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A novel technique to prevent inadvertent sheath migration
SURGEON’S WORKSHOP
A NOVEL TECHNIQUE TO PREVENT INADVERTENT SHEATH MIGRATION THAI T. NGUYEN, DAVID S. WANG,
AND
HOWARD N. WINFIELD
ABSTRACT Inadvertent trocar-sheath migration is annoying to the surgeon and may result in serious visceral injury. Herein is described a novel technique to prevent such migration. A 0.25-in. Penrose drain is wrapped around the trocar-sheath unit as a collar to prevent sheath migration. UROLOGY 62: 344–345, 2003. © 2003 Elsevier Inc.
I
nadvertent sheath migration during laparoscopic surgery is a nuisance and is potentially dangerous in certain instances. We present a novel technique for preventing unintentional advancement of the laparoscopic sheath. The technique is simple to apply and adds minimal costs to the procedure. TECHNIQUE
Once pneumoperitoneum has been established, the laparoscopic trocar-sheath unit is placed in the usual manner and advanced to the desired position under direct vision. A 0.25-in. Penrose drain is then tightly wrapped twice around the base of the sheath at the level of the skin, similar to placement of a tourniquet (Fig. 1). The ends of the Penrose drain are then clamped with a hemostat to secure them in place. This “collar” acts as a stopper, effectively preventing sheath advancement. COMMENT Inadvertent sheath migration can be troublesome during laparoscopic surgery. To maintain the pneumoperitoneum, the laparoscopic ports must keep a tight seal around the instruments that are introduced through them. If the friction between the instrument and the sheath is greater than the friction between the sheath and the body wall, advancement or withdrawal of the instrument will From the Department of Urology, University of Iowa Hospitals and Clinics, Iowa City, Iowa Reprint requests: Howard N. Winfield, M.D., Department of Urology, University of Iowa Hospitals and Clinics, 200 Hawkins Drive, RCP 3235, Iowa City, IA 52242-1089 Submitted: January 27, 2003, accepted (with revisions): April 10, 2003
344
© 2003 ELSEVIER INC. ALL RIGHTS RESERVED
FIGURE 1. Trocar-sheath unit with Penrose drain wrapped and secured at the base of the sheath.
result in inadvertent sheath migration in the same direction. This occurs frequently during the introduction or complete withdrawal of an instrument, especially with the smaller 5-mm sheaths. Manually securing the sheath during instrument introduction or removal would prevent migration; however, the surgeon’s other hand is usually occupied with a second instrument, and the assistant’s hands are occupied with the laparoscope and a retractor. Unintentional removal of a laparoscopic sheath will result in loss of pneumoperitoneum and thus, loss of visualization and an adequate working space. Harm to the patient may ensue if this were to occur at a crucial point in the case. At best, the time it takes to re-establish insufflation may be a nuisance and, if it occurs repetitively, can add substantially to the total operative time. Fortunately, this UROLOGY 62: 344 –345, 2003 • 0090-4295/03/$30.00 doi:10.1016/S0090-4295(03)00458-8
can be avoided by simply securing the sheath with a skin suture wrapped around the gas valve.1,2 Unintentional sheath advancement may also be problematic. The trivial task of introducing an instrument through a port may be very trying if the cannula were to move inward with each attempt. This usually necessitates the assistance of a second hand—which may have previously been engaged in a different task—to secure the port before introduction of the laparoscopic instrument. When faced with a small working space, such as in retroperitoneoscopy or in pediatric laparoscopy, a “buried” sheath may hamper vision or the movement of the instruments. Finally, any inadvertent advancement of a sheath may potentially be harmful, especially if located near organs that are easily lacerated such as the liver or spleen. The visual field of the laparoscope is usually centered on the instrument tips; sheaths are therefore frequently excluded from the operative field. Impending injuries due to inadvertent sheath migration will not be seen and thus will not be avoided. For similar reasons, once these injuries occur, they may not immediately be recognized. Inadvertent advancement does not pose a problem with some types of ports. For example, Hasson cannulas are often manufactured with coneshaped collars that are pushed down to occlude the skin incision and prevent the escape of carbon dioxide during insufflation.1,2 These collars have the added benefit of preventing sheath advancement. Most cannulas, however, do not come with such collars and therefore may freely advance into the body. Trocar systems that stretch rather than incise the tissues of the abdominal wall are less prone to sheath migration because of a tighter grip between the abdominal wall and the sheath. The One-Step Port (U.S. Surgical, Norwalk, Conn) is one example of a tissue-dilating trocar. In addition, a Siloxane coating allows for smooth passage of instru-
UROLOGY 62 (2), 2003
ments, further decreasing the tendency for sheath migration. Screw-type cannulas are introduced by controlled rotation, causing displacement and blunt dilation of the tissues. One of the advantages inherent in the design of this trocar system is that the sheath stays securely in place unless intentionally “screwed” in or out.2 Although the innovative designs mentioned above offer an advantage, these trocar systems are generally more costly. The technique presented here is simple, effective, and quick to apply for preventing sheath migration. The technique works effectively with any type of sheath, because the latex grips any material firmly as long as the Penrose drain is tightly wrapped. Surgical cost is an important concern in laparoscopy because of the already expensive equipment. Penrose drains are very inexpensive ($0.33 each at our institution) and readily available in any operating room. A single drain can easily be wrapped around two separate sheaths, or it can be divided to individually wrap multiple sheaths. In certain procedures, such as laparoscopic pyeloplasty, a Penrose drain is placed at the conclusion of the case. Thus, our technique would have no added costs if the same drain were then used for postoperative drainage. Should a sheath need to be advanced, the Penrose collar is simply removed by releasing the hemostat, and then just as quickly replaced once the new sheath position has been established. REFERENCES 1. Bishoff JT: Basic techniques in laparoscopic surgery, in Bishoff JT, and Kavoussi LR (Eds): Atlas of Laparoscopic Retroperitoneal Surgery. Philadelphia, WB Saunders, 2000, pp 1–32. 2. Gill IS, Kerbl K, Meraney AM, et al: Basics of laparoscopic urologic surgery, in Walsh PC, Retik AB, Vaughan ED, et al (Eds): Campbell’s Urology, 8th ed. Philadelphia, WB Saunders, 2002, vol 4, pp 3455–3505.
345
A NOVEL TECHNIQUE TO PREVENT INADVERTENT SHEATH MIGRATION THAI T. NGUYEN, DAVID S. WANG,
AND
HOWARD N. WINFIELD
ABSTRACT Inadvertent trocar-sheath migration is annoying to the surgeon and may result in serious visceral injury. Herein is described a novel technique to prevent such migration. A 0.25-in. Penrose drain is wrapped around the trocar-sheath unit as a collar to prevent sheath migration. UROLOGY 62: 344–345, 2003. © 2003 Elsevier Inc.
I
nadvertent sheath migration during laparoscopic surgery is a nuisance and is potentially dangerous in certain instances. We present a novel technique for preventing unintentional advancement of the laparoscopic sheath. The technique is simple to apply and adds minimal costs to the procedure. TECHNIQUE
Once pneumoperitoneum has been established, the laparoscopic trocar-sheath unit is placed in the usual manner and advanced to the desired position under direct vision. A 0.25-in. Penrose drain is then tightly wrapped twice around the base of the sheath at the level of the skin, similar to placement of a tourniquet (Fig. 1). The ends of the Penrose drain are then clamped with a hemostat to secure them in place. This “collar” acts as a stopper, effectively preventing sheath advancement. COMMENT Inadvertent sheath migration can be troublesome during laparoscopic surgery. To maintain the pneumoperitoneum, the laparoscopic ports must keep a tight seal around the instruments that are introduced through them. If the friction between the instrument and the sheath is greater than the friction between the sheath and the body wall, advancement or withdrawal of the instrument will From the Department of Urology, University of Iowa Hospitals and Clinics, Iowa City, Iowa Reprint requests: Howard N. Winfield, M.D., Department of Urology, University of Iowa Hospitals and Clinics, 200 Hawkins Drive, RCP 3235, Iowa City, IA 52242-1089 Submitted: January 27, 2003, accepted (with revisions): April 10, 2003
344
© 2003 ELSEVIER INC. ALL RIGHTS RESERVED
FIGURE 1. Trocar-sheath unit with Penrose drain wrapped and secured at the base of the sheath.
result in inadvertent sheath migration in the same direction. This occurs frequently during the introduction or complete withdrawal of an instrument, especially with the smaller 5-mm sheaths. Manually securing the sheath during instrument introduction or removal would prevent migration; however, the surgeon’s other hand is usually occupied with a second instrument, and the assistant’s hands are occupied with the laparoscope and a retractor. Unintentional removal of a laparoscopic sheath will result in loss of pneumoperitoneum and thus, loss of visualization and an adequate working space. Harm to the patient may ensue if this were to occur at a crucial point in the case. At best, the time it takes to re-establish insufflation may be a nuisance and, if it occurs repetitively, can add substantially to the total operative time. Fortunately, this UROLOGY 62: 344 –345, 2003 • 0090-4295/03/$30.00 doi:10.1016/S0090-4295(03)00458-8
can be avoided by simply securing the sheath with a skin suture wrapped around the gas valve.1,2 Unintentional sheath advancement may also be problematic. The trivial task of introducing an instrument through a port may be very trying if the cannula were to move inward with each attempt. This usually necessitates the assistance of a second hand—which may have previously been engaged in a different task—to secure the port before introduction of the laparoscopic instrument. When faced with a small working space, such as in retroperitoneoscopy or in pediatric laparoscopy, a “buried” sheath may hamper vision or the movement of the instruments. Finally, any inadvertent advancement of a sheath may potentially be harmful, especially if located near organs that are easily lacerated such as the liver or spleen. The visual field of the laparoscope is usually centered on the instrument tips; sheaths are therefore frequently excluded from the operative field. Impending injuries due to inadvertent sheath migration will not be seen and thus will not be avoided. For similar reasons, once these injuries occur, they may not immediately be recognized. Inadvertent advancement does not pose a problem with some types of ports. For example, Hasson cannulas are often manufactured with coneshaped collars that are pushed down to occlude the skin incision and prevent the escape of carbon dioxide during insufflation.1,2 These collars have the added benefit of preventing sheath advancement. Most cannulas, however, do not come with such collars and therefore may freely advance into the body. Trocar systems that stretch rather than incise the tissues of the abdominal wall are less prone to sheath migration because of a tighter grip between the abdominal wall and the sheath. The One-Step Port (U.S. Surgical, Norwalk, Conn) is one example of a tissue-dilating trocar. In addition, a Siloxane coating allows for smooth passage of instru-
UROLOGY 62 (2), 2003
ments, further decreasing the tendency for sheath migration. Screw-type cannulas are introduced by controlled rotation, causing displacement and blunt dilation of the tissues. One of the advantages inherent in the design of this trocar system is that the sheath stays securely in place unless intentionally “screwed” in or out.2 Although the innovative designs mentioned above offer an advantage, these trocar systems are generally more costly. The technique presented here is simple, effective, and quick to apply for preventing sheath migration. The technique works effectively with any type of sheath, because the latex grips any material firmly as long as the Penrose drain is tightly wrapped. Surgical cost is an important concern in laparoscopy because of the already expensive equipment. Penrose drains are very inexpensive ($0.33 each at our institution) and readily available in any operating room. A single drain can easily be wrapped around two separate sheaths, or it can be divided to individually wrap multiple sheaths. In certain procedures, such as laparoscopic pyeloplasty, a Penrose drain is placed at the conclusion of the case. Thus, our technique would have no added costs if the same drain were then used for postoperative drainage. Should a sheath need to be advanced, the Penrose collar is simply removed by releasing the hemostat, and then just as quickly replaced once the new sheath position has been established. REFERENCES 1. Bishoff JT: Basic techniques in laparoscopic surgery, in Bishoff JT, and Kavoussi LR (Eds): Atlas of Laparoscopic Retroperitoneal Surgery. Philadelphia, WB Saunders, 2000, pp 1–32. 2. Gill IS, Kerbl K, Meraney AM, et al: Basics of laparoscopic urologic surgery, in Walsh PC, Retik AB, Vaughan ED, et al (Eds): Campbell’s Urology, 8th ed. Philadelphia, WB Saunders, 2002, vol 4, pp 3455–3505.
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