Safety Control in Trocar Use: How To Avoid Vascular And Visceral Injury Complications

https://www.cookmedical.com/products/ir_dtn_webds/

The incidence of trocar-related complications is approximately 0.1%–0.5%, but the mortality rate of major vascular injury can reach 30%–50%. Therefore, "safe use" is the hottest topic in the industry. Mastering injury mechanisms and preventive measures is a prerequisite for every laparoscopic surgery.

Main Types of Complications:​ ① Bleeding from the inferior epigastric artery or deep circumflex iliac artery (puncture site too medial or too low); ② Laceration of the abdominal aorta/inferior vena cava/common iliac artery (first port vertical blind puncture too deep, thin abdominal wall in emaciated patients); ③ Bowel/bladder perforation (blind puncture in patients with a history of abdominal surgery and adhesions, or intestinal obstruction with abdominal distension); ④ Subcutaneous emphysema/hypercapnia (partial trocar dislodgement or poor sealing); ⑤ Incisional hernia (failure to suture fascia at ≥10 mm ports).

Key Technical Points for Safe Use:

• Lift the Abdominal Wall:​ During the first port puncture, forcefully lift the skin and fascia with towel clamps to maximize the distance between the anterior abdominal wall and the posterior peritoneum and great vessels-this must be executed especially for emaciated patients.
• Depth-Limiting Finger Protection:​ When holding the trocar, extend the thumb/index finger to press against the proximal end of the cannula to limit how far the obturator protrudes into the abdominal cavity. Stop immediately upon sensing the loss of resistance to prevent the trocar tip from penetrating too deeply and injuring the abdominal aorta behind the peritoneum.
• Rotate and Advance Instead of Violent Stabbing:​ Use wrist rotation combined with moderate downward pressure. When encountering fascial resistance, apply slightly more force-never make sudden thrusts. For obese patients with tough abdominal walls, penetration can be done in two stages-first through the fascia, then adjust the angle to go through the peritoneum.
• Prefer Safety/Visual Trocars:​ Trocars with spring-retractable shields automatically deploy a blunt tip to cover the sharp point the instant resistance disappears upon penetrating the peritoneum. Optical trocars allow direct visualization of the entire puncture process. Both significantly reduce visceral injury and are recommended for high-risk patients or teaching hospitals.
• Hasson Open Method (Mini-laparotomy):​ For patients with multiple previous abdominal surgeries, large abdominal hernias, mid-to-late pregnancy, or suspected extensive adhesions, abandon blind puncture-incise layer by layer down to the peritoneum, open the peritoneum under direct vision, insert a Hasson-type trocar, and fix it with sutures to establish pneumoperitoneum. This is the safest alternative.
• Add Lateral Ports Under Direct Vision:​ The second and third trocars must be placed under laparoscopic illumination and "transillumination" to select avascular areas. Rotate slowly, constantly observing whether the needle tip is pressing against bowel before fully penetrating.

If active bleeding from the cannula, spillage of intestinal contents, or sudden intraoperative hypotension occurs after trocar insertion, immediately assess the nature of the injury-minor abdominal wall bleeding can be managed with electrocautery or compression after sheath removal; suspected major vascular or bowel injury requires prompt conversion to open surgery. Systematic safety training is the fundamental way to minimize trocar use risks.