What techniques are recommended for macro bracing in trocar placement to minimize complications?

Macro Bracing in Trocar Placement

To minimize complications during trocar placement, use the smallest appropriate trocar size in an off-midline location, employ non-bladed (radially expanding) trocars, and close all fascial defects ≥10 mm. 1

Optimal Trocar Size and Location

The most critical preventive measure is using smaller trocars positioned off-midline whenever procedurally feasible. 1

• Trocar-site hernia rates significantly increase when trocars ≥10 mm are used, with incidence ranging from 0.1-1.0% overall 1
• Midline trocar placement carries substantially higher hernia risk compared to off-midline positioning 1
• The World Society of Emergency Surgery recommends selecting the smallest trocar size appropriate for the procedure and placing it off-midline when possible (Grade 2C recommendation) 1

Trocar Type Selection

Non-bladed (radially expanding) trocars demonstrate superior safety profiles compared to cutting trocars. 1

• Clear evidence shows statistically significant lower incidence of trocar-site hernias with non-bladed instruments 1
• Radially expanding trocars reduce trocar site bleeding risk from 11.5% to 3.5% compared to cutting trocars (Peto OR 0.28,95% CI 0.14-0.54) 2
• These trocars require less insertion force (mean 2.76 PSI) compared to reusable cutting trocars (mean 4.80 PSI), potentially reducing injury risk 3
• No intraoperative cannula site bleeding occurred with radially expanding trocars versus 16 episodes in cutting trocar groups 4

Safe Entry Technique

The "safe track" maneuver is mandatory before trocar insertion to confirm absence of interposed bowel loops. 1

• After local anesthetic application, advance the anesthetic needle while aspirating with the plunger 1
• Simultaneously confirm gastric/peritoneal puncture by visual inspection and air aspiration into the syringe 1
• This technique prevents inadvertent bowel injury during trocar placement 1

Direct trocar insertion with elevation of the rectus sheath using towel clips provides enhanced safety. 5

• This technique reduces total complication rates from 15.7% to 3.3% compared to blind Veress needle insertion 5
• Elevation of the rectus sheath (not just skin) creates a safer entry plane 5
• The open technique for first trocar placement shows zero visceral or vascular complications in 6,000 consecutive cases 6

Fascial Closure Requirements

Close all fascial defects from trocars ≥10 mm to prevent trocar-site hernias. 1

• The World Society of Emergency Surgery suggests closing fascial defects when trocars ≥10 mm are used (Grade 2C recommendation) 1
• Recent evidence comparing 5-10 mm ports shows no difference in hernia rates, though leaving fascia open may reduce operative time 1
• Radially expanding trocars create defects requiring closure in only 3% of cases, with no incisional hernias at 6-18 month follow-up 4

Single Incision Laparoscopic Surgery (SILS) Considerations

Avoid SILS when possible due to significantly higher incisional hernia risk; if performed, meticulous fascial closure is mandatory. 1

• Conventional multiport laparoscopy is strongly recommended over SILS (Grade 1B recommendation, moderate certainty of evidence) 1
• SILS demonstrates increased incisional hernia risk compared to traditional laparoscopy across multiple systematic reviews 1
• When SILS is unavoidable, meticulous fascial closure decreases hernia formation risk (99.1% panel agreement) 1

Common Pitfalls to Avoid

• Never skip the safe track maneuver - this single step prevents catastrophic bowel injury 1
• Avoid reusable trocars that have been previously used - they require 74% more insertion force (4.80 vs 2.76 PSI), increasing injury risk 3
• Do not place large trocars in the midline - this combination maximizes hernia risk 1
• Never leave ≥10 mm fascial defects unclosed unless using radially expanding trocars that create minimal defects 1, 4