For more information, please visit Disposable Trocar Ease of Insertion.
Hormone pellet insertion is a useful way to provide men and women with effective hormone replacement therapy (HRT). The placement of the trocar during the pellet procedure plays an important role in the success of the treatment, so practitioners should be well-versed in proper trocar placement for different patients.
Here’s what to know about the best HRT trocar placement sites, how to choose the right size trocar kit, and effective techniques for patient insertion.
Trocar insertion is easy with a disposable trocar kit and most medical practitioners can usually complete the entire procedure in just a few minutes. Patients may feel some pressure and discomfort, but insertion isn’t painful for most people.
First, the patient is positioned on the procedure table, so the practitioner can access the trocar insertion site. Then, the sterile field is prepared and the patient is cleaned and numbed for the insertion procedure. A small incision is made into the subcuticular tissue and the trocar is inserted at a 45-degree angle to place the pellet deep into the fat layer.
Once the pellet is inserted, the trocar is removed and pressure is applied to the incision. Disposable trocar kits can then be thrown away in their entirety, without the need forsterilization and prep for the next procedure. The incision can be closed with Steri-strips or a few dissolvable stitches depending on the provider's preference.
It’s imperative that practitioners choose a placement site based on each patient’s weight, medical history, and other individual circumstances. Choosing the wrong site for someone can lead to prolonged discomfort for the patient and can make the pellet more likely cause problems. Here are the most common HRT pellet placement sites and how to choose the area for the right patient:
For most people receiving hormone therapy, HRT pellets are placed in the upper outer region of either the left or right buttock, below the waistline. This allows for the pellet to be inserted into an area with maximum fat retention and minimum external interference.
Abdominal Insertion Placement
Abdominal placement may be ideal for patients who have more body fat around their abdomen than in their hips and buttocks. The pellet may be inserted into any fatty tissue in the lower abdomen between the groin and the waistline, which gives medical providers more flexibility when choosing a surgical site.
However, this placement site may not be a good choice for very overweight patients or whose fat distribution is largely in their abdominal area due to the risk of pellet migration.
Flank insertion is also a commonly used insertion site.
Inguinal placement is uncommon for pellet therapy, but it may be used in some circumstances where abdominal and gluteal placement aren’t desirable. For this procedure, the pellet is inserted low in the groin area below the swimsuit line, either to the left or right of the navel.
Choosing the right sizetrocar kit is crucial for procedure success. An improperly sized kit will result in poor pellet placement, potentially causing infection, pellet rejection, and other complications.
Trocar kits generally come in three sizes:
3.2 mm
– Short trocars are better suited for thin patients and individuals without much body fat in the ideal insertion areas.
3.5 mm
– These standard-size trocars are the most commonly used for pellet insertion for patients with average body types.
4.5 mm
– Long trocars are required for proper pellet insertion for overweight or obese patients.
Each size can be purchased with either adiamond orbevel tip for minimal tissue damage and maximum results.
No two pellet insertion procedures are the same, and it’s critical for medical providers to take into account each patient’s condition, body size, and other individual criteria before choosing a trocar size and placement site for someone. Providers can help reduce the increased risk of complications for certain patients by adjusting the trocar insertion procedure to suit their specific needs.
For example, patients with bleeding disorders may still be a candidate for pellet therapy if a provider uses abdominal placement in a less vascular area. Or, patients who are prone to keloid scarring may be able to have their pellet inserted in the inguinal area to keep the scar below the bikini line.
Here are some more helpful tips for proper trocar insertion and pellet placement for different types of patients:
Overweight andobese patients typically require insertion with longer trocars to ensure that pellets are placed deep enough into the patient’s fatty tissue to work properly. Medical practitioners may also need to make a larger incision to adequately position the hormone pellet.
Patients with larger bodies are well-suited to gluteal placement, since abdominal placement may be more difficult with overlapping areas of skin and fatty tissue. Inguinal insertion is generally contraindicated for patients with a large panniculus that extends over the groin, regardless of whether they are male or female.
Patients who are very thin need a delicate hand when it comes to trocar insertion and pellet placement. Usually, shorter trocars are better for these individuals and smaller incisions can be made to accommodate them.
Which area is best for insertion depends on the patient’s body fat distribution. Even if they have very little, try to choose the area with the thickest subcutaneous layer. This is often in the gluteal region, but may be in the abdomen.
Trocar Supplies is a leading provider of HRT medical devices and disposable trocar kits for pellet therapy. We offer a broad selection of different size trocars to choose from, and each tray is specifically designed for the practitioner’s convenience and ease of use.
Browse ourproduct catalog today orcontact us by calling (937) 478-0469, and we’ll be happy to answer your questions and guide you to the right products for your practice needs.
Reusable trocars have the advantage of being more cost-effective than disposable trocars. However, the reusable trocar does lose its sharpness on insertion with repetitive insertion. Nonreusable trocars are expensive, but the sharpness of the knife facilitates insertion. Nonreusable trocars have a safety shield system designed to decrease abdominal organ injury, though the potential problem of bleeding from the abdominal wall port site has yet to be resolved. We therefore developed a novel ultrasonic vibrating trocar that does not lose its sharpness even with repetitive insertion. This trocar prevents bleeding by means of an ultrasonic cavitation effect. The ultrasonic vibrating trocar has the advantage of ease of insertion, and the force required for new reusable trocar insertion was only 34% of the force required for insertion of commercially available nonreusable trocars. The force required for multiply used conventional reusable ultrasonic vibrating trocar insertion, ie, 900 insertions, was maintained at less than 46% of the force required by the corresponding nonreusable trocars. Bleeding from the abdominal wall was prevented by an ultrasonic cavitation effect.
Keywords:
Ultrasonic device, Trocar, Cavitation, Abdominal organ injury
Endoscopic surgery, either by laparoscopy or thoracoscopy, was achieved through a trocar that inserted into the cavity where the target organ was located. All surgeons were obliged to use trocars as long as they adopted the CO2 gas insufflation method. Because the first trocar was always inserted through the abdominal or chest wall, a risk has always been present of inadvertently injuring an abdominal or thoracic organ,1,2 as well as the possibility of bleeding. Two types of trocars, reusable and disposable, are available. We have often used the disposable trocar because of its sharpness on insertion. Reusable trocars have the potential advantage of costing less than disposable trocars, if they can be used many times without losing the sharpness of the knife. Dull reusable trocars might tear the abdominal wall much more than a sharp disposable trocar on insertion. Injury on insertion of the trocar has been among the possible major complications of laparoscopic surgery. The safety shield system in which the knife popped in and out across the tip of the trocar was later developed, and this improvement has decreased injuries.3 However, a problem that surgeons cannot ignore has remained in regard to the procedure for inserting the trocar: bleeding from abdominal wall muscles torn by the trocar knife. Drops of blood along the trocar conceal the target organ from laparoscopic view and create problems for surgeons. In a French survey, this accounted for 38% of all trocar accidents.4
We developed an ultrasonic (US) vibrating trocar, the sharpness of which was not diminished even with more than 900 repetitive insertions, overcoming the disadvantages of commercially available trocars, and also preventing bleeding from the tract at insertion. However, the friction due to movement of the obturator generated heat in the adjacent tissue along the insertion tract. This novel instrument raises the possibility of delaying wound-healing reactions. Therefore, we examined the degree of histological damage along the insertion tract and the recovery of abdominal wall tension by comparing port-site skin tensile strength with each trocar, in a porcine model.
A generator and ultrasonic vibrating trocar (Olympus Optical Co., Tokyo, Japan) were used in this study. The frequency of the generator was set at 23.5 kHz, the vibration amplitude at 150 µm. The ultrasonic trocar is composed of an obturator, which conducts ultrasonic vibratory movements, and a trocar ( ). The diameter of the obturator is 12.6 mm, and the diameter of the trocar is 14.8 mm.
Open in a separate windowSwine were purchased from Sumichiku Limited, and six 9- to 11-week-old female swine were raised on specific-pathogen-free food for young swine purchased from Shimizukou Feed Company. Tap water was provided for drinking. General anesthesia was achieved with midazolam (Yamanouchi, Japan) 0.2 mg/kg and medetomidine hydrochloride (Meiji Seika, Japan) 40 µg/kg for presedation, ketamine hydrochloride (Sankyo, Tokyo, Japan) 10 to 15 mg/kg for induction, and Isoflurane (Dainihon Pharm. Co., Japan) 2% to 3%. Sodium sulbactam/sodium ampicillin (1.5g) was administered intravenously during the operation. Veterinary ampicillin was administered orally (2 g/day) for 5 days after the operation.
The phantom was a block of swine muscle 200 mm x 300 mm x 35 mm. The ultrasonic trocar attached to a Digital Push-Pull gauge (Aiko Engineering Co., Tokyo, Japan, Model-9500) ( ) was pushed into the muscle block, and the strength of the force was measured and recorded by a computer. Four trocars were compared: a new ultrasonic trocar (USN), a conventional trocar (USO) that had been inserted 900 times, a 12-mm Dilating tip (DT) trocar (Ethicon Endosurgery, USA) and a 12-mm VERSAPORT (VE) trocar (US Surgical Co., Tokyo, Japan). The force required for insertion into the abdominal wall could be varied according to the means of insertion. Rapid and forceful insertion required much more force than gentle insertion. Therefore, we kept in mind the necessity of arranging the times for insertion so as to be the same length, and compared the levels of force among the trocars. It took an average of 6.5 seconds to completely insert the new and conventional US trocars; the average insertion time was 6.6 seconds for the DT trocar and 6.4 seconds for the VE trocar. Each trocar was inserted 10 times, and the insertion force was recorded. The average force was calculated and statistical significance was evaluated with the Student t test.
Open in a separate windowFor more Surgical Staples Made ofinformation, please contact us. We will provide professional answers.
Six animals were used in this experiment. An 18-mm incision was made in the skin of a pig, and the US trocar, Dilating Tip trocar, and VERSAPORT trocar were inserted into the abdominal cavity through the incision. Trocars were then removed, and the wound was closed with 2 skin staples. Bleeding from under the skin was equally controlled by monopolar electrocautery with all 3 types of trocars. In the actual procedure, 1 vertical full-thickness skin stitch up to the muscle fascia layer was placed 1 cm from the wound line, and the suture was retracted with a Digital Push-Pull gauge. The force at which the wound opened 5 mm was recorded as the break strength. Each of the trocars was tested at 4 sites in each animal.
The port site not used in the tensile strength evaluation was saved for pathological examination. The full thickness of the abdominal wall around the port was removed, fixed with formalin, and stained with hematoxylin-eosin (HE). The specimens were examined for degree of wound healing.
The temperature around the port site was measured and recorded with a Thermal Video System TVS 8000 (Nihon Avionics, Tokyo, Japan) to detect temperature elevations. The ultrasonic vibrations stopped when the trocar tip entered the cavity through the peritoneum. Statistical analysis was performed with the Student t test, and P <0.05 was considered significant.
We compared the force necessary to insert the trocar through swine muscle ( ). The new and conventional US trocar insertion forces were significantly less than the forces of the other 2 trocars, but the insertion procedure was performed in almost the same time. The DT and VE trocars required the same level of force.
The respective break forces at 1 and 2 weeks were 2.4 ± 0.7 kg (n = 4) and 4.8 ± 0.3 kg (n = 4) for the US trocar, 1.3 ± 0.2 kg (n = 4) and 5.7 ± 0.6 kg (n = 3), for the DT trocar; and 2.9 ± 0.9 kg (n = 4) and 3.9 ± 0.4 kg (n = 4) for the VE trocar ( ). The break forces for the US and VE trocars were higher than that of the DT trocar at 1 week, while that of the DT trocar was highest at 2 weeks.
Open in a separate windowThe widths of the scars made by the trocars were compared. The US trocar scar was larger than the DT trocar scar. Degenerative changes caused by burning were found in the muscle tissue when the US trocar was used. This change was thought to be due to heat generated by friction. No difference was found between the US and DT trocars in the epidermal layer ( ).
Open in a separate windowWe measured temperature changes produced by the US trocar because the other 2 trocars did not produce friction that generated heat. Skin temperature around the port site started to increase after the trocar was inserted, and rose to 78.8°C just before the peritoneum was broken. The temperature gradually decreased thereafter, and fell to 43.2°C in 30 seconds.
We developed an ultrasonic trocar that does not lose blade edge sharpness, and prevents the problem of bleeding. This instrument decreased bleeding. The insertion force of the new US trocar through the abdominal wall was 34% of the force required by commercially available DT trocars. We examined the force with the conventional US trocar, which had been used 900 times. The conventional US trocar insertion force decreased to only 22% less than that of the new US trocar, maintaining ease of insertion as compared with other trocars. The value of the insertion force for the conventional US trocar was only 42.3% of that of the DT trocar, and 45.8% of that of the VE trocar. The US trocar maintained its capacity even with 900 insertions, and this novel instrument had the added advantage that the heat generated by friction between the ultrasonic vibrating trocar and adjacent tissue induced protein denaturation and thereby decreased bleeding. The force of the US trocar insertion was less than that required by the DT and VE trocars. This meant that the US trocar was inserted through the abdominal wall more easily than either the DT or the VE trocar.
When we did not insert the trocar smoothly through the abdominal wall, we pushed the trocar more forcefully than usual. Champault5 reported 7 perioperative deaths due to vascular injuries. The insertion force through the abdominal wall by the US trocar was less than that required by either the DT or the VE trocar. The US trocar had the advantage of a lower probability of abdominal organ injury when not vibrated, even when an organ was touched, because the edge of the US trocar tip was made nontraumatic in order to decrease injuries. Therefore, we speculated that the US trocar might decrease the probability of injuring an abdominal organ, or vessels, or both, and thereby decrease potentially fatal complications. This observation indicated that we had developed a reusable trocar with the advantage of cost-effectiveness.
We have often experienced stress due to unexpected bleeding from the port site. Bleeding from the port requiring conversion to open surgery was reported in 10 out of 537 cholecystectomies in the Japan Society of Endoscopic Surgery 1998 Survey.6 We have used US tro-cars in clinical practice since 1998 and have performed 35 cholecystectomies, 5 gastrectomies, and 10 colonic resections. We have never encountered bleeding when inserting the US trocar. This advantage may be attributable to the nontraumatic tip of the US trocar, which decreased the likelihood of injuring vessels and may also be ascribed to the ultrasonic vibrating tip dividing tissues and thereby preventing vessels from being torn.
The US trocar produced friction that generated heat in adjacent tissues. Despite the wider scar generated by the US trocar, as compared to the DT trocar, in HE-stained specimens, the tensile strength of port site at 1 week was 2.4 kg, which was no less strong than those of the others. The strength at 2 weeks was 4.8 kg and was almost the same as the 5.7 kg achieved with the DT trocar and was stronger than the 3.9 kg achieved with the VE trocar. These findings confirmed the absence of clinical problems in regard to the tensile strength of the port site with the US trocar. However, this thermal scar might allow surgeons to add a stitch between the fascia split made by the US trocar.
The skin burn injury associated with temperature elevation has the potential to delay the healing process. Shortening the time of contact between the obturator and tissue could decrease the degree of the burn injury. This was accomplished by making the trocar surface smoother and thinner, which decreased resistance during insertion and allowed the trocar to be inserted quickly. The issue of the burning effect on the peritoneum remains to be resolved, but it is anticipated that resolution will be achieved with a smoother and thinner trocar.
We developed a reusable ultrasonic vibrating trocar that could be bloodlessly and smoothly inserted more than 900 times through the abdominal wall. This instrument is inexpensive and is anticipated to decrease organ injury and other complications.
Blind versus open approach to laparoscopic cholecystectomy. A randomized study
.Surg Laparosc Endosc
. 1998;8
:353–355 [Google Scholar]Cogliandolo A, Manganaro T, Saitta FP, Micali B.. 1998;:353–355 [ PubMed
1.
Trocar injuries during laparoscopic gynaecological surgery. Report from the French Society of Gynaecological Laparoscopy
.Gynaecol Endoscopy
. 1998;7
:235–241 Google Scholar]Marret H, Harchaoui Y, Chapron C, Lansac J, Pierre F.. 1998;:235–241
2.
Comparison of direct insertion of disposable and standarad reusable laparoscopic trocars and previous pneumoperitoneum with Veress needle
.Obstet Gynecol
. 1991;78
:148–150 [Google Scholar]Nezhat FR, Silfen SL, Evans D, Nezhat C.. 1991;:148–150 [ PubMed
3.
Complications of laparoscopic cholecystectomy: a national survey of 4,292 hospitals and an analysis of 77,605 cases
.Amer J Surg
. 1993;165
:9–14 [Google Scholar]Deziel D, Millikan KW, Economou SG, Doolas A, Ko ST, Airan MC.. 1993;:9–14 [ PubMed
4.
Serious trocar accidents in laparoscopic surgery: a French survey of 103,852 operations
.Surg Laparosc Endosc
. 1996;6
:367–370 [Google Scholar]Champault G, Cazacu F, Taffinder N.. 1996;:367–370 [ PubMed
5.
JSES
. 1998;3
:510–580 Google Scholar]Japan Society of Endoscopic Surgery survey. 1998;:510–580
6.
Want more information on Cervical Punch Biopsy Forceps Endoscopy? Feel free to contact us.