Fragmentation of a disposable trocar during laparoscopy

Abstract

Objective

To report a case of breakage of the tip of a disposable trocar in the course of laparoscopic surgery, and to seek to establish the causes of the incident, analyse the incident itself, and to attempt to draw conclusions, in order to prevent recurrences.

Results

This was an generally difficult laparoscopic procedure in an obese patient, but no notable incident occurred. Towards the end of surgery, we noticed the presence of small plastic fragments and saw that the 10-mm disposable trocar was broken at its tip. Because it would be difficult to locate the small clear fragments, even if the abdomen were incised, and despite the fact that the fragments were sharp, we decided not to convert to laparotomy. We retrieved as many fragments as possible via laparoscopy. The postoperative course was completely normal.

Conclusions

The case illustrates the actual occurrence of a theoretical risk. In order to reduce the risk to a minimum, impacts between plastic trocars and metallic instruments should be avoided. Despite the lack of reaction from the manufacturers, it may be useful to raise the standard of robustness demanded for this product.