Top

Published in:

Open Access 13-07-2023 | Dynamic Manuscript

The influence of prolonged instrument manipulation on gas leakage through trocars

Authors: Daniel Robertson, Matthijs van Duijn, Alberto Arezzo, Yoav Mintz, Tim Horeman-Franse, Technology Committee of the EAES

Published in: Surgical Endoscopy | Issue 9/2023

Abstract

Background

During laparoscopic surgery, CO₂ insufflation gas could leak from the intra-abdominal cavity into the operating theater. Medical staff could therefore be exposed to hazardous substances present in leaked gas. Although previous studies have shown that leakage through trocars is a contributing factor, trocar performance over longer periods remains unclear. This study investigates the influence of prolonged instrument manipulation on gas leakage through trocars.

Methods

Twenty-five trocars with diameters ranging from 10 to 15 mm were included in the study. An experimental model was developed to facilitate instrument manipulation in a trocar under loading. The trocar was mounted to a custom airtight container insufflated with CO₂ to a pressure of 15 mmHg, similar to clinical practice. A linear stage was used for prolonged instrument manipulation. At the same time, a fixed load was applied radially to the trocar cannula to mimic the reaction force of the abdominal wall. Gas leakage was measured before, after, and during instrument manipulation.

Results

After instrument manipulation, leakage rates per trocar varied between 0.0 and 5.58 L/min. No large differences were found between leakage rates before and after prolonged manipulation in static and dynamic measurements. However, the prolonged instrument manipulation did cause visible damage to two trocars and revealed unintended leakage pathways in others that can be related to production flaws.

Conclusion

Prolonged instrument manipulation did not increase gas leakage rates through trocars, despite damage to some individual trocars. Nevertheless, gas leakage through trocars occurs and is caused by different trocar-specific mechanisms and design issues.

Available only for authorised users

Gurusamy KS, Vaughan J, Davidson BR (2014) Low pressure versus standard pressure pneumoperitoneum in laparoscopic cholecystectomy. Cochrane Database Syst Rev. https://doi.org/10.1002/14651858.CD006930.pub3CrossRefPubMedPubMedCentral

la Chapelle CF, Bemelman WA, Rademaker BMP, van Barneveld TA, Jansen FW (2012) A multidisciplinary evidence-based guideline for minimally invasive surgery Part 1: entry techniques and the pneumoperitoneum. Gynecol Surg 9:271–282. https://doi.org/10.1007/s10397-012-0731-yCrossRefPubMedPubMedCentral

Cahill RA, Dalli J, Khan M, Flood M, Nolan K (2020) Solving the problems of gas leakage at laparoscopy. Br J Surg 107:1401–1405. https://doi.org/10.1002/bjs.11977CrossRefPubMed

Robertson D, Sterke F, van Weteringen W, Arezzo A, Mintz Y, Nickel F, Boni L, Baldari L, Carus T, Chand M, Fuchs H, Ficuciello F, Marconi S, Mylonas G, Kim YW, Nakajima K, Schijven M, Valdastri P, Sagiv C, Mascagni P, Myśliwiec P, Petz W, Sánchez-Margallo F, Horeman T (2022) Characterisation of trocar associated gas leaks during laparoscopic surgery. Surg Endosc 36:4542–4551. https://doi.org/10.1007/s00464-021-08807-1CrossRefPubMed

Choi SH, Kwon TG, Chung SK, Kim TH (2014) Surgical smoke may be a biohazard to surgeons performing laparoscopic surgery. Surg Endosc 28:2374–2380. https://doi.org/10.1007/s00464-014-3472-3CrossRefPubMed

Dobrogowski M, Wesołowski W, Kucharska M, Sapota A, Pomorski LS (2014) Chemical composition of surgical smoke formed in the abdominal cavity during laparoscopic cholecystectomy—assessment of the risk to the patient. Int J Occup Med Environ Health 27:314–325. https://doi.org/10.2478/s13382-014-0250-3CrossRefPubMed

Fitzgerald JEF, Malik M, Ahmed I (2012) A single-blind controlled study of electrocautery and ultrasonic scalpel smoke plumes in laparoscopic surgery. Surg Endosc 26:337–342. https://doi.org/10.1007/s00464-011-1872-1CrossRefPubMed

Georgesen C, Lipner SR (2018) Surgical smoke: risk assessment and mitigation strategies. J Am Acad Dermatol 79:746–755. https://doi.org/10.1016/j.jaad.2018.06.003CrossRefPubMed

Mowbray N, Ansell J, Warren N, Wall P, Torkington J (2013) Is surgical smoke harmful to theater staff? A systematic review. Surg Endosc 27:3100–3107. https://doi.org/10.1007/s00464-013-2940-5CrossRefPubMed

10.

Pasquier J, Villalta O, Sarria Lamorú S, Balagué C, Vilallonga R, Targarona EM (2021) Are smoke and aerosols generated during laparoscopic surgery a biohazard? A systematic evidence-based review. Surg Innov 28:485–495. https://doi.org/10.1177/1553350621992309CrossRefPubMed

11.

van Doremalen N, Bushmaker T, Morris DH, Holbrook MG, Gamble A, Williamson BN, Tamin A, Harcourt JL, Thornburg NJ, Gerber SI, Lloyd-Smith JO, de Wit E, Munster VJ (2020) Aerosol and surface stability of HCoV-19 (SARS-CoV-2) compared to SARS-CoV-1. medRxiv. https://doi.org/10.1101/2020.03.09.20033217CrossRefPubMedPubMedCentral

12.

Rymarowicz J, Stefura T, Major P, Szeliga J, Wallner G, Nowakowski M, Pędziwiatr M (2021) General surgeons’ attitudes towards COVID-19: a national survey during the SARS-CoV-2 virus outbreak. Eur Surg 53:5–10. https://doi.org/10.1007/s10353-020-00649-wCrossRefPubMed

13.

Hardy N, Dalli J, Khan MF, Nolan K, Cahill RA (2021) Aerosols, airflow, and airspace contamination during laparoscopy. Br J Surg 108:1022–1025. https://doi.org/10.1093/bjs/znab114CrossRefPubMed

14.

Li CI, Pai JY, Chen CH (2020) Characterization of smoke generated during the use of surgical knife in laparotomy surgeries. J Air Waste Manage Assoc 70:324–332. https://doi.org/10.1080/10962247.2020.1717675CrossRef

15.

Wang HK, Mo F, Ma CG, Dai B, Shi GH, Zhu Y, Zhang HL, Ye DW (2015) Evaluation of fine particles in surgical smoke from an urologist’s operating room by time and by distance. Int Urol Nephrol 47:1671–1678. https://doi.org/10.1007/s11255-015-1080-3CrossRefPubMed

16.

Uecker JM, Fagerberg A, Ahmad N, Cohen A, Gilkey M, Alembeigi F, Idelson CR (2021) Stop the leak!: mitigating potential exposure of aerosolized COVID-19 during laparoscopic surgery. Surg Endosc 35:493–501. https://doi.org/10.1007/s00464-020-08006-4CrossRefPubMed

17.

Rosen J, Solazzo M, Hannaford B, Sinanan M (2002) Task decomposition of laparoscopic surgery for objective evaluation of surgical residents’ learning curve using Hidden Markov Model. Comput Aided Surg 7:49–61. https://doi.org/10.1002/igs.100262002CrossRefPubMed

18.

Rosen J, Macfarlane M, Richards C, Hannaford B, Sinanan M (1999) Surgeon-tool force/torque signatures-evaluation of surgical skills in minimally invasive surgery. IOS Press, Amsterdam

19.

Ebina K, Abe T, Higuchi M, Furumido J, Iwahara N, Kon M, Hotta K, Komizunai S, Kurashima Y, Kikuchi H, Matsumoto R, Osawa T, Murai S, Tsujita T, Sase K, Chen X, Konno A, Shinohara N (2021) Motion analysis for better understanding of psychomotor skills in laparoscopy: objective assessment-based simulation training using animal organs. Surg Endosc 35:4399–4416. https://doi.org/10.1007/s00464-020-07940-7CrossRefPubMed

20.

Aitchison LP, Cui CK, Arnold A, Nesbitt-Hawes E, Abbott J (2016) The ergonomics of laparoscopic surgery: a quantitative study of the time and motion of laparoscopic surgeons in live surgical environments. Surg Endosc 30:5068–5076. https://doi.org/10.1007/s00464-016-4855-4CrossRefPubMed

21.

den Boer KT, de Wit LT, Dankelman J, Gouma DJ (2002) Peroperative time–motion analysis of diagnostic laparoscopy with laparoscopic ultrasonography. Br J Surg 86:951–955. https://doi.org/10.1046/j.1365-2168.1999.01134.xCrossRef

22.

Geryane MH, Hanna GB, Cuschieri A (2004) Time-motion analysis of operation theater time use during laparoscopic cholecystectomy by surgical specialist residents. Surg Endosc Other Interv Tech 18:1597–1600. https://doi.org/10.1007/s00464-003-8210-1CrossRef

23.

Gokceimam M, Akbulut S, Erten O, Kahramangil B, Kim YS, Li P, Berber E (2021) An intra-operative video comparison of laparoscopic versus robotic transabdominal lateral adrenalectomy. Int J Med Robot Comput Assist Surg. https://doi.org/10.1002/rcs.2203CrossRef

24.

Kranzfelder M, Schneider A, Fiolka A, Ing D, Schwan E, Gillen S, Wilhelm D, Schirren R, Reiser S, Jensen B, Inf D, Feussner H (2013) Real-time instrument detection in minimally invasive surgery using radiofrequency identification technology. J Surg Res 185:704–710. https://doi.org/10.1016/j.jss.2013.06.022CrossRefPubMed

25.

Liu H, Kinoshita T, Tonouchi A, Kaito A, Tokunaga M (2019) What are the reasons for a longer operation time in robotic gastrectomy than in laparoscopic gastrectomy for stomach cancer? Surg Endosc 33:192–198. https://doi.org/10.1007/s00464-018-6294-xCrossRefPubMed

26.

Miller DJ, Nelson CA, Oleynikov D (2009) Shortened or time and decreased patient risk through use of a modular surgical instrument with artificial intelligence. Surg Endosc 23:1099–1105. https://doi.org/10.1007/s00464-008-0321-2CrossRefPubMed

27.

Stotz L, Joukhadar R, Hamza A, Thangarajah F, Bardens D, Juhasz-Böss I, Solomayer EF, Radosa MP, Radosa JC (2018) Instrument usage in laparoscopic gynecologic surgery: a prospective clinical trial. Arch Gynecol Obstet 298:773–779. https://doi.org/10.1007/s00404-018-4867-5CrossRefPubMed

28.

Sutton E, Youssef Y, Meenaghan N, Godinez C, Xiao Y, Lee T, Dexter D, Park A (2010) Gaze disruptions experienced by the laparoscopic operating surgeon. Surg Endosc 24:1240–1244. https://doi.org/10.1007/s00464-009-0753-3CrossRefPubMed

29.

von Strauss und Torney M, Aghlmandi S, Zeindler J, Nowakowski D, Nebiker CA, Kettelhack C, Rosenthal R, Droeser RA, Soysal SD, Hoffmann H, Mechera R (2018) High-resolution standardization reduces delay due to workflow disruptions in laparoscopic cholecystectomy. Surg Endosc 32:4763–4771. https://doi.org/10.1007/s00464-018-6224-yCrossRef

30.

von Strauss und Torney M, Dell-Kuster S, Hoffmann H, von Holzen U, Oertli D, Rosenthal R (2016) Microcomplications in laparoscopic cholecystectomy: impact on duration of surgery and costs. Surg Endosc 30:2512–2522. https://doi.org/10.1007/s00464-015-4512-3CrossRef

31.

White NA, Oude Vrielink TJC, van der Bogt KEA, Cohen AF, Rotmans JI, Horeman T (2023) Question-based development of high-risk medical devices: a proposal for a structured design and review process. Br J Clin Pharmacol. https://doi.org/10.1111/bcp.156852023CrossRefPubMed

32.

Mues AC, Haramis G, Casazza C, Okhunov Z, Badani KK, Landman J (2010) Prospective randomized single-blinded in vitro and ex vivo evaluation of new and reprocessed laparoscopic trocars. J Am Coll Surg 211:738–743. https://doi.org/10.1016/j.jamcollsurg.2010.08.003CrossRefPubMed

33.

Cepress JM, Cummings JF, Ricketts CD, Clymer JW, Tommaselli GA (2020) Comparison of trocar performance in consideration of the COVID-19 pandemic. Med Devices Diagn Eng 5:1–7. https://doi.org/10.15761/MDDE.1000129CrossRef

34.

Mintz Y, Arezzo A, Boni L, Chand M, Brodie R, Fingerhut A (2020) A low-cost, safe, and effective method for smoke evacuation in laparoscopic surgery for suspected coronavirus patients. Ann Surg. https://doi.org/10.1097/SLA.0000000000003965CrossRefPubMed

35.

Vaishnav D, Patel B (2021) Laparoscopic gastrointestinal surgery during COVID-19 pandemic: single-center experience. J Laparoendosc Adv Surg Tech 31:455–457. https://doi.org/10.1089/lap.2020.0481CrossRef

36.

Vigneswaran Y, Prachand VN, Posner MC, Matthews JB, Hussain M (2020) What is the appropriate use of laparoscopy over open procedures in the current COVID-19 climate? J Gastrointest Surg 24:1686–1691. https://doi.org/10.1007/s11605-020-04592-9CrossRefPubMedPubMedCentral

37.

Baggish MS (1993) Comparison of smoke and sprayback leakage from two different trocar sleeves during operative laparoscopy. J Gynecol Surg 9:65–76. https://doi.org/10.1089/gyn.1993.9.65CrossRef

38.

Lans JLA, Mathijssen NMC, Bode A, van den Dobbelsteen JJ, van der Elst M, Luscuere PG (2022) Operating room ventilation systems: recovery degree, cleanliness recovery rate and air change effectiveness in an ultra-clean area. J Hosp Infect 122:115–125. https://doi.org/10.1016/j.jhin.2021.12.018CrossRefPubMed

Title: The influence of prolonged instrument manipulation on gas leakage through trocars
Authors: Daniel Robertson
Matthijs van Duijn
Alberto Arezzo
Yoav Mintz
Tim Horeman-Franse
Technology Committee of the EAES
Publication date: 13-07-2023
Publisher: Springer US
Published in: Surgical Endoscopy / Issue 9/2023
Print ISSN: 0930-2794
Electronic ISSN: 1432-2218
DOI: https://doi.org/10.1007/s00464-023-10240-5

Keynote webinar | Spotlight on medication adherence

Springer Medicine

The influence of prolonged instrument manipulation on gas leakage through trocars

Abstract

Background

Methods

Results

Conclusion

Keynote webinar | Spotlight on medication adherence

Springer Medicine

Abstract

Background

Methods

Results

Conclusion

Please log in to get access to this content

Other articles of this Issue 9/2023

Transanal total mesorectal excision versus laparoscopic intersphincteric resection for low rectal cancer: a propensity score matching analysis

The long weight: association between distressed communities index and long-term weight outcomes following bariatric surgery

Analysis of training pathway to reach expert performance levels based on proficiency-based progression in robotic-assisted minimally invasive esophagectomy (RAMIE)

Diagnostic accuracy of frozen section biopsy for early gastric cancer extent during endoscopic submucosal dissection: a prospective study

Endoscopic vacuum therapy versus self-expandable metal stent for treatment of anastomotic leaks < 30 mm following oncologic Ivor-Lewis esophagectomy: a matched case–control study

Three-year survival and distribution of lymph node metastases in gastric cancer following neoadjuvant chemotherapy: results from a European randomized clinical trial