Laypeople have described surgical procedures and hormone pellet insertion with a trocar as the "tiniest, kindest cut of all." Doctors have used trocars for over 150 years to drain accumulations of fluid, such as hydrothorax and ascites. Trocars are an essential tool for laparoscopic surgery and other minimally invasive surgical procedures.
But the trocars of today are nothing like the trocars of a generation ago.
These universally useful laparoscopic access systems have evolved from reusable bladed trocars to disposable bladed trocars to bladeless trocars. There are still dilating trocars, but there are also optical-view trocars without blades that allow the physician to visualize tissues as the instrument passes through them. The goal of all of these changes has been to minimize trauma to tissues, greatly reducing the risk of herniation after the physician removes the trocar.
Today's trocars require less pressure for insertion. Or the instrument may permit high pressure for insertion, and then "dial back" the pressure on the blade as the obturator advances. The less pressure insertion requires, the lower the risk of trauma from the procedure. Design innovations for the latest generation of trocars have also reduced the risk of injury during trocar insertion.
Innovations in trocar design allow physicians to perform procedures with instruments of a smaller diameter. Smaller incisions result in fewer hernias, or none at all. Smaller trocars also save office time, since a 5 mm incision through the fascia does not require stitches. Threading on the exterior of the cannula prevents slippage after insertion.
Let's take a look at some of the kinds of trocars used in office practice.
Bladed trocars provide a sharp blade that cuts through tissue for insertion. Because bladed trocars do not offer visualization, they cannot be used to initiate an incision.
Bladed trocars have fallen out of favor with surgeons for abdominal surgery because the risk of injury to the peritoneal wall and to abdominal organs without visualization is high. However, bladed trocars are still useful when there is a need to close a fascial defect, or the surgeon needs a trocar large enough for the insertion of an instrument through the fascia.
Non-optiview, non-bladed trocars push tissue out of the way as the physician applies pressure to the obturator, like dilating trocars. However, these devices require more pressure than dilating trocars.
Although this kind of trocar is often called “non-bladed” or “bladeless,” even blunt trocars still cut some tissue. However, there is a lower incidence of tissue injury with blunt trocars than with bladed trocars. Blunt tip trocars are less traumatic than bladed trocars. They are useful in operations like the insertion of a hormone pellet after the initial incision has been made.
Non-optiview, non-bladed trocars are considerably less expensive than optical trocars. After they are placed, they can be used from almost any position, and they are unlikely to cause fascial defects.
These trocars come in 5 mm, 10 mm, and 12 mm sizes.
Disposable, single-use, trocars do not require autoclaving for infection control. They do not add to paperwork and clerical time for inventory control.
Reusable, multiple-used, trocars have to be autoclaved and tracked through inventory. They may have a disposable component that surgical staff will need to replace each time the instrument is used. Keeping the obturator tip sharp is a common concern, since a dull blade increases the risk of injury to the patient, and cannulas require special attention through processing for additional use.
One of the most common applications of trocars and trocar kits is the insertion of hormone pellets for contraception and both femaleand male hormone replacement therapy. Commonplace applications of hormone pellets inserted by trocar include the insertion of progestin (Implanon) pellets for endometriosis pain, continuous hormone treatment for premenstrual syndrome, etonogestrel implants for male contraception, and insertion of testosterone pellets such as Testopel to provide continuous testosterone replacement for men with erectile dysfunction.
A trocar can be used for gluteal, inguinal, or abdominal insertion of hormone pellets. The nurse sterilizes the skin over the insertion site with betadine or a chlorascrub swab stick, and covers the incision site with a fenestrated drape.
Then the physician makes sure that a subcutaneous tract 5 to 7 cm long and at least 1 cm deep is anesthetized. It is necessary to get through thesubcuticular tissue along the entire length of the incision to avoid resistance.
The physician guides a sterile cannula with a sharp trocar about 4 cm distal into the subcutaneous tissue, from medial to lateral. The depth required depends on the amount of subcutaneous fatty tissue.
Next the doctor removes the sharp trocar, and places the hormone pellets into the well of the cannula with sterile forceps. The doctor inserts a blunt trocar into the cannula and advances the pellets beyond its tip, holding the cannula securely.
Next, the cannula and the blunt trocar are removed and the doctor applies pressure. The skin is taped with sterile strips, and the patient is asked to apply pressure to stop bleeding. The doctor disposes of the needle, scalpel, and sharp trocar into an appropriate container, and applies a dressing to the wound. The patient then applies pressure to the dressing for 3 up to 10 minutes.
What supplies are required in a trocar kit for hormone pellet insertion?
Every trocar kit needs to be complete, so the practice can avoid the time and expense of repeated processing of equipment through an autoclave. Disposable trocars also have the added advantage of being sharp when they are used.
Packaging also makes a difference: The kits should be stackable so they can be kept in an easily accessible location in the supply cabinet.
Trocar Supplies specializes in providing trocars for the insertion of extended-release pellets for hormone treatment. We feature products that minimize the risk of herniation, reduce the risk of infection, and leave patients with minimal post-procedural discomfort.Trocar Supplies sells disposable medical tray kits and trocar wrap kits. We offer disposable trocars just 3.5 mm wide, for either shallow or deep insertion. We also sell a reusable 3.5 mm stainless steel bevel or diamond tip, to be autoclaved between uses.