open laparoscopy as a method of access in laparoscopic surgery

q1999 Blackwell Science Ltd Gynaecological Endoscopy 1999 8, 353–362 353

OPEN LAPAROSCOPY

Open laparoscopy as a method of access in laparoscopicsurgery

Harrith M. HassonLouis A. Weiss Memorial Hospital, Chicago, USA

ABSTRACT

Objective To describe the technique of open laparoscopy and compare therates of its complications to those of closed laparoscopy.Design Medline search, review of the literature and the author’s experi-ence.Results For open laparoscopy, the rate of umbilical infection in 15 622 caseswas 0.4%, that of bowel injury in 20 335 cases was 0.1%, based on prospec-tive, retrospective studies and a mail survey. Prospective and retrospectivestudies dealing with closed laparoscopy reported the following complicationrates: umbilical infection: 1% of 4377 cases; vascular injury: 0.2% of 94 863cases: visceral injury: 0.2% of 91 272 cases. The operating time for open andclosed laparoscopy were substantially similar.Conclusion Open laparoscopy is advocated as the preferred method ofaccess for laparoscopic surgery.

Keywords

access techniques, complications,laparoscopy, open laparoscopy.

CorrespondenceH. M. Hasson, Louis A. Weiss MemorialHospital, 4640 N. Marine Drive, Suite 6150,Chicago, Illinois 60640, USA.

Accepted for publication 25 June 1999

INTRODUCTION

The use of laparoscopy as a preferred surgical approachhas recently expanded dramatically in the fields ofgynaecology, general surgery and urology. Surprisinglyhowever, in spite of the increasingly complex nature ofsurgical procedures performed through the laparo-scope, the relatively simple step of gaining access to theabdominal cavity has remained the dominant problem. Itis generally agreed that most major complications occuras a result of development of a pneumoperitoneum andthe blind insertion of the first trocar, not because of thelaparoscopic operation that follows1–5 (Table 1). Amajor complication is one resulting in death or furthersurgery by laparotomy,1 or laparoscopy.3

Open laparoscopy is a surgical procedure that utilizesa small abdominal incision to advance a blunt-tippedlaparoscopy cannula into the peritoneal cavity, undercontinuous visual control. This method does notrequire a needle to establish the pneumoperitoneumor a sharp trocar to lead the laparoscopy cannula intothe abdominal cavity. I developed this technique because

I was uncomfortable about inserting needles and sharptrocars blindly into the abdomen to gain access.6,7

METHODS

Basic principles

After a period of trial and error, I realized that safe andeffective performance of open laparoscopy is groundedon the following basic principles:1 Entering the abdomen under visual control, elevating thefascia and deeper layers during incision. This principle is anessential aspect of open laparoscopy. Entering theabdomen with a knife without proper dissection andfascial elevation carries considerable risk. For instance,it is reported that the superior mesenteric vein of apatient undergoing an intended closed laparoscopyprocedure was inadvertently cut during the initial sub-umbilical skin incision.8

2 After confirming entry, insufflating gas into the abdomendirectly through the cannula with the blunt obturator in place.This eliminates the possibility of inappropriate gasinsufflation and shortens the time needed to establish

354 H.M. HASSON

an adequate pneumoperitoneum. Withdrawing theblunt trocar only after the abdomen is partially dis-tended avoids the possibility of injury to internal struc-tures by the sharp edge of the bare cannula.3 Blocking the escape of gas from the abdomen. Partial orcomplete loss of the pneumoperitoneum through gasleaks exposes the surgeon to the risk of inadequatevisualization. Using my cannula design and method ofpulling the fascial edges against the cone of the cannulawith fixed sutures is one effective way of maintainingthe gas bubble.4 Closing the fascial defect properly at the end of the procedure.This essential step minimizes the possibility of post-operative herniation.

Instruments

Standard surgical instruments needed for openlaparoscopy include two Allis clamps, a knife withsmall blade, scissors, tissue forceps with teeth, needleholder, two Kocher clamps and two small haemostats.In addition, narrow S-shaped retractors are used toexpose the small operative field. Standard laparoscopyinstruments are used with the exception of the firstcannula. The reusable open laparoscopy cannula isfitted with a cone-shaped sleeve which moves freelybut can be locked in any position along the cannula’sshaft. The cone is sealed by a rubber cap. Sutureholders are mounted near the proximal end of thecannula. A blunt obturator replaces the sharp trocar.Currently, several companies offer disposable andreusable blunt-tipped open laparoscopy cannulas with

suture holders mounted on the cone or with a distalballoon.

Technique

The technical difficulties of open laparoscopy arerelated to the small size of the operative field and tothe strength of the abdominal wall. The procedure ismost difficult in nulliparous patients with excellentabdominal supports and easiest in multiparous patientswith weak supports. A history of previous abdominalsurgery merits careful attention to dissection techniqueto minimize the possibility of bowel injury. Markedobesity per se has no significant effect on difficultybecause of the unique anatomical characteristics of theumbilical region.9 The technique of open laparoscopydescribed in 19747 has been updated as described inthe current text.

When satisfactory anaesthesia has been achieved, thesurgeon applies two Allis clamps on the lateral bordersof the umbilicus and makes a vertical midline skinincision of 1–2.5 cm, starting at the lower umbilicalmargin and extending inferiorly. Vertical incisions inthis area result in scars which are more cosmetic as theyare aligned with the lines of Langer, as opposed totransverse incisions which cut across these lines ofnatural skin cleavage.10,11 The incision should be longenough to adequately expose the umbilical window, anatural cleavage located at the lower border of theumbilicus, where the skin is directly attached to thefascia without any intervening subcutaneous adiposetissues regardless of degree of patient obesity.9 The

Gynaecological Endoscopy 1999 8, 353–362 q1999 Blackwell Science Ltd

Table 1 Major laparoscopiccomplications of access and operativeprocedure

Study Major laparoscopic complications

Access-related Procedure-related

Jansen et al.3

Nationwide multicentre studyinvolving 25 764 cases145 major complications 83a (57%) 62 (43%)

Chapron et al.4

Personal series17 major vessel injuries 13b,c (76.5%) 4 (23.5%)

Literature review41 major vessel injuries 34d (82.9%) 7 (17.1%)

a Trocar injuries 13 times more frequent than needle injuries.b Trocar injuries five times more frequent than needle injuries.c More than half (54.5%) of trocar complications associated with disposable

instruments.d Trocar injuries slightly less frequent than needle injuries.

OPEN LAPAROSCOPY AS A METHOD OF ACCESS 355

surgeon repositions the Allis clamps on the incisionaledges, and uses them for retraction and exposure of thedeep fascia (linea alba). Additional exposure may beprovided by applying the curved ends of the S-shapedretractors on the skin edges and retracting the edgeslaterally in the horizontal plane, in a balancedfashion. Greater retraction on one side of the incisionpulls the operative field over to the rectus muscleof that side. Retracting the skin edges upwardsinvariably diminishes exposure and increases technicaldifficulty.

The surgeon directs a strong toothed clamp towardthe upper angle of the incision and grasps the inferiormargin of the umbilical ring, a fibrotic opening in thelinea alba. This is the site where the fascia is fused withthe skin.9 The surgeon lifts and everts the fascia withthis clamp and applies a second clamp below it torealize a secure purchase of the linear alba. The fasciais clearly identified by separating it from surroundingareolar, fibrous and adipose tissue using blunt or sharpdissection. The first clamp is reapplied below thesecond one for an improved grip on the fascia, asneeded. The surgeon incises the clean fascia transver-sely between the clamps while maintaining fascial eleva-tion to separate the abdominal wall from the bowel andomentum. The initial size of incision need not exceed0.5 cm. The fascial gap is then enlarged by means of aspreading haemostat to facilitate placement of suturesinto the fascia and introduction of the laparoscopiccannula into the abdomen. Usually, the peritoneum isentered by the spreading haemostat. Otherwise, the flatend of one S-shaped retractor is pressed against theperitoneum for abdominal entry. The surgeon passes asuture of adequate tensile strength attached to a smallstrong needle through each fascial edge and tags it. TheS-shaped retractor lodged within the incision acts as abackstop to the needle. The second S-shaped retractoris then placed through the fascial gap into the perito-neal cavity, and the abdominal wall is raised with bothretractors to confirm peritoneal entry by viewing thebowel and omentum.

If the abdominal cavity is not yet entered, an openingis created by thrusting a small haemostat against theremaining layers of transversalis fascia and peritoneum.The haemostat is then opened inside the peritonealcavity, one retractor is placed between the open jaws ofthe haemostat, the haemostat is removed and thesecond retractor applied on the other side. In somepatients the transversalis fascia is highly condensed intoa strong layer called Richet’s fascia.12 In this case, thesurgeon lifts Richet’s fascia and attached peritoneum

and incises them carefully between two haemostats. Aseparate incision, using a similar procedure, maybe required for the peritoneum. In all cases, the thinS-shaped retractors are placed into the incisional gapand raised to confirm abdominal entry.

The surgeon prepares the open laparoscopy cannulafor insertion by adjusting and locking its cone in aposition consistent with the individual thickness ofthe abdominal wall. The cannula, with its bluntobturator is then introduced gently between theretractors into the abdominal cavity. The retractorsguide the placement of the cannula and preclude itsimproper placement in the preperitoneal space. Thefascial tag sutures are held firmly upward and pulledinto the suture holders tightly. Gas insufflation isinitiated during this process. The surgeon pressesthe cannula against the abdomen when the fascialsutures are being threaded into the suture holders toprevent the cannula from being accidentally dis-lodged into the preperitoneal space. The suturesanchor the cannula to the abdominal wall and pullthe fascia snugly against the cone to prevent escape ofthe gas and create an airtight seal. Finally, the surgeonwithdraws the blunt obturator, replaces it by thelaparoscope and proceeds as intended.

At the end of the procedure, the surgeon deflates thedistended peritoneal cavity, withdraws the cannula, andcloses the abdominal wall in two layers. The fascial tagsutures are used to approximate the fascia: the surgeonpositions the sutures in parallel alignment, ties a squareknot on one side, tests the knot, pulls the tied sutureagainst the fascia and ties a square knot on the oppositeside. Should one of the knots unravel, the possibility ofumbilical herniation is significantly increased. The skinis approximated loosely.

A paramedian approach to open laparoscopyusing the basic principles of the procedure and theblunt-tipped cannula has been recently described.13

Other operations utilizing similar concepts

Several operations applying similar concepts of abdom-inal entry for laparoscopy have been proposed. Theseprocedures employ a standard laparoscopic cannulaand do not utilize the open laparoscopy cannula. Theauthor had experimented with similar approaches inthe early 1970s. These were abandoned in favour of amore secure method of creating an airtight seal. Themodified techniques of open laparoscopy are safe andeffective to the extent that they observe the basicprinciples of the procedure and succeed in providing

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356 H.M. HASSON

an airtight seal around the cannula. Additionally, caremust be exercised while introducing the cannula intothe abdomen without a protective blunt obturator sinceinternal injury by the sharp edge of the bare cannula isdistinctly possible.

Examples of methods described to block escape ofthe gas around a standard cannula include the use of apurse-string suture in the fascia (with or without arubber tube choker),14,15 or in the subcutaneous tis-sue,16 and applying towel clips,17–19 Allis clamps,20 orsuture21 to the skin and subcutaneous tissues surround-ing the cannula. It should be noted that acquiringproper instrumentation and adequate instruction andtraining is almost as essential for open laparoscopy as itis for closed laparoscopy.

RESULTS

Complications of open laparoscopy

In 1978, I reported on a series of 800 open laparoscopycases22 and found that most of the complicationsrelated to access occurred during the first 50 cases.This phenomenon was also noted by other authors,Table 2.23,24 Since that time, our group has performedover 5000 diagnostic, simple and advanced operativeopen laparoscopy procedures with very few complica-tions. In fact, we have not encountered a bowel injurysince 1971, in spite of operating on increasingly diffi-cult high risk patients. Occurrences of umbilical woundinfection diminished after we initiated routine pre-operative antibiotic treatment. One of my associateshad a case of postoperative umbilical herniation pre-senting on postoperative day 2 which was repaired onthe same day. Loose suture stands were noted at thetime of surgical repair.

Studies reporting on the use of open laparoscopy andits complications are shown in Table 3.5,20–35 The

overall rate of wound infection was 0.4%; that of bowelinjury was 0.1%. There were no instances of gas embo-lism or other visceral damage. One study, collectingdata on laparoscopic cholecystectomy procedures per-formed at 94 military medical facilities, reported aninjury to the common iliac artery with open laparo-scopy.30 It is difficult to conceive how a retroperitonealstructure could be cut with a blunt obturator intro-duced into the abdomen under vision following astandard minilaparotomy incision and dissection.

DISCUSSION

When the bowel injury cases reported with open laparo-scopy were analysed, they appeared to be caused by oneof two factors:1 Surgeon unfamiliarity with the technique. This isexemplified by my own experience22 and that of Zaracaet al.23 The one instance of bowel injury in each studyoccurred during the learning phase, very early in theseries.2 Presence of patient risk factors. The operation wascarried out on a high risk patient who probably wouldhave suffered a bowel injury if a laparotomy had beenperformed. For instance, the only patient who hadbowel damage in the study by Bateman et al.29 hadCrohn’s disease and unprepared bowel. Likewise, thesingle instance of bowel injury in the series reported byDecloedt et al.33 occurred in a cancer patient with verydense adhesions.

Although details of the 11 cases reported from mili-tary medical units are not available, physician unfami-liarity with the technique may have played a role. Therate of bowel injury with open laparoscopy was threetimes that of closed laparoscopy and a major vessel wasinjured using the open entry technique in that study.30

In a later publication, Penfield provided further detailsof the six bowel injury cases,36 but did not discuss


Complications

Wound infection Bowel injury Umbilical hernia

Schnepper24

First 50 cases 3 (4%) 0 0Next 763 cases 0 0 0

Hasson22

First 50 cases 3 (6%) 1 (2%) 0Next 750 cases 3 (0.4%) 0 0

Zaraca et al.23

First 50 cases 1 (2%) 1 (2%) 1 (2%)Next 956 cases 18 (1.8) 0 0

Table 2 Effect of experience oncomplication rates in open laparoscopystudies



Table 3 Complications of open laparoscopy

Study Cases Umbilical infection Bowel injury

Prospective studiesSigman et al.25

General surgerya 247 2 (0.8%) 0Nuzzo et al.5

General surgeryb 330 5c (1.6%) 0

Retrospective studiesHasson22

Gynaecological surgery 800 6 (0.7%) 1 (0.1%)FitzGibbons et al.26

General surgery 343 2 (0.6%) 1 (0.3%)Perone20

Gynaecological surgery 585 —— 0Ballem et al.27

General surgery 150 0 0Adana et al.28

General surgeryd 184 2 (1.1%) 0Bateman et al.29

High risk gynaecological reproductive surgerye 258 —— 1f (0.4%)Wherry et al.30

General surgery 3 839 —— 11 (0.3%)Casey et al.31

High risk gynaecological oncology surgery 31 —— 0Wallace21

General surgery 568 4 0Schnepper24

Gynaecological sterilization (office setting, local anaesthesia) 815 2 (0.2%) 0Bonjer et al.32

General surgery 438 3 (0.7%) 0Decloedt et al.33

High risk gynaecological oncology surgeryg 90 0 1h (1%)Pelosi & Pelosi34

Gynaecological surgery, markedly obese patients 67 0 0Zaraca et al.23

General surgeryi 1 006 19 (1.9%) 1 (0.1%)

Mail surveyPenfield35

Gynaecological surgery 10 840 19 (0.2%) 6j (0.05%)

All studiesUmbilical infection 15 622 64 (0.4%)Bowel injury 20 335 22 (0.1%)

a Also one case of umbilical haematoma (0.4%).b Also one case of haematoma and two cases of subumbilical hernia, caused by dehiscence of the fascial suture, because of infection

secondary to bile leakage during gallbladder extraction and because of liver cirrhosis.c Some caused by bile leakage and liver cirrhosis.d Also one case of haematoma and one hernia.e Open laparoscopy selected only for high risk cases with three or more laparotomies, previous peritonitis, previous bowel surgery,

inflammatory bowel disease.f Colon injury in a patient with Crohn’s disease and unprepared bowel.g High risk gynaecological oncology cases with three or more previous laparotomies, previous debulking, large omental cake or

previous radiotherapy.h Small-bowel incision in a patient with very dense adhesions.i Also one case of umbilical herniation and one case of abdominal wall haematoma.j Four cases recognized at surgery, two not suspected.

358 H.M. HASSON

probable causation. Four were recognized and repairedintraoperatively without subsequent morbidity. Onepatient developed fever and pain on the third post-operative day and was found to have a scalpel lacerationof the ileum which was repaired, with prompt recovery.The remaining patient experienced sudden pain on the11th postoperative day. She had a pinhole perforationof the ileum which was oversewn followed by anuneventful recovery.

A case report of serosal bowel injury was described ina 2-year-old patient with intra-abdominal testis. The tearwas repaired with a single silk suture and the procedurecontinued, as intended.37 The authors used a standard5-mm cannula without a trocar and a purse-stringsuture in the fascia to provide a gas-tight seal. Thesuture caught the bowel.

Complications of closed laparoscopy

Gas embolism

Venous gas embolism is one of the most feared compli-cations of closed laparoscopy. It results from insuffla-tion of gas into the venous system through thepneumoperitoneum neeedle (P-needle). The reportedincidence of this infrequent yet catastrophic problem is0.002–0.02% according to two recent reviews38,39 rely-ing on seven different sources of information. Theincidence of non-catastrophic occurrences of gas embo-lism may be much higher. For instance, the rate was0.59% in a study of 1194 laparoscopies which werecarefully monitored for this event.40 Fatal outcomesinvolving 1–6 patients have been reported 14 authors.I cited three references in 1978;22 Wolf & Stoller citedsix additional references;39 Bongard et al. included twomore reports;38 Nord41 added one, and Lantz &Smith42 reported one case of fatal gas embolism andcited another case which was not included in otherreviews. These authors also discussed 12 additionalreports dealing with non-fatal gas embolism.42

Major vascular injury

Injury to major vessels is a serious problem of closedlaparoscopy. The incidence of this complicationin various studies and mail surveys is shown inTable 4.3,25,27,29–32,43–54 Fatal outcomes resultingfrom injuries sustained from the P-needle or first tro-cars are listed in Table 5.4,54–59 This type of complica-tion is probably grossly under-reported because ofmedicolegal concerns.

Bowel and other visceral injury

Examples of visceral complications associated with theclosed method of laparoscopic access are shown inTable 4.3,25,27,29–32,43–48,50,52–54 The vast majority ofthese cases are caused by bowel injury. Bowel lesionsare less dramatic than major vessel injury. However, theyare potentially more life-threatening since they usuallyremain unrecognized at the time of the laparoscopicprocedure and are diagnosed later, when the patientdevelops peritonitis, abdominal abscess or fistula.32,54,60

Failed laparoscopy attempts and inappropriate insufflation

Failed laparoscopy attempts because of inability toachieve an adequate pneumoperitoneum with theVeress needle occur with some regularity. This con-dition is generally managed by converting to openlaparoscopy.2,29,61

Extraperitoneal insufflation is one of the most com-mon complications of laparoscopy with rates of 0.4% to3.5%.2,38,62 Inappropriate gas insuffflation because of amisplaced P-needle results in the development of sub-cutaneous emphysema, preperitoneal or omental insuf-flation. These conditions are generally innocuous.However, subcutaneous emphysema and preperitonealdistension increase technical difficulty as they compli-cate the process of gaining access to the abdomen. Thismay lead to a failed attempt and require conversion toopen laparoscopy.2,62 If either condition is allowed tobecome extensive it may cause serious complicationsincluding pneumothorax, pneumomediastinum, pneu-mopericardium and hypercarbia.2,38,62

Postoperative herniation

The reported incidence of postoperative hernias at theumbilical port site is 0.1–0.3%.22,38,62 The actual rate isprobably much higher since the fascial defect is notrepaired in closed laparoscopy. A recent survey of theAmerican Association of Gynecologic Laparoscopistsreported 113 hernias at the umbilical site representing76% of all herniations following laparoscopy.63 Thereare numerous reports of umbilical hernias after closedlaparoscopy: I reviewed 21 cases from 10 studies,22

Mintz50 cited seven cases, Boike et al.64 reported fivepersonal cases and included seven others from sixinvestigators. Seven new cases have since beenreported.38,41,65–67 This is a potentially seriousproblem since it may lead to bowel incarceration andobstruction.38,50,62,66



Wound infection and operating time comparisons

Initial concerns about greater umbilical wound infec-tion rates and longer operating times with open laparo-scopy, as compared with closed laparoscopy, were notsubstantiated. The cumulative wound infection rate for

15 622 open laparoscopy cases in studies listed in Table 3was 0.4%, while that of the 4377 closed laparoscopycases in studies listed in Table 6 was 1%. Crist &Gadacz62 reviewed nine additional closed laparoscopystudies and reported the following approximate woundinfection rates: 0.1% for diagnostic cases; 0.25–1%


Table 4 Vascular and visceralcomplications of closed laparoscopy Study Cases Vascular injury Visceral injury

Prospective studiesJansen et al.3

Gynaecological surgery, nationwide 25 764 9 (0.03%) 27 (0.1%)Southern Journal Club43

General surgery, multicentre 1 518 0 2 (0.1%)Sigman et al.25

General surgery, multicentre 781 1 (0.1% 3 (0.4%)All prospective studies 28 063 10 (0.04%) 32 (0.1%)

Retrospective studiesDuignan et al.44

Gynaecological surgery 1 000 3 (0.3%) 0Corson & Bolognese45

Gynaecological surgery 1 545 2 (0.1%) 2 (0.1%)Kleppinger46

Gynaecological surgery 1 098 2 (0.2%) 3 (0.3%)Lieberman et al.47

Gynaecological surgery 533 3 (0.5%) 7 (1.3%)Chamberlain 198048

Gynaecological surgery, nationwide audit 50 247 155 (0.3%) 157 (0.3%)Bateman et al.29

Gynaecological surgery 2 066 0 4 (0.2%)Casey et al.31

High risk gynaecological oncology surgery 62 1 (1.6%) 3 (5%)Ballem & Rudomanski27

General surgery 150 0 2 (1.3%Saville & Woods49

General surgery 3 591 4 (0.1%) ——Wherry et al.30

General surgery 5 215 2 (0.04%) 4 (0.08%)Bonjer et al.32

General surgery 1 293 1 (0.08%) 3 (0.2%)

All retrospective studiesVascular injury 66 800 173 (0.26%)Visceral injury 63 209 185 (0.29%)

Mail surveysMintz 50

Gynaecological surgery 99 204 31 (0.03%) 26 (0.03%)Bergquist & Bergquist 198751

Gynaecological surgery 75 035 6 (0.01%) ——Yuzpe52

Gynaecological surgery 112 997 59 (0.05%) 76 (0.07%)Lehman-Willenbrock et al.53

Gynaecological surgery 260 206 155 (0.06%) 157 (0.06%)Deziel et al.54

General surgery 77 604 71 (0.09%) 109 (0.14%)

All mail surveysVascular injury 625 046 251 (0.04%)Visceral injury 550 011 259 (0.05%)

360 H.M. HASSON

for cholecystectomy, and 2–3% for laparoscopicappendectomy.

The operating times for open and closed laparoscopywere compared in several studies. The open methodrequired a significantly shorter amount of time to estab-lish an adequate pneumoperitoneum in two studies,25,27

at least the same amount of time if not shorter in onestudy5 and 1 minute longer in a study which utilized anopen technique with a conventional cannula9

CONCLUSION

Open laparoscopy is easy to learn because it utilizesfamiliar surgical technique. Once the anatomical pecu-liarities of the umbilical region are known and theprinciples upon which the technique is based areappreciated, open laparoscopy can be consistently per-formed safely and in a timely manner. However, variant

techniques which do not adhere to these basic princi-ples may carry considerable risk. For instance, using aknife to enter the abdomen without fascial elevationand proper dissection is not open laparoscopy, butdirect closed laparoscopy using a knife rather than asharp trocar.

Open laparoscopy may be the preferred method ofaccess for laparoscopic surgery. When the technique isperformed properly, it eliminates the possibility offailed laparoscopy attempts, inappropriate insuffla-tions, gas embolism, major vessel injury and otherpenetrative damage to abdominal structures, as demon-strated in numerous studies. Open laparoscopy doesnot avoid bowel injury in high risk patients with boweladherent to the abdominal wall and it does noteliminate postoperative umbilical herniation. The avail-able evidence suggests that operative time and woundinfection rates of open laparoscopy compare favourablywith those of closed laparoscopy. Routine use of openlaparoscopy should minimize the occurrence of com-plications, even in high risk patients, because of theincreased experience of the surgeon.

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Table 5 Major vessel injury caused by P-needles and first trocars,resulting in death

Study Injury resulting in fatal outcome

P-needle First trocar

Gynaecological surgeryPeterson et al.55 1Baadsgaard et al.57

quoting Lignitz & Erkrath 2Bellamy57 1Hanney et al.58 3Chapron et al.4 1 1

General surgeryNenner et al.59 1Deziel et al.54 2Hanney et al.58 1

Total for all studies 8 5

Table 6 Umbilical wound infection rates with closed laparoscopy

Study Cases Umbilical infection

ProspectiveSouthern Journal Club43

General surgery, multicentre 1518 16 (1.1%)Sigman et al.25

General surgery, multicentre 781 12 (1.5%)

RetrospectiveCorson & Bolognese45

Gynaecological surgery 1545 9 (0.6%)Lieberman et al.47

Gynaecological surgery 533 9 (1.7%)

Total for all studies 4377 46 (1%)


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open laparoscopy as a method of access in laparoscopic surgery

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