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Comment and Controversy

Use of laparoscopic instruments challenged

November 2002 · Vol. 14, No. 11
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I would like to congratulate Dr. John George on his very thorough article, “Laparoscopic evaluation of the pelvis: refocusing on the basics” [September].

I do, however, have 2 concerns. First, Dr. George states that the surgeon should “insert a…0° laparoscope into the channel of a 10-12 transparent, bladeless trocar.” I do not know of any data suggesting that a 10-12 transparent bladeless trocar is any safer or easier to use than a simple reusable metal trocar. If Dr. George’s recommendation is based on any scientific data, I would enjoy seeing that information.

I have found ultrasonic shears to be slow and relatively useless in many of the 8,000 laparoscopic procedures I have performed in the last 20 years.

Second, Dr. George suggests the surgeon “consider using ultrasonic shears to minimize thermal injury to the bowel.” Again, I am not aware of any study published in a peer-reviewed journal that reaches this conclusion and would appreciate any data that supports his claim. Although I have no argument with another surgeon choosing to use this technology, I personally have found it to be slow and relatively useless in many of the 8,000 laparoscopic procedures I have performed in the last 20 years.

If the use of transparent bladeless trocars and ultrasonic shears are simply Dr. George’s preference, it should be stated. Otherwise, it appears as though Dr. George could be promoting certain products or companies.


Dr. George responds:

While I have never met Dr. Johns, I am familiar with some of his publications relevant to Gyn endoscopy. He is obviously a well-accomplished endoscopist, having performed more than 8,000 procedures. I respect his opinion, and am flattered that he has made positive comments about my article. His suggestion, however, that 2 of my statements are commercially motivated have no basis in fact.

In all phases of laparoscopy, I strive for patient safety. It is well recognized that the blind phase of laparoscopy—abdominal entry—is the most hazardous.1 Complications have been described with open as well as closed techniques, and with all varieties of trocar systems, including shielded trocars and those with optical enhancement.2,3 Until scientific data indicates superiority of any method, I will continue to recommend the promotion of patient safety by selecting patients wisely, using safety precautions in high-risk patients, minimizing the blind phase, and using preferred techniques of trocar insertion as mentioned in the article.

I adopt a similar philosophy in the use of energy sources. Whenever possible, I lyse adhesions mechanically using scissors. When an energy source is indicated, the risk of thermal injury is assessed. For the physician skilled in electrosurgery, that modality is relatively safe and cost-effective. Thermal injury may be difficult to predict, regardless of the surgical expertise of the operator and his knowledge of the physics of electrosurgery. The hazards of monopolar electrosurgery are many. Electron density, the flow path of electrons, capacitance coupling, and lateral thermal spread are features which, if not well understood, pose risk of patient injury out of the operative view field. The ultrasonic shears is an alternative with less inherent risk of thermal injury.

When data is not yet available, we should use current knowledge, along with a commonsense approach, to provide safe, quality care to our patients.

Undoubtedly, gynecologic endoscopy has made dramatic progress in the past 25 years. During this time, it has survived the criticisms of those who would claim “no scientific data,” as proven techniques of minimally invasive surgery began to supplant traditional methods with resulting patient benefits. We must shape our practice on a solid scientific foundation. However, when data is not yet available we should use current knowledge, along with a common-sense approach to provide safe, quality care to our patients.


1. Leonard F, Lecuru F, Rizk E, Chasset S, Robin F, Taurelle R. Perioperative morbidity of gynecological laparoscopy. A prospective monocenter observational study. Acta Obstet Gynecol Scand. 2000;79(2):129-134.

2. Bhoyrul S, Vierra MA, Nezhat CR, Krummel TM, Way LW. Trocar injuries in laparoscopic surgery. J Am Coll Surg. 2001;192(6):677-683.

3. Corson SL, Chandler JG, Way LW. Survey of laparoscopic entry injuries provoking litigation. J Am Assoc Gynecol Laparosc. 2001;8(3):341-347.

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