Laparoscopic surgery began in the early 1990s with laparoscopic cholecystectomy. For many surgeons, it’s their first experience with laparoscopic surgery. In those early days, the variety of laparoscopic instruments was quite limited. However, as it quickly became evident that surgery was evolving in this direction, an impressive array of instruments began to emerge.

Trocars followed the same trajectory. Initially, rudimentary trocars were invented and used, although it is unclear when exactly they were first introduced. I vividly remember seeing my first trocar in the 1980s as a fourth-year medical student in the gastroenterology department, where a laparoscopic liver biopsy was being performed. The trocars we commonly use in laparoscopic surgery today were introduced in the late 1980s.

As you may know, a trocar consists of two main components: the cannula and the obturator. The obturator facilitates entry into the abdominal cavity, after which it is removed, leaving the cannula in place for surgical instruments to pass through. The obturator often has a bladed mechanism that cuts through soft tissue, fascia, and muscle. Once resistance is overcome upon entering the abdominal cavity, the blade retracts immediately into the obturator, completing its function and preserving the viscera from injury.

Dr. Harrith M. Hasson, an Egyptian gynecologist, developed and successfully used the first bladeless trocar. Today, this technique is widely preferred and is commonly referred to as the Hasson technique, with such trocars known as Hasson trocars.

Why Bladed Trocars Should Be Avoided

As indicated in the title, I firmly believe that bladed trocars should no longer be used, and I’d like to explain why. Let me share a Twitter exchange I had with my colleague, Edinburgh-based abdominal wall surgeon Andrew de Beaux. During a discussion about bladed trocars, Andrew referred to them as ‘Tools for cavemen’—a striking but entirely apt description.

Bladed trocars are associated with various complications, including:

• Abdominal wall injuries: Bleeding, hematoma, nerve damage leading to denervation and muscle atrophy, or chronic pain.
• Intra-abdominal injuries: These include potentially life-threatening damage to hollow organs (small intestine, colon, stomach, or bladder) and less frequently, vascular injuries. These injuries may sometimes go unnoticed during surgery, only to manifest later.
• Trocar site hernias: It’s much more common with the bladed trocars.

Bladed trocars create incisions wider than their actual diameter, unlike blunt trocars, which separate tissues without cutting them. This ensures smaller holes on the abdominal wall compared to the bladed ones and makes blunt trocars much safer, as they reduce the risk of abdominal wall trauma and trocar site hernia.

Practical Recommendations

To minimize complications, consider the following tips:

1. Always use blunt trocars, even for 5 mm sizes.
2. Opt for optical trocars to enter under direct visualisation.
3. Avoid using bladed trocars for initial entry—ideally, avoid them altogether.
4. Use the open (Hasson) technique when necessary.
5. If the abdomen has previously been entered (via laparotomy or laparoscopy), choose a safer alternative entry point.
6. Insert secondary trocars under direct visualisation.
7. Stick to trocars you are familiar with.
8. Avoid the midline (linea alba) when possible, as it is a weak point prone to herniation.
9. Close fascia for all trocar sites ≥10 mm. Use dedicated tools for this purpose if needed.
10. Do not place drains through trocar sites ≥10 mm.
11. Remove trocars under direct visualisation.

Final Thoughts

A surgeon must refine their technique to prevent the complications outlined above. By doing so, they ensure the safety and well-being of their patients while maintaining the highest surgical standards.

#SayNoToBladedTrocars