Trocar Injuries in Laparoscopy: Techniques, Tools, and Means for Prevention. A Systematic Review of the Literature.

Trocar injuries are a possible cause for severe morbidity and mortality when performing laparoscopic surgery. This systematic review investigates the differences in the incidence of complications depending on the method of entry. A meta-analysis of the medical literature was performed. Search results were limited to clinical trials and the following languages: English, French, German, or Dutch. All results that compared the Veress, Hasson, and direct entry technique or compared sharp, blunt, and radially expanding trocars (RET) were included (n = 19). Studies involving pediatric and pregnant patients were excluded. When comparing the Veress needle to direct trocar insertion (DTI), pooled analysis showed a borderline significant reduction for major complications (p = 0.04) based on five events in 2 RCT's (n = 978) and a reduction in minor complications (p < 0.001) in favor of DTI. RCT's comparing the Hasson and Veress techniques showed no significant reduction in major complications (p = 0.17), but the Hasson technique showed significantly less minor complications (p = 0.01) and failed entries (p = 0.002). CO2 leakage was far more common when using the Hasson technique (p < 0.001). Our search method did not reveal any studies comparing the Hasson technique to DTI. When comparing bladed to RET, three studies (n = 408) showed less minor complications when using a RET (p = 0.003) and a qualitative analysis showed a trend toward pain reduction when using RET. This meta-analysis concludes that there are less minor complications and failed attempts when using the Hasson or direct entry technique when compared to the Veress method, but there is limited evidence regarding major complications. RET reduce minor vascular complications when compared to bladed trocars.