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Of all the
tools available to the modern surgeon, none is as completely invaluable to
minimally invasive surgery as is the trocar. An apparently innocuous device consisting
of a cannula and pointed obturator, the trocar is the doorway to the inner
geography of the human body. In laparoscopic, thoracoscopic, or robotically
assisted procedures, the device provides safe access with low invasiveness to
procedures as well as to tissue trauma.
Although most important to optimal performance, the trocar is overlooked about other tools. Indeed, its design, its use, its safety features, and its complications all play a rather blatant role in optimal surgery. It is aimed at thoroughly describing history, design evolution, types, applications, innovation, and clinical features of trocars to acquire advanced information about when and how to utilize this invaluable surgical tool.
• The origin
of the name trocar is from French trocart, from "trois" (three) and
"carre" (side), for the original three-sided, pyramidal tip design.
• Originally a fluid or gas drainage device of the body cavities, it became a
general access device by the 20th century.
• As with the growing popularity of laparoscopy during the 1980s and 1990s, trocars were needed in procedures involving minimal cutting and viewing from within the body.
Trocars are
typically three fundamental elements:
→ShortestREMSin the body as a
passageway.
→Typically made from stainless steel
or good-quality polymers.
→Some come with valves against gas
leakage during insufflation.
→For
penetration of the abdominal wall.
→Can be
bladed, conical, or shielded depending on surgical need and protection.
→Allow instruments to travel through without loss of gas for insufflation.
universal (will accommodate varying instrument diameters) or fixed diameters.
Contains a metallic blade.
Allows easy
entry but with an increased risk of organ or vascular injury.
Uses blunt
or conical obturators.
Forces
layers of tissue ahead without cutting them.
Integrated
camera to offer intra-abdominal visualization during entry in real time.
Reduces
blind entry risk.
Contains retractable safety features.
The blade is
protected by the shield during entry into the peritoneum.
•Ranges
typically are 3 mm to 15 mm.
•Small
robotically assisted and pediatric trocars.
•Large ones
are appropriate for staplers, specimen collection bags, or suction devices.
Used once,
pre-sterilized.
Does not
cause cross-contamination.
Cost-effective when high volumes are being done.
No requiring meticulous reprocessing and maintenance.
Trocars are
the workhorse in each subspecialty of surgery. Placement and utilization
dictate structure and timing of procedure.
•Appendicectomy,
cholecystectomy, hernioplasty.
•Trocars
offer portals for camera and instrumentation manipulation.
•Hysterectomy,
oophorectomy, myomectomy.
•Used to
image pelvic organs and control bleeding.
•Prostatectomy,
nephrectomy.
•Optic
trocars obviate the risk of bowel and vascular structures.
•Facilitates
minimally invasive lung biopsy and wedge resections.
•Insertion
considers the mechanics of lung deflation and inflation.
•Specialized trocars are robotic ports.
•Accurate positioning to achieve triangulation.
Trocars are
inserted carefully with a demand for anatomical skill and operative finesse.
•Blind
placement of the needle to establish pneumoperitoneum.
•Secondary
insertion of the trocar after abdominal cavity distension.
•Direct
visualisation of a small wound.
•Suture-backed
trocar with minimized blind entry.
•A laparoscope is directed through the trocar to visually assist.
•Best in patients with prior history of abdominal surgery or adhesions.
Safe use of the trocar depends on awareness of many anatomical as well as technical
considerations:
Most likely to cause a vessel tear would be with a sharp angle.
Perpendicular placement is standard in the area of the umbilicus.
Avoid large
vessels like the aorta and the inferior epigastric artery.
Position
yourself laterally to the rectus abdominis when inserting lower quadrant
trocars.
Excessive force leads to deep penetration injuries.
Surgeons feel the planes of resistance as they push deeper.
Convenient
as they are, trocars are linked to complications in abuse:
Aorta or
iliac artery puncture with blind technique.
Bleeding may
be occult because of insufflation.
Perforation
of omentum, bladder, or bowel.
Risk is
multiplied by previous surgery because of adhesions.
Fascial
defects at the port sites lead to the development of a hernia.
Closure of
≥10 mm trocar ports is standard to avoid this.
Trapping of
gas in an arterial vessel is the pathophysiology of cardiac arrest.
An extremely
rare, but potentially lethal, emergency.
Rare, but inadequate antisepsis or technique can lead to infection at the port site.
New trocar
sets have been recently augmented with new technologies intended to render the
procedure more effective and safer:
Reduce
trauma by expanding rather than cutting tissue.
Come with
less postoperative pain.
Threaded
sleeves or implanted balloons secure trocars without fixation sutures.
Used with abdominal wall lifters.
Benefits for cardiopulmonary compromised patients.
Proper
trocar placement maximizes surgeon comfort and procedure effectiveness:
The instrument and scope should be in a triangle position for optimal reach.
Incorrectly
shaped angles restrict control and promote fatigue.
Trocar
bunching results in external handle collision.
Port
planning spacing should be maintained when placing ports.
Should
provide retraction without interfering with the chief surgeon's movements.
Trocars will
have to be inserted for patient comorbidities and size:
LENG/s small ports (3–5 mm).
Minimal cardiopulmonary compromise to prevent.
• Bariatric
Surgery:
Longer trocar shafts to traverse thicker abdominal walls.
Need to seal ports against slippage with thick subcutaneous tissue.
Proper use
of trocars is an essential skill for surgical residents:
• Box
Trainers:
Facilitate
port practice and instrument movement.
• Virtual
Simulators:
Teach safe
entry methods and interaction with tissue.
• Cadaveric
Labs:
Provide
authentic anatomical feedback.
The
widespread application of disposable trocars has environmental effects:
Contributes
to the landfill burden of the operating suite.
Single-use
steel and plastic refuse.
Less
expensive long-term for reusable trocars.
Involves
initial capital investment in sterilizers.
Trocars will
become more advanced with robotic and minimally invasive surgery technologies:
• Smart
Trocars:
Sensor-activated
for the detection of tissue layers and vessels.
•
Embedded Energy Sources:
Dual-purpose
cautery trocars.
•
Magnetic Access Ports:
No actuating cannulas are in use in the magnetic field direction of the instruments.
Anything but
a passage, the trocar is an integral part of today's surgery. As an access
route by which surgery must be performed, it requires a high-order understanding
of design nuance, tissue interface, and surgeon competence. The correct type must
be selected, placed carefully, and danger factors minimized to attain
success in the process and safety to the patient.
From its earliest origins to current adaptations, the trocar represents the principles of entry, control, and minimal invasiveness present in operative surgery. Whether a rookie surgical trainee or an old vet, one must become proficient in the science and art of trocar use to survive operative care.