Abstract Introduction: The laparoscopic and robot-assisted laparoscopic surgeries are widely accepted in the pediatric urology practice.1 The small abdominal cavity and the elastic abdominal wall make it difficult to insert a trocar safely into the abdominal cavity because of tenting, especially in infants.2–4 The Hasson technique is preferred for insertion of initial trocar because of lower complication rates.5 Although the pneumoperitoneum that is created by using an initial trocar allows a direct observation by moving the intra-abdominal organs away from the abdominal wall, the insertion of the instrument trocar requires special care.2,6 Also, unbounded twisting movements and the excessive force that is applied to pass through the elastic abdominal wall may mislead the trocar in the abdomen, leading to vascular or visceral injury. We overcame tending problem by sling the abdominal wall with two retraction sutures before inserting the instrument trocar. This trocar insertion technique reduces the abdominal wall flexibility and the tenting of the peritoneum, providing an easy, fast, and safe penetration into the abdomen. Materials and Methods: Sixty-eight trocar accesses were evaluated retrospectively in 32 pediatric patients, who underwent laparoscopic (n = 11) and robot-assisted laparoscopic surgery (n = 21) in terms of duration to create pneumoperitoneum and insert instrument trocar along with the complications (January 2018 to December 2019). Surgical technique: initial paraumbilical trocar access and pneumoperitoneum were achieved by the Hasson open technique. After making a 0.3–0.5 cm skin crease incision and dissecting the subcutaneous tissue, fascia was identified. Fullthickness abdominal wall (fascia, muscle, and peritoneum) sling sutures were placed under direct vision. The suture placement has to include the peritoneum for maximum benefit. The suture material should be selected depending on the patients’ anatomy (4.0 or 3.0 Vicryl [CT-1, -2, or -3]). Elevating sling sutures at the corners of incision supports and strengthens the abdominal wall, reducing the flexibility of fascia and tenting of the peritoneum. During the trocar instrument insertion, sling sutures were elevated, and a minimal force was applied to the trocar with controlled twisting movements. Results: The median age of 32 patients was 8.4 years (range 6 months to 17 years). The median time of initial trocar insertion (n = 32) was 4 minutes (range 3–6 minutes), whereas the median time of an instrument trocar insertion (n: 68) was 2 minutes (range 1–3 minutes). The average follow-up time after surgery was 21 months (range 8–41 months). We did not experience any periods of pressure drop; neither we recorded any perioperative (vascular or visceral laceration) or postoperative (wound infection or incisional hernia) complications. Conclusion: Abdominal wall sling with two sutures reduces the flexibility of fascia and tending of the peritoneum, providing an easy, fast, and safe way to insert the instrument trocar into the abdominal cavity. To discuss the superiority of the method, further studies with comparison groups are required. No competing financial interests exist. The study design was approved by the institutional ethics review board. All surgical procedures were performed after obtaining informed consent from both parents of the patients. The authors received and archived the patient consent for video recording/publication in advance of the video recording of the procedure. Runtime of video: 4 mins 6 secs Keywords: trocar insertion, laparoscopy, robotic surgery, children Cite this video Bu¨ lent O¨ nal, Deniz Abdullahog˘lu, Emre Bu¨ lbu¨ l, Elif Altınay Kırlı, Fahri Yavuz _ Ilk, Abdominal Wall Retraction Sutures for Laparoscopic Trocar Insertion in Children, Videourology. 2020, DOI: 10.1089/ vid.2020.0051. References 1. Casale P, Kojima Y. Robotic-assisted laparoscopic surgery in pediatric urology: An update. Scand J Surg 2009;98:110–119. 2. Levitt MA, Tantoco JG. Operative endoscopy and endoscopic surgery in infants and children. London: CRC Press, 2005. 3. Tro¨ bs RB, Vahdad MR, Cernaianu G. Transumbilical cord access (TUCA) for laparoscopy in infants and children: Simple, safe and fast. Surg Today 2016;46:235–240. 4. Godbole PP, Koyle MA, Wilcox DT. Pediatric endourology techniques. London: Springer, 2007. 5. Yokomori K, Terawaki K, Kamii Y, et al. Anew technique applicable to pediatric laparoscopic surgery: Abdominal wall area lifting with wall area lifting with subcutaneous wiring. J Pediatr Surg 1998;33:1589–1592. 6. Pachl M, Sundararanjan L, Jawaheer G. Secondary port insertion for laparoscopic surgery in infants: A simple safe technique. Ann R Coll Surg Eng 2009;91:350. Original Publication Date: 2020
Bu¨lent O¨nal, MD Department of Urology, Istanbul University-Cerrahpasxa School of Medicine, Istanbul, Turkey. E-mail: email@example.com Deniz Abdullahog˘lu, MD Department of Urology, Istanbul University-Cerrahpasxa School of Medicine, Istanbul, Turkey. Emre Bu¨lbu¨l Department of Urology, Istanbul University-Cerrahpasxa School of Medicine, Istanbul, Turkey. Elif Altınay Kırlı, MD Department of Urology, Istanbul University-Cerrahpasxa School of Medicine, Istanbul, Turkey. Fahri Yavuz _ Ilki, MD Department of Urology, Istanbul University-Cerrahpasxa School of Medicine, Istanbul, Turkey.