Friday, March 29, 2013

Direct trocar insertion in Laparoscopic cholecystectomy

The direct trocar insertion technique (DTI) for the creation of pneumoperitoneum has been described as an alternative to open and Veress needle (VN) techniques. 

After adequate patient relaxation, a 10-mm skin incision is made at the level of the umbilicus to allow the introduction of a 5-mm trocar . With the patient in a supine position, the abdominal wall is elevated by grabbing the portion of the abdominal wall around the proposed site of the entry of the trocar. Care is taken to make the incision length slightly greater than the diameter of the trocar, and all layers of skin must be cut down to the peritoneum through the entire length of the umbilical incision. These simple manoeuvres allow easier introduction of the trocar with minimal force and maximal control. 

In contrast to Veress needle insertion, where one can feel the penetration through the fascia and peritoneum separately, a distinct and single “pop” signifies that the trocar has pierced the fascia and peritoneum. Once a 5 mm trocar is placed and pneumoperitoneum is established we change the trocar to 10 mm trocar.

The contra-indication that we follow is previous abdominal surgery as adhesions will make DTI risky.In that case we follow open technique.

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