Thinking of Buying...Trocars

Laparoscopic surgery depends on access. Unlike open surgery, where hands are able to reach the field, laparoscopy demands specialized instruments to operate inside the challenging environment of the abdominal cavity and, by extension, a way to get there.

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As a result, any purchasing decision you make regarding trocars should be based, first and foremost, on the types of laparoscopic cases that your facility hosts and the range of instruments that your surgeons employ in them. To a large degree, surgeon preference will drive the decision, since a trocar that doesn't suit the task at hand or isn't compatible with the instruments needed will bring surgery to a halt. Here are some of the considerations that you and your surgeons will be taking into account in your selection.

• Method of access. There's more than 1 way to access the abdominal cavity, and trocars designed to facilitate each method. Do your surgeons use bladed, bladeless or blunt trocars? Users may still debate which type is quicker and more efficient in its entry. But the safety-minded firmly back blunt trocars, whose open technique (making an incision and separating the fascia for insertion) sidesteps the risks of inadvertent internal injuries and their resulting complications that are posed by traditional sharp-tipped trocars' direct (and blind) entry. Blunt trocars can also prevent sharps injuries during staff handling. Note well, however, that without caution the force exerted during insertion can still cause injury.
• Design adaptations. The optical trocar steps up the safety aspect of the bladeless type by accommodating a laparoscopic camera in its chamber. This allows surgeons a view on the trocar's progress as they twist it in, to further prevent the accidental puncturing of organs or blood vessels. Dilating trocars, also designed for safety, radially expand as they're inserted (and retract as they're removed) to spread fascial tissue, not slice through it. This feature has the added benefit of leaving a smaller port at the procedure's end, with less risk of herniated tissue, though they can be more difficult to deploy.
• Size and number. The narrowing of laparoscopic instruments has reduced the diameter and, consequently, the impact of trocars on tissue. They now range from about 15mm down to the "needlescopic" 2mm, though 5mm to 10mm are still the most commonly used. While surgeons need no longer use a larger size than is necessary to accommodate a camera or other instrument (since many instruments except for staplers can now fit through a 5mm port), narrower ports have created newer issues, namely needlescopic trocars' inability to carry sufficient insufflation flow or the possibility that they'll bend or break when twisted in the abdomens of obese patients. So a procedure may require several trocars in several sizes to support a camera, instruments, insufflation, mesh delivery and other needs. (This is where single-incision laparoscopic surgery and its multiple-port access devices have been innovating the field.)
• Features for fit. While some ports are designed with a low-profile shape, allowing their placement closer together with more degrees of working space and without impeding instrument access or handling, others are longer in order to facilitate access through the wider abdominal walls of larger patients. Some are designed with ridged cannulas, inflatable seals and other anchoring devices to prevent them from dislodging mid-procedure — a frustrating interruption in any laparoscopic case. And some provide open access for convenient instrument insertion or anti-smudge advances to prevent delays caused by the repeated need to clean off the camera lens.

Aesculap
Reusable Trocar System
(800) 282-9000
www.aesculapusa.com
List price: not disclosed
FYI: This lightweight, low-profile and ergonomically designed reusable trocar system provides surgical facilities with a money-saving, waste-reducing alternative to disposable trocars, says Aesculap. The entirely modular system allows simple and effective cleaning after every case. It's available in 3.5mm, 5mm, 10mm and 12mm diameters, each one color-coded for easy identification by surgical personnel of compatible components.

Applied Medical
5mm Kii Balloon Blunt Tip System
(800) 282-2212
www.appliedmedical.com
List price: $55.21 each
FYI: The Kii Balloon Blunt Tip Trocar's soft gel cone bolster conforms to the abdominal wall, allowing for greater instrument articulation while maintaining the pneumoperitoneum. The latex-free, non-fragmenting balloon ensures stability and visibility throughout lengthy procedures by minimizing trocar intrusion into the abdomen, while suture ties assist in instrument reach and port site closures. The obturator accommodates a 5mm scope, enabling placement under direct visualization.

Ethicon Endo-Surgery
Endopath Xcel Trocar
(800) USE-ENDO
www.endopathxcel.com
List price: not disclosed
FYI: The Endopath Xcel Trocar features Optiview technology, which prevents the smudging of laparoscopic lenses when they're reinserted into the trocar. During insertion and removal, the trocar wipes fluid from scopes' shafts and wicks it into an absorbent ring to keep lenses clean. Compatible with instruments from 4.7mm to 12.9mm, the bladeless trocar includes integrated threads for stability, a low-profile design for instrument access and a secure seal to maintain insufflation.

SurgiQuest
AirSeal Trocar System
(203) 799-2400
www.surgiquest.com
List price: $97.92 each
FYI: Like many other conventional trocars, the AirSeal features a bladeless optical tip for visualized entry and integrated threads for abdominal wall stability. Unlike other trocars, however, it also incorporates a valveless cannula, which enables friction-free instrument insertion and withdrawal, smudge-free scope insertion, easy mesh and suture delivery and intact specimen removal. An air curtain provides a stable pneumoperitoneum and allows continuous smoke evacuation throughout laparoscopic and robotic procedures.

If you want to learn more, please visit our website What Is Trocar Used for.

Teleflex
Taut Adapt Balloon Open Access Port
(866) 246-6990
www.teleflex.com
List price: $76 to $100 each
FYI: Designed to replace metal- or plastic-bladed trocars, and to reduce the risks of injury and complication they pose, the Adapt port eliminates the blade in favor of a tip that passes through tissue without cutting. The result is open laparoscopic access with a smaller wound than most bladed trocars. Its low-profile housing maximizes access to the surgical site, while a unique seal system resists tissue tearing and minimizes instrument drag without the use of camera-lens-smudging lubricant.

Alveolar bone grafting in cleft patients

John Dudley Langdon, Mohan Francis Patel, Robert Andrew Ord, Peter Brennan in Operative Oral and Maxillofacial Surgery, 2017

In patients older than 2 years of age, cancellous bone can be harvested from the iliac crest with the help of a trocar. The use of a trocar reduces the invasion of the donor site procedure and also reduces the pain at the donor site. However, the core graft obtained is compressed which can be a disadvantage in contrast to cancellous bone chips harvested openly from the iliac crest which can be packed into every nook and cranny of the alveolar defect and compressed into it. The iliac crest itself can be raised as an osteoplastic flap and cancellous bone chips harvested from inside the ilium and the lid replaced. The anterior crest is our site of choice because it provides adequate cancellous bone and can be harvested simultaneously to the cleft procedure. The keys to prevention of post-operative morbidity at this site are the avoidance of any muscle stripping in particular on the lateral aspect of the crest, as well as the use of a cannula inserted into the wound at surgery after the lid has been replaced and used to infuse long acting local analgesia on a few occasions during the first 24 hours after surgery.

Abdominal surgery: General principles of access

Mark Davenport, James D. Geiger, Nigel J. Hall, Steven S. Rothenberg in Operative Pediatric Surgery, 2020

Additional trocar placement methods depend upon the type of trocar being used. Reusable metal trocars are frequently use for pediatric laparoscopic procedures, particularly in infants and young children. These trocars come equipped with both sharp (cutting) and blunt tip obturators. A sharp-tip obturator requires a skin incision that approximates the diameter size of the trocar. The sharp obturator is then used to cut through the remaining musculofascial planes, as the trocar is advanced into position. The sharp tip of the obturator should be visualized at all times, to minimize the risk of inadvertent visceral injuries. A blunt-tip obturator requires a full-thickness incision to facilitate passage of the port. Under direct laparoscopic vision, an 11-blade scalpel is used to cut full-thickness through the skin and musculofascial planes. A fine dissecting instrument is then passed through the incision and a gentle spread opens up the incision to allow passage of the blunt obturator and trocar. Reusable metal trocars generally will require some type of suture to secure the trocar to the skin.

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