Diagnostic Peritoneal Lavage: Blunt Tip 5mm Trocar - Channeled Drain Technique, Novel Technique

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After scrubbing and draping of abdomen, a local anesthetic was injected supra umbilical in the dermal and subcutaneous layers. Two towel clips were applied at the superior edge of the umbilicus. A small longitudinal or transverse incision was made supra-umbilical. The towel clips were used to lift up strongly the abdominal wall in order to lift the abdomen wall away from bowel (Figure 1 a.b).

A 5 mm blunt tip trocar (Kii Access-Applied Medical) is introduced slowly using screwing clockwise - anticlockwise technique with a fine tilt toward the pelvis till the tip passes into the peritoneal cavity (Figure 2 a,b).

Figure 2. a, b: A 5 mm blunt tip trocar is introduced slowly using screwing clockwise - anticlockwise technique with a fine tilt toward the pelvis till the tip passes into the peritoneal cavity

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The obturator of trocar is taken out and then a 15Fr channeled Blake drain is advanced into the pelvic cavity. Using 30 ml syringe, a negative pressure is applied. If no effluent is coming out then 1 liter normal saline is introduced and withdrawn back using the syringe. The trocar was then taken out and only skin was closed (Figure 3 a, b).

Figure 3. a, b: The obturator of trocar is taken out and then a 15 Fr Blake drain is advanced into the pelvic cavity

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3. Results

Over a period of three years, eleven BAT male patients were subjected to the 5mm blunt tip trocar-Channeled drain DPL technique, with a mean age of 23.3±7.3 (15-52) years. In 9 patient (81.8%) the DPL was grossly positive for blood, subsequently a therapeutic laparotomy was performed in all these patients. Four (81.8%) of these patient were found to have liver laceration of grade 3, managed with packing and a second look laparotomy with removal of packs. Two patients (22.2%) was found to have splenic laceration of grade 3 an were all managed by splenectomy. In one patient (11.1%) the reason for bleeding was a mesenteric tear and in another patient (11.1%) he was found to have right diaphragmatic tear with lung laceration leaking blood into the peritoneal caving. In two patients (18.1%) the DPL was negative grossly and microscopically. In this DPL negative group of patients, one patient was having multiple pelvic fractures and the other patient was having bilateral femur fractures.

4. Discussion

Initially the of DPL been made under the name of abdominal puncture to diagnose acute abdominal diseases. In I906, Solomon 1 devised an ingenious but rather complicated apparatus that he recommended for abdominal puncture. It consists of a needle within a trocar, through which a ureteral catheter is passed into the peritoneal cavity. Solomon described a few cases in which the procedure appeared to be of value ^[6]. Diagnostic peritoneal lavage (DPL) has been used as a diagnostic procedure in patients with blunt abdominal trauma for almost a century. Its accuracy and reliability are high. However DPL is an invasive procedure and carries a small but significant risk of iatrogenic intra-abdominal injury ^[7].

DPL is performed in one of three different ways. The open technique utilizes a vertical infra-umbilical incision and direct visualization of peritoneal entry with a scalpel. The closed technique relies on percutaneous needle access to the peritoneal cavity, followed by the insertion of a catheter using Seldinger technique. The semi-open technique follows the same principles of the open technique except that the midline fascia is penetrated with a needle and the catheter is advanced using the Seldinger technique ^{[8, 9]}.

There is no difference in overall outcomes or rates of injury to visceral contents between the techniques. The closed method is faster, but often has more technical complications such as wire placement and inadequate fluid return ^[10].

Dingfelder was the first to publish in 1978 direct entry into the abdomen with a trocar. There are several retrospective studies published on the safety of this method of entry. Although a few studies were prospective, only three were randomized ^[11]. The methodology of the three RCTs is sound, and two reported on insertion time as well as morbidity and mortality. Nezhat et al. excluded past abdominal surgery but took into account BMI; they showed fewer minor complications with direct trocar entry than with the Veress needle ^{[12, 13]}. Such concerns would be also applicable with our technique especially previous infra - umbilical surgery.

Figure 4. Tip of the drain with its flutes

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