired. This happened to the surgeon who was inexperienced with the technique. The rest of all the Visiport cases were safe and faster in creating pneumoperitoneum during the surgery; there was no statistical significance on comparison of both the techniques. There were three omental injuries with the Veress needle (2%). There was one omental tear among the Visiport group (0.7%). There were five cases of preperitoneal insufflation among the Veress group (3.3%); no preperitoneal insufflation was noted in the Visiport group. There was one failure of technique in the Veress group (0.7%). No failure of technique was noted in the Visiport group. There was one port site hematoma in the Veress needle group (0.07%) and four cases of port site hematoma in the Visiport group (2.7%).

Time required to induce pneumoperitoneum using Veress needle was 3.1 ± 0.7 minutes and that of Visiport was 2.1 ± 0.4 minutes. p value is 0.001. The observed difference was statistically significant. Time required to induce pneumoperitoneum among the Veress needle group was significantly greater than the Visiport group.

Duration of surgery: average duration of surgery among Veress needle was 56 ± 17.2 minutes and that of Visiport was 60 ± 25.6 minutes. Observed difference was not statistically significant (p > 0.05).

Duration of surgery among Veress needle was significantly greater than Visiport.

In the 5-year study of Lapham et al. from 2001 to 2006 using Visiport, 1,623 out of 1,626 cases were successful in inducing pneumoperitoneum.⁸ There were three (0.2%) retroperitoneal vascular injuries. In the study of Dunne et al., there was visceral injury with the Veress needle (0.1%) but there was no vascular injury with the Veress needle technique.⁷

In Struge et al.’s 4-year study, there were only (0.3%) complications with Visiport in creating pneumoperitoneum.

In Berch et al.’s 4-year study in optical trocar, there were no trocar-related bowel or vascular injuries with Visiport.

DEMOGRAPHIC DATA OF PATIENTS AND RESULTS

COMPLICATIONS

CONCLUSION

In this study of comparison, both techniques seemed to have been associated with their own complications. But Visiport is a safe and faster method of creating pneumoperitoneum, though there was statistically insignificant major vascular injury. It happened with an inexperienced surgeon. There is no strong evidence of superiority of one technique over the other.

Even though both techniques are associated with potential danger of perforating injuries on inserting the first trocar, the undervision technique allows early recognition of injuries and immediate repair. No single technique and instrument has been accepted as the “gold standard” for creating pneumoperitoneum in laparoscopic surgery.^9,10

Good surgical skills and proper evaluation of the patient are important for safe access in minimal access surgery.¹¹ The surgeon should be competent in both the techniques. Regardless of the technique that has been chosen, one must abide by the safe general principles of surgery, be meticulous, take your own time, and be highly alert for appearance of signs of injury.

With further research and development, an optimal form of the laparoscopic entry technique for creating and maintaining pneumoperitoneum in laparoscopic surgery needs to be designed.

The surgeons should be familiar with both the techniques and adapt their entry technique to individual patient’s circumstances.

REFERENCES

1. Mishra RK. Textbook of practical laparoscopic surgery. 2009. pp. 67–94.

2. Opilka MN, Lorenc Z, Starzewski J. Laparoscopic access techniques. J Silesian Med Univ. Poland,ch. 6.

3. Akbar M, Khan IA, Naveed D, et al. Comparison of closed and open methods of pneumoperitoneum in laparoscopic cholecystectomy. J Ayub Med Coll 2008;20(2):85–89.

4. Kumar R, Hastir A, Bandlish MK, et al. Pneumoperitoneum by direct trocar insertion: safe laparoscopic access. J Evol Med Dent Sci 2015;4(15):2432–2437. DOI: 10.14260/jemds/2015/352.

5. Toro A, Mannino M, Cappello G, et al. Comparison of two entry methods for laparoscopic port entry: technical point of view. Diagn Ther Endosc 2012;2012: 305428. DOI: 10.1155/2012/305428.

6. Vilos GA, Teernamian A, Dempster J, et al. Laparoscopic entry: a review of techniques, technologies and complications. J Obstet Gynaecol Can 2007;29(5):433–465. DOI: 10.1016/S1701-2163(16)35496-2.

7. Dunne N, Booth MI, Dehn TCB, et al. Establishing pneumoperitoneum: Veress or Hasson? The debate continues. Ann R Coll Surg Engl 2011;93(1):22–24. DOI: 10.1308/003588411X12851639107557.

8. Lapham T, Tarnoff M, Kim J, et al. Five-year experience with a bladed optical trocar in an uninsufflated abdomen in bariatric surgery. J Tufts-N Engl Med Cent 2007.

9. Berch BR, Torquati A, Lutfi RE, et al. Experience with the optical access trocar for safe and rapid entry in the performance of laparoscopic gastric bypass. Surg Endosc 2006;20(8):1238–1241. DOI: 10.1007/s00464-005-0188-4.

10. Access to the Abdomen, Manual of Strategic Decision Making, SAGES Manualpage 1–3.

11. Hashizume M, Sugimachi K. Needle and trocar injury during laparoscopic surgery in Japan. Surg Endosc 1997;11(12):1198–1201. DOI: 10.1007/s004649900568.