Laparoscopic entry techniques
Ahmad G., Duffy JM., Phillips K., Watson A.
BACKGROUND: Laparoscopy is a very common procedure in gynaecology. Complications associated with laparoscopy are often related to entry. The life-threatening complications include injury to the bowel, bladder, major abdominal vessels, and anterior abdominal-wall vessel. Other less serious complications can also occur, such as post-operative infection, subcutaneous emphysema and extraperitoneal insufflation. There is no clear consensus as to the optimal method of entry into the peritoneal cavity. OBJECTIVES: The objective of this study was to compare the different laparoscopic entry techniques in terms of their influence on intra-operative and post-operative complications. SEARCH STRATEGY: This review has drawn on the search strategy developed by the Menstrual Disorders and Subfertility Group. In addition MEDLINE and EMBASE were searched through to July, 2007. SELECTION CRITERIA: Randomised controlled trials were included when one laparoscopic primary-port-entry technique was compared with another. DATA COLLECTION AND ANALYSIS: Data were extracted independently by the first two authors. Differences of opinion were registered and resolved by the fourth author. Results for each study were expressed as odds ratio (Peto version) with their 95% confidence intervals. MAIN RESULTS: The 17 included randomised controlled trials concerned 3,040 individuals undergoing laparoscopy. Overall there was no evidence of advantage using any single technique in terms of preventing major complications. However, there were two advantages with direct-trocar entry when compared with Veress-Needle entry, in terms of avoiding extraperitoneal insufflation (OR 0.06, 95%CI 0.02, 0.23) and failed entry (OR 0.22, 95%CI 0.08, 0.56). There was also an advantage with radially expanding access system (STEP) trocar entry when compared with standard trocar entry, in terms of trocar site bleeding (OR 0.06, 95%CI 0.01, 0.46). Finally, there was an advantage of not lifting the abdominal wall before Veress-Needle insertion when compared to lifting in terms of failed entry without an increase in the complication rate (OR 5.17, 95%CI 2.24, 11.90). However, studies were limited to small numbers, excluding many patients with previous abdominal surgery and women with a raised body mass index, who often had unusually high complication rates. AUTHORS' CONCLUSIONS: On the basis of evidence investigated in this review, there appears to be no evidence of benefit in terms of safety of one technique over another. However, the included studies are small and cannot be used to confirm safety of any particular technique.