Single center bariatric surgery experience with an optical access trocar in an uninsufflated abdomen and a critical review of minimally invasive peritoneal access techniques

Background:The Visiport is a widely-used bladed optical access device that provides convenient, safe peritoneal entry. We use this device as our primary method of entry and insufflation in bariatric surgery and provide an overview of our cumulative experience. In addition, we provide a comprehensive analysis of the literature to analyze all methods of peritoneal access in minimally invasive surgery. Clinical research methods: From 7/30/01 to 8/31/07, laparoscopic access for all bariatric surgery at a single center was gained using the 5-12 mm Visiport device without prior insufflation. Three attending surgeons and six laparoscopic bariatric fellows used the device for a total of 2,036 cases, including 1,533 laparoscopic gastric bypass procedures (LGBP) and 503 laparoscopic adjustable gastric band placements (LAGB). All LAGB had an off-midline Visiport insertion. All LGBP procedures entailed midline placement with the exception of the first 50 cases in which an off-midline approach was utilized.
Literature search methods: In May 2007, the MEDLINE database from 1950 to June 2007 was searched for trials employing optical trocars. The key words and subject terms used were “optical trocars,” “Visiport,” “Optiview,” “direct trocar,” and “direct trocar injury.” All publications as well as translated articles were included. Relevant bibliographies pertaining to optical trocars were also searched for additional references. All the studies were categorized according to the level of evidence based on the Levels of Evidence and Grades of Recommendation supplied by the Oxford Centre of Evidence-Based Medicine.
Clinical results: Three injuries occurred (0.15%). Two required conversion to laparotomy and vascular repair, one was managed conservatively. All injuries occurred with placement of the device off the midline. No injuries occurred with midline placement. There were no mortalities associated with the injuries. Literature review: Our review of the literature reveals only 2 randomized prospective trials that have analyzed various methods of peritoneal access. The remainder of the literature consists of retrospective studies and case reports. Through this review, a total of 20,989 cases have been reported on. The incidence of vascular complications was 0.07% while visceral complications occurred in 0.10%. Conclusion: Use of the Visiport without prior insufflation continues to be safe in the morbidly obese population. Our literature review validates that this method is as safe as any other method of entry and insufflation.

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Program Number: P020

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