Trocar types in laparoscopy

Claire F la Chapelle; Hilko A Swank; Monique E Wessels; Ben Willem J Mol; Sidney M Rubinstein; Frank Willem Jansen

doi:10.1002/14651858.CD009814.pub2

Cochrane Database of Systematic Reviews

Tipos de trócar en la laparoscopia

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DOI:

https://doi.org/10.1002/14651858.CD009814.pub2 Copiar DOI

Base de datos:

Cochrane Database of Systematic Reviews

Versión publicada:

16 diciembre 2015see what's new

Tipo:

Intervention

Etapa:

Review

Grupo Editorial Cochrane:

Grupo Cochrane de Ginecología y fertilidad

Copyright:

Copyright © 2015 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.

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Autores

Claire F la Chapelle

Correspondencia a: Leiden University Medical Centre, Leiden, Netherlands

[email protected]
Hilko A Swank

Department of Surgery, Academic Medical Centre, Amsterdam, Netherlands
Monique E Wessels

Department of Quality in Healthcare, Dutch Association of Medical Specialists, Utrecht, Netherlands
Ben Willem J Mol

Discipline of Obstetrics and Gynaecology, School of Medicine, Robinson Research Institute, The University of Adelaide, Adelaide, Australia
Sidney M Rubinstein

Department of Health Sciences, Faculty of Earth and Life Sciences, VU University Amsterdam, Amsterdam, Netherlands
Frank Willem Jansen

Department of Obstetrics and Gynaecology, Leiden University Medical Center, Leiden, Netherlands

Contributions of authors

CC contributed to the conception of the review, co‐ordinated the review, wrote to authors of papers for additional information and worked on the data management.

CC and HS together designed and drafted the review, collected data for the review, organised retrieval of papers, screened the retrieved papers, appraised the quality of the papers, extracted the data of the papers, obtained and screened data on unpublished studies, entered data into Review Manager 5, analysed and interpreted the data and wrote the review.

SMR contributed to the conception and designing of the review, helped in providing a methodological perspective, helped with the interpretation of data and critically revised the draft review.

MW and CC together designed search strategies.

MW undertook the searches (in consultation with the Trials Search Co‐ordinator of the Cochrane Gynaecology and Fertility Group, Marian Showell).

FWJ contributed to the conception and design of the review, helped interpreting the data, provided a clinical and consumer perspective and critically reviewed the draft review.

BWM contributed to the conception of the review and critically reviewed the draft review.

All authors approved the final version of the review.

Sources of support

Internal sources

None, Other.

External sources

None, Other.

Declarations of interest

The authors do not have any potential conflicts of interest.

Acknowledgements

The review authors thank the members and reviewers of the Editorial Board of the Cochrane Gynaecology and Fertility Group (formerly Menstrual Disorders and Subfertility Group) for constructive comments on the protocol of this review, Ms Marian Showell for her assistance with the development of search strategies and Ms Helen Nagels for her assistance in managing the review process.

Version history

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Authors

Version

2015 Dec 16

Trocar types in laparoscopy

Review

Claire F la Chapelle, Hilko A Swank, Monique E Wessels, Ben Willem J Mol, Sidney M Rubinstein, Frank Willem Jansen

https://doi.org/10.1002/14651858.CD009814.pub2

2012 Apr 18

Trocar types in laparoscopy

Protocol

Claire F la Chapelle, Hilko A. Swank, Monique E Wessels, Ben Willem J Mol, Sidney M Rubinstein, Frank Willem Jansen

https://doi.org/10.1002/14651858.CD009814

Differences between protocol and review

We used a fixed‐effect model for meta‐analysis of dichotomous data.

We have added three subgroups: primary entry technique, secondary entry technique and differing trocar diameter.

We removed the planned sensitivity analysis where eligibility would be restricted to studies on bariatric surgery.

Keywords

MeSH

Medical Subject Headings (MeSH) Keywords

Medical Subject Headings Check Words

Humans;

PICO

Population

Intervention

Comparison

Outcome

El uso y la enseñanza del modelo PICO están muy extendidos en el ámbito de la atención sanitaria basada en la evidencia para formular preguntas y estrategias de búsqueda y para caracterizar estudios o metanálisis clínicos. PICO son las siglas en inglés de cuatro posibles componentes de una pregunta de investigación: paciente, población o problema; intervención; comparación; desenlace (outcome).

Para saber más sobre el uso del modelo PICO, puede consultar el Manual Cochrane.

Figure 1

Study flow diagram.

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Figure 2

Risk of bias summary: review authors' judgements about each risk of bias item for each included study.

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Figure 3

Risk of bias graph: review authors' judgements about each risk of bias item presented as percentages across all included studies.

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Figure 4

Forest plot of comparison: 1 Radially expanding trocar versus cutting trocar for primary and secondary port entry, outcome: 1.3 Trocar site herniation.

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Figure 5

Forest plot of comparison: 1 Radially expanding trocar versus cutting trocar for primary and secondary port entry, outcome: 1.4 Trocar site bleeding.

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Figure 6

Forest plot of comparison: 1 Radially expanding trocar versus cutting trocar for primary and secondary port entry, outcome: 1.5 Trocar site haematoma.

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Figure 7

Forest plot of comparison: 2 Conical blunt‐tipped trocar versus cutting trocar for secondary port entry, outcome: 2.1 Visceral injury.

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Figure 8

Forest plot of comparison: 2 Conical blunt‐tipped trocar versus cutting trocar for secondary port entry, outcome: 2.2 Vascular injury.

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Figure 9

Forest plot of comparison: 2 Conical blunt‐tipped trocar versus cutting trocar for secondary port entry, outcome: 2.3 Trocar site herniation.

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Figure 10

Forest plot of comparison: 3 Radially expanding trocar versus conical blunt‐tipped trocar for secondary port entry, outcome: 3.1 Visceral injury.

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Figure 11

Forest plot of comparison: 3 Radially expanding trocar versus conical blunt‐tipped trocar for secondary port entry, outcome: 3.2 Vascular injury.

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Figure 12

Forest plot of comparison: 4 Single‐bladed trocar versus pyramidal‐bladed trocar, outcome: 4.1 Visceral injury.

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Figure 13

Forest plot of comparison: 4 Single‐bladed trocar versus pyramidal‐bladed trocar, outcome: 4.2 Vascular injury.

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Analysis 1.1

Comparison 1 Radially expanding trocar versus cutting trocar for primary and secondary port entry, Outcome 1 Visceral injury.

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Analysis 1.2

Comparison 1 Radially expanding trocar versus cutting trocar for primary and secondary port entry, Outcome 2 Vascular injury.

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Analysis 1.3

Comparison 1 Radially expanding trocar versus cutting trocar for primary and secondary port entry, Outcome 3 Trocar site herniation.

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Analysis 1.4

Comparison 1 Radially expanding trocar versus cutting trocar for primary and secondary port entry, Outcome 4 Trocar site bleeding.

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Analysis 1.5

Comparison 1 Radially expanding trocar versus cutting trocar for primary and secondary port entry, Outcome 5 Trocar site haematoma.

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Analysis 2.1

Comparison 2 Conical blunt‐tipped trocar versus cutting trocar for secondary port entry, Outcome 1 Visceral injury.

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Analysis 2.2

Comparison 2 Conical blunt‐tipped trocar versus cutting trocar for secondary port entry, Outcome 2 Vascular injury.

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Analysis 2.3

Comparison 2 Conical blunt‐tipped trocar versus cutting trocar for secondary port entry, Outcome 3 Trocar site herniation.

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Analysis 2.4

Comparison 2 Conical blunt‐tipped trocar versus cutting trocar for secondary port entry, Outcome 4 Trocar site bleeding, intraoperative.

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Analysis 3.1

Comparison 3 Radially expanding trocar versus conical blunt‐tipped trocar for secondary port entry, Outcome 1 Visceral injury.

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Analysis 3.2

Comparison 3 Radially expanding trocar versus conical blunt‐tipped trocar for secondary port entry, Outcome 2 Vascular injury.

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Analysis 4.1

Comparison 4 Single‐bladed trocar versus pyramidal‐bladed trocar, Outcome 1 Visceral injury.

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Analysis 4.2

Comparison 4 Single‐bladed trocar versus pyramidal‐bladed trocar, Outcome 2 Vascular injury.

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Summary of findings for the main comparison. Radially expanding trocars compared to cutting trocars for laparoscopy

Radially expanding trocars compared to cutting trocars for laparoscopy
Patient or population: people undergoing laparoscopy Settings: surgical Intervention: radially expanding trocars Comparison: cutting trocars
Outcomes	*Illustrative comparative risks (95% CI)**		Relative effect (95% CI)	No of participants (studies)	Quality of the evidence (GRADE)	Comments
	Assumed risk	Corresponding risk
	Cutting trocars	Radially expanding trocars
Visceral injury	4 per 1000	4 per 1000 (0 to 60)	OR 0.95 (0.06 to 15.32)	473 (4 studies)	⊕⊝⊝⊝ very low^1,2	‐
Vascular injury	4 per 1000	1 per 1000 (0 to 28)	OR 0.14 (0.00 to 7.16)	473 (4 studies)	⊕⊝⊝⊝ very low^1,2	‐
Trocar site herniation Follow‐up: 6‐46 months	No events reported	No events reported	Not estimable³	463 (4 studies)	⊕⊝⊝⊝ very low^2,4	‐
Trocar site bleeding	115 per 1000	35 per 1000 (18 to 66)	OR 0.28 (0.14 to 0.54)	553 (5 studies)	⊕⊝⊝⊝ very low^2,4	‐
Trocar site haematoma⁵	See comment⁵	See comment⁵	Not estimable⁵	238 (2 studies)	⊕⊝⊝⊝ very low^2,4	‐
Postoperative pain⁶	See comment⁶	See comment⁶	Not estimable⁶	306 (4 studies)	See comment⁶	‐
The basis for the assumed risk* is the mean control group risk across studies. The corresponding risk (and its 95% confidence interval) is based on the assumed risk in the comparison group and the relative effect of the intervention (and its 95% CI). CI: confidence interval; OR: odds ratio.
GRADE Working Group grades of evidence High quality: Further research is very unlikely to change our confidence in the estimate of effect. Moderate quality: Further research is likely to have an important impact on our confidence in the estimate of effect and may change the estimate. Low quality: Further research is very likely to have an important impact on our confidence in the estimate of effect and is likely to change the estimate. Very low quality: We are very uncertain about the estimate.
¹ Downgraded one level due to high risk of attrition bias. ² Downgraded two levels due to imprecision: the number of events was fewer than 300 (the threshold rule‐of‐thumb value). ³ No events reported. ⁴ Downgraded one level due to risk of bias: in all included studies, high risk of performance bias, due to differences between groups for fascial closure or other types of port manipulation. Method of assessment mostly unclear. ⁵ Data could not be pooled because of clinical heterogeneity. ⁶ All studies provided insufficient statistical data, making it inappropriate to pool the data.

Summary of findings for the main comparison. Radially expanding trocars compared to cutting trocars for laparoscopy

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Summary of findings 2. Conical blunt‐tipped trocar compared to cutting trocar for laparoscopy

Conical blunt‐tipped trocar compared to cutting trocar for laparoscopy
Patient or population: people undergoing laparoscopy Settings: surgical Intervention: conical blunt‐tipped trocar Comparison: cutting trocar
Outcomes	*Illustrative comparative risks (95% CI)**		Relative effect (95% CI)	No of participants (studies)	Quality of the evidence (GRADE)	Comments
	Assumed risk	Corresponding risk
	Cutting trocar	Conical blunt‐tipped trocar
Visceral injury	No events reported	No events reported	Not estimable¹	42 (1 study)	⊕⊝⊝⊝ very low^2,3	‐
Vascular injury	No events reported	No events reported	Not estimable¹	42 (1 study)	⊕⊝⊝⊝ very low^2,3	‐
Trocar site bleeding	133 per 1000	20 per 1000 (2 to 246)	OR 0.13 (0.01 to 2.12)	30 (1 study)	⊕⊝⊝⊝ very low^3,4	‐
Postoperative pain⁵	See comment⁵	See comment⁵	Not estimable⁵	42 (1 study)	⊕⊝⊝⊝ very low^2,6,7	‐
The basis for the assumed risk* is the mean control group risk across studies. The corresponding risk (and its 95% confidence interval) is based on the assumed risk in the comparison group and the relative effect of the intervention (and its 95% CI). CI: confidence interval; OR: odds ratio.
GRADE Working Group grades of evidence High quality: Further research is very unlikely to change our confidence in the estimate of effect. Moderate quality: Further research is likely to have an important impact on our confidence in the estimate of effect and may change the estimate. Low quality: Further research is very likely to have an important impact on our confidence in the estimate of effect and is likely to change the estimate. Very low quality: We are very uncertain about the estimate.
¹ No events reported. ² Downgraded one level due to high risk of selection bias: unclear randomisation and allocation. ³ Downgraded two levels due to imprecision: the number of events was fewer than 300 (the threshold rule‐of‐thumb value). ⁴ Downgraded one level due to high risk of performance bias: personnel not blinded, unclear type and frequency of port manipulation. ⁵ Study provided insufficient statistical data, making it inappropriate to calculate adequate measures. ⁶ Downgraded one level due to risk of bias: attrition bias due lack of clarity on completeness of the outcome data and 'unit of analysis' issues and performance bias due to lack of clarity on degree and frequency of port manipulation. ⁷ Downgraded one level due to imprecision.

Summary of findings 2. Conical blunt‐tipped trocar compared to cutting trocar for laparoscopy

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Summary of findings 3. Radially expanding trocar compared to conical blunt‐tipped trocar for laparoscopy

Radially expanding trocar compared to conical blunt‐tipped trocar for laparoscopy
Patient or population: people undergoing laparoscopy Settings: surgical Intervention: radially expanding trocar Comparison: conical blunt‐tipped trocar
Outcomes	*Illustrative comparative risks (95% CI)**		Relative effect (95% CI)	No of participants (studies)	Quality of the evidence (GRADE)	Comments
	Assumed risk	Corresponding risk
	Conical blunt‐tipped trocar	Radially expanding trocar
Visceral injury	No events reported	No events reported	Not estimable¹	28 (1 study)	⊕⊝⊝⊝ very low^2,3	‐
Vascular injury	No events reported	No events reported	Not estimable¹	28 (1 study)	⊕⊝⊝⊝ very low^2,3	‐
Trocar site herniation	No events reported	No events reported	Not estimable¹	28 (1 study)	⊕⊝⊝⊝ very low^3,4	‐
The basis for the assumed risk* is the mean control group risk across studies. The corresponding risk (and its 95% confidence interval) is based on the assumed risk in the comparison group and the relative effect of the intervention (and its 95% CI). CI: confidence interval; OR: odds ratio.
GRADE Working Group grades of evidence High quality: Further research is very unlikely to change our confidence in the estimate of effect. Moderate quality: Further research is likely to have an important impact on our confidence in the estimate of effect and may change the estimate. Low quality: Further research is very likely to have an important impact on our confidence in the estimate of effect and is likely to change the estimate. Very low quality: We are very uncertain about the estimate.
¹ No events reported. ² Downgraded one level due to high risk of selection bias: unclear randomisation and allocation. ³ Downgraded two levels due to imprecision: Only 28 participants. ⁴ Downgraded one level due to risk of bias: attrition bias due to unclear loss to follow‐up and performance bias.

Summary of findings 3. Radially expanding trocar compared to conical blunt‐tipped trocar for laparoscopy

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Summary of findings 4. Single‐bladed trocar compared to pyramidal‐bladed trocar for laparoscopy

Single‐bladed trocar compared to pyramidal‐bladed trocar for laparoscopy
Patient or population: people undergoing laparoscopy Settings: surgical Intervention: single‐bladed trocar Comparison: pyramidal‐bladed trocar
Outcomes	*Illustrative comparative risks (95% CI)**		Relative effect (95% CI)	No of participants (studies)	Quality of the evidence (GRADE)	Comments
	Assumed risk	Corresponding risk
	Pyramidal‐bladed trocar	Single‐bladed trocar
Visceral injury	No events reported	No events reported	Not estimable¹	28 (1 study)	⊕⊝⊝⊝ very low^2,3	‐
Vascular injury	No events reported	No events reported	Not estimable¹	28 (1 study)	⊕⊝⊝⊝ very low^2,3	‐
Trocar site herniation	No events reported	No events reported	Not estimable¹	28 (1 study)	⊕⊝⊝⊝ very low^3,4	‐
The basis for the assumed risk* is the mean control group risk across studies. The corresponding risk (and its 95% confidence interval) is based on the assumed risk in the comparison group and the relative effect of the intervention (and its 95% CI). CI: confidence interval; OR: odds ratio.
GRADE Working Group grades of evidence High quality: Further research is very unlikely to change our confidence in the estimate of effect. Moderate quality: Further research is likely to have an important impact on our confidence in the estimate of effect and may change the estimate. Low quality: Further research is very likely to have an important impact on our confidence in the estimate of effect and is likely to change the estimate. Very low quality: We are very uncertain about the estimate.
¹ No events reported. ² Downgraded one level due to high risk of selection bias: unclear randomisation and allocation. ³ Downgraded two levels due to imprecision: only 28 participants. ⁴ Downgraded one level due to risk of bias: attrition bias due to unclear loss to follow‐up and performance bias.

Summary of findings 4. Single‐bladed trocar compared to pyramidal‐bladed trocar for laparoscopy

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Comparison 1. Radially expanding trocar versus cutting trocar for primary and secondary port entry

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1 Visceral injury Show forest plot	4		Peto Odds Ratio (Peto, Fixed, 95% CI)	Subtotals only

2 Vascular injury Show forest plot	4		Peto Odds Ratio (Peto, Fixed, 95% CI)	Subtotals only

3 Trocar site herniation Show forest plot	4	463	Peto Odds Ratio (Peto, Fixed, 95% CI)	0.0 [0.0, 0.0]

4 Trocar site bleeding Show forest plot	5	553	Peto Odds Ratio (Peto, Fixed, 95% CI)	0.28 [0.14, 0.54]

5 Trocar site haematoma Show forest plot	2		Peto Odds Ratio (Peto, Fixed, 95% CI)	Subtotals only

Comparison 1. Radially expanding trocar versus cutting trocar for primary and secondary port entry

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Comparison 2. Conical blunt‐tipped trocar versus cutting trocar for secondary port entry

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1 Visceral injury Show forest plot	1		Peto Odds Ratio (Peto, Fixed, 95% CI)	Subtotals only

2 Vascular injury Show forest plot	1		Peto Odds Ratio (Peto, Fixed, 95% CI)	Subtotals only

3 Trocar site herniation Show forest plot	1		Peto Odds Ratio (Peto, Fixed, 95% CI)	Subtotals only

4 Trocar site bleeding, intraoperative Show forest plot	1		Peto Odds Ratio (Peto, Fixed, 95% CI)	Subtotals only

Comparison 2. Conical blunt‐tipped trocar versus cutting trocar for secondary port entry

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Comparison 3. Radially expanding trocar versus conical blunt‐tipped trocar for secondary port entry

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1 Visceral injury Show forest plot	1		Peto Odds Ratio (Peto, Fixed, 95% CI)	Subtotals only

2 Vascular injury Show forest plot	1		Peto Odds Ratio (Peto, Fixed, 95% CI)	Subtotals only

Comparison 3. Radially expanding trocar versus conical blunt‐tipped trocar for secondary port entry

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Comparison 4. Single‐bladed trocar versus pyramidal‐bladed trocar

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1 Visceral injury Show forest plot	1		Peto Odds Ratio (Peto, Fixed, 95% CI)	Subtotals only

2 Vascular injury Show forest plot	1		Peto Odds Ratio (Peto, Fixed, 95% CI)	Subtotals only

Comparison 4. Single‐bladed trocar versus pyramidal‐bladed trocar

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Medical Subject Headings Check Words

PICO

PICO

Population

Intervention

Comparison

Outcome

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PICO

PICO

Population

Intervention

Comparison

Outcome

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