使用逆行性內視鏡檢查尋獲遺落於Airseal套管內的縫針 – 病例報告

蘇楷森¹、鍾孝仁^1,2、黃志賢^1,2 

¹臺北榮總泌尿部；²國立陽明交通大學書田泌尿科學研究中心

Retained Needle in the AirSeal Trocar Identified

by Retrograde Endoscopic Inspection – A Case Report

Kai-Sen Su¹, Hsiao-Jen Chung^1,2, William J. Huang^1,2

¹ Department of Urology, Taipei Veterans General Hospital;

² Department of Urology, School of Medicine and Shu-Tien Urological Science Research Center, National Yang Ming Chiao Tung University

Introduction:

Needle loss during laparoscopic operations is a potentially serious problem. Safe retrieval is challenging even for highly experienced surgeons. Here, we present a case of needle loss during robot-assisted laparoscopic radical prostatectomy (RaLRP), where the needle was entrapped by the Airseal trocar and was finally located using a unique retrograde endoscopic inspection approach.

Case report:

A 72-year-old male was diagnosed with prostate adenocarcinoma, with an initial prostate-specific antigen (iPSA) level of 82.6 ng/ml and a Gleason score of 4+4 based on biopsy results. Image staging revealed cT3a disease through preoperative multiparametric magnetic resonance imaging (mpMRI), with no evidence of lymphadenopathy or distant organ metastasis according to computed tomography (CT) and whole-body bone scan (WBBS). Given the impression of high-risk clinically localized prostate cancer, the patient underwent robot-assisted laparoscopic radical prostatectomy (RaLRP) as the initial treatment

The key surgical steps of the case were largely unremarkable. The patient was placed in a Trendelenburg position. We approached the prostate intraperitoneally from anterior aspect. Modified pelvic lymph node dissection was performed. The vesicourethral anastomosis was performed with 3-O Monocryl Suture. However, during the extraction of the 3-O Monocryl suture with a laparoscopic needle driver through the AirSeal trocar, a needle loss occurred.

A systematic search for the needle was initiated, including within the intra-abdominal space through endoscopic inspection, on the sterilized plane, and on the theater floor. The robotic 30-degree camera was introduced into the AirSeal trocar to evaluate the potential entrapment of the needle within the trocar. Despite thorough antegrade inspection, the needle was not visualized within the working lumen. The AirSeal trocar was temporarily removed from the abdominal wall for a thorough hand inspection, but nothing could be spotted from its outer appearance. Careful endoscopic exploration of the abdomen in a methodical manner did not reveal the needle intra-abdominally. We hesitated to perform a fluoroscopic search since it would require repositioning the patient from a Trendelenburg position to a supine position. Repositioning, if the needle is retained intra-abdominally, may cause further difficulty in retrieval or even bowel injury by the needle.

Finally, we introduced the robotic 30-degree camera through a robotic trocar and further advanced it from the intra-abdominal cavity into the AirSeal trocar to perform a retrograde in-lumen search. The needle was ultimately identified as entrapped at the evacuation filter of the AirSeal trocar, which was a blind spot for both antegrade endoscopic search and visual inspection of the outer appearance. The exhaustive search for the needle came to an end, and the remaining steps were completed smoothly.

Conclusions:

The use of an AirSeal system allows for a stable pneumoperitoneum and constant evacuation of surgical smoke. However, the port design exhibited a limitation by potentially allowing for the entrapment of the needle. The filter area of the AirSeal trocar serves as a blind spot for both direct visual inspection and antegrade endoscopic inspection, even with a 30-degree camera. Introducing the 30-degree camera from the trocar tip into the trocar body to perform a retrograde inspection proved to be an efficient way to detect needle retention at such a blind spot. We advocate for this approach during the search for a lost needle to identify in-lumen entrapment within the AirSeal trocar.