This comparative study was conducted during the period of January 2012 to December 2014. A total of 3000 cases were included with 1500 cases of open laparoscopy and 1500 cases of closed laparoscopy. The complications that occurred with the primary trocar, the Verres needle or opening the peritoneal cavity during open laparoscopy were only included in this study. The cases excluded from this study were: postoperative scar in the abdomen, past history of abdominal or pelvic tuberculosis, past history of puerperal sepsis, extremes of age (less than 10 years and more than 70 years), the cases with confusion regarding the time of injury or complications, and the cases of machinery failure for establishment of pneumoperitoneum. There were 16 cases with obesity and divided equally in both groups. Patients were followed up for 14 days following operation for delayed manifestation of complications which may occur during the phase of pneumoperitoneum or intended procedure. The results were presented in terms of percentages. The statistical significance of the differences between the two groups was tested by Fisher’s-exact test using Graph Pad online calculator and a p-value of less than 0.05 was considered as significant.

The cases were performed by one accredited general laparoscopic surgeons, one accredited gynaecological laparoscopic surgeons, one newly trained general laparoscopic surgeon and one newly trained gynaecological laparoscopic surgeon in three different institutions at Dibrugarh district, Assam, India.

Out of these 3000 cases; 800 were cases of cholecystectomy; 550 were laparoscopic assisted vaginal hysterectomy (LAVH); 450 were appendectomy only; 300 were diagnostic laparoscopy with chromopertubation for infertility; 250 were laparoscopic tubal occlusion (LTO) under GA; 250 were endometriosis; 150 were cholecystectomy with appendectomy; 150 were appendectomy with LTO and 100 were total laparoscopic hysterectomy (TLH).

The accredited general laparoscopic surgeons and gynaecological laparoscopic surgeons have experience of more than 8 years in laparoscopy and performed more than 1000 thousand cases individually and as assistant. The newly trained gynaecological and general laparoscopic surgeon performed all their cases in presence of the accredited gynaecological surgeon and accredited general laparoscopic surgeon respectively. In closed laparoscopy the primary trocar entry was tried through sub- umbilical longitudinal skin incision in 66.77% (1000) of the cases following pneumoperitoneum with Verres needle and in 33.33% (500) of the cases directly into the peritoneal cavity without prior pneumoperitoneum. The entry of the Verres needle was detected by double click sound, hiss test, loss of resistance and confirmed by aspiration test , saline drop test and initial intra-peritoneal pressure. In all the cases of open laparoscopy {Hasson technique} (1500) the cannula (without the trocar) entry was done after opening the peritoneal cavity with a small longitudinal sub-umbilical skin incision (1.3-1.5cm) followed by opening the rectus sheath with a triangular knife (size 11) in the same direction and separating it and the rectus muscle with straight artery forceps both transversely and longitudinally and picking up the peritoneum with same artery forceps and making a nick with separate triangular knife to open the peritoneal cavity.

Two different types of trocars were used in this study- metallic trocar with pyramidal tip 10mm (Olympus America) and WOM PM 1287-13-11;11mm (Germany). Both the trocars were used in equal number of cases in both obese and normal cases in both the techniques to avoid bias.

The abdominal cavity was thoroughly inspected after pneumoperitoneum for complications before the intended procedure and the complications were divided into major and minor depending upon the nature and severity of injuries. As this was a comparative study between open and closed laparoscopy, when closed laparoscopies were converted to open laparoscopies or laparotomies due to failure of pneumoperitoneum then it was considered as a major complication. On the same ground the cases which required laparotomy due to failure in opening the peritoneal cavity in open laparoscopy were considered as major complication. Difficulty in inserting the Verres needle or primary trocar is considered when two attempts fail to enter in to the peritoneal cavity. The minor complications were difficulty in primary trocar entry, abdominal bruise, localized emphysema, small haematoma, omental injury and bowel serosal injury. The major complications were failure to create pneumoperitoneum, emphysema extending up to the neck causing dyspnoea, bowel perforation, bladder perforation and mesenteric vascular injury.

Difficulty in primary trocar entry and bruise in the abdomen were the commonest minor complications observed in closed laparoscopy. In open technique difficulty in primary entry was not observed as the primary trocar was inserted only after opening the peritoneal cavity. As gripping of the abdominal wall was not required, bruising was rare in open technique and significantly high in closed technique. Leakage of gas was observed significantly more in the early part of the study in open laparoscopy because of a bigger incision which were managed by high flow rate (3L/min) of gas and purse string suture along with a wet piece of gauge in the skin in early part and by a absorbable purse string suture in the rectus sheath in the later part to maintain intra peritoneal pressure around 12 mmHg. Omental injury was observed in a few cases of closed technique which were dealt with bipolar coagulations. Injury to the bowel serosa was also observed only in early part of the study in open technique because of incising the peritoneum without properly lifting it with small curved artery forceps in three cases of endometriosis and in three cases of appendicitis.

Failure to create pneumoperitoneum was the commonest major complication observed in closed technique. In seven of these cases open technique was adopted and in three cases conventional laparotomy was carried out. The cases in which conventional laparotomy was required had adhesions under the umbilicus and they were not suspected at the time of primary trocar entry. The cases were later on diagnosed as endometriosis in one case and abdominal tuberculosis in two cases in histopathology. Only in two cases there was failure of pneumoperitoneum in open laparoscopy which later on came out to be abdominal tuberculosis on histopathology. The cases of emphysema extending up to the neck required ventilatory support for 12 hours. These cases were associated with difficulties in inserting the Verres needle because of obesity. Bowel perforations were observed in two cases with Verres needle and in one with primary trocar (Pyramidal tip). All of the bowel injuries occurred in the ileum and required laparotomy for repair. Bladder injuries caused by Verres needle were repaired laparoscopically. Mesenteric vessel injuries observed, one with Verres needle and in the other case with WOM trocar were detected & ligated following laparotomies. The complications occurred in the hands of the both accredited and newly trained surgeons. In one case of LTO sudden death occurred at the time of creation of pneumoperitoneum, which was likely to be due to major vessel injury and/or carbon di-oxide embolism. The cause could not be elucidated properly as the relatives refused to do autopsy [Table/Fig-1].

Technique of primary trocar entry in laparoscopy is still a debatable topic. No single method is suitable for all cases. Entry technique may be individualized in each case depending on proper preoperative evaluation and surgical skill. The different methods under evolution, to reduce complications need multi-centric studies for their safety and routine practical applicability. Our study was an effort to compare the complications in both the techniques and we feel more studies with bigger sample are required to compare both and their uses in different cases.

In our study, we did not find bowel perforation, bladder injury and mesenteric vessel injury in open laparoscopy. On the other hand, three (0.2%) cases of bowel perforations, two (0.13%) cases of bladder injury and two (0.13%) cases of mesenteric vessel injury occurred in closed laparoscopy. Shailesh kumar et al., reported abdominal wall emphysema in 12 (0.3%) cases, omental injury in 11 (0.28%) cases, small bowel injury in 2 (0.050%) cases, mesenteric vascular injury in 2 (0.050) cases of their total 4014 cases with Verres needle [14].

Christopher et al., in their national survey of 248 registered members of Canadian Association of General Surgeons reported that 50% of laparoscopic complications were entry related and most injury related litigations were trocar related [15]. In our study 13 (0.87%) cases of localised emphysema and two (0.13%) cases of severe emphysema occurred with closed laparoscopy. Pawan Lal et al., reported 2.91% (22) periumbilical haematoma out of 755 cases of modified open laparoscopy, but in our study sub umbilical haematoma was only 0.47% (7) in the open method [16]. A Pickersgill et al., reported leakage of gas in less than 5% cases out of 647 open laparoscopy [17]. We have found leakage of gas in 0.8% (12) and 1.8% (27) in closed and open laparoscopy respectively. Though leakage of gas was found more in cases of open laparoscopy, this as such did not increase the risk of the operation or delayed complication. Chapron et al., reported in a nonrandomized comparison of open versus closed laparoscopic entry practiced by university affiliated hospital teams. The bowel and major vessels injury rates were 0.04 % and 0.01% in the closed technique and 0.19% and 0% in the open technique respectively. They concluded that open laparoscopy does not reduce the risk of major complications in laparoscopic access [18]. Jansen et al., conducted a clinical trial that compared closed and open entry techniques and the complications rate were 0.07% and 0.17% for the closed and open technique respectively. The number of entry related complications with the open technique was significantly higher than with the closed technique [19]. Hasson et al., concluded that there is no evidence to support abandoning the closed entry technique in laparoscopy; however, the selection of patient for an open or alternative procedure is still recommended [3]. M Larobina and P Nottle in a meta analysis of 760,890 closed laparocopy and 22,465 open laparoscopy cases reported that the incidence of vascular injury rate in closed laparoscopy was 0.44% compared with 0% in open laparoscopy. The incidence of bowel injury was 0.7% compared to 0.5% respectively. The authors concluded that the open (Hasson) technique eliminates the risk of vascular injury and gas embolism and reduces the risk of bowel injury and recommended open technique to be adopted for primary laparoscopic entry [20].

Catarci et al., in retrospective analysis of 12919 cases reported major vessel injury 0.5% (7), visceral injury 0.6% (8) and minor vascular lesion in 0.07% (9) during creation of pneumoperitoneum. The rate of complications was 0.18% (20/10664), 0.09% (1/1135) and 0.27% (3/1009) in closed, open and optical trocar method respectively. They concluded that there is no foolproof method for the creation of pneumoperitoneum [21]. Adriana Toro et al., in their review literature cited that major vascular injuries caused by abdominal midline insertion of Verres needle occur even in the hands of experienced surgeons [1]. Schafer et al., evaluated 26 major vascular injuries and reported that only four (15%) of them caused by inexperienced surgeon (surgeons who had performed fewer than 50 laparoscopic procedures). The other 22 (85%) injuries had been caused either by experienced surgeons (51and 100 procedures) or very experienced surgeons (>100procedures) [22].

We have observed statistically significant difference in major and a few of minor complications in our study. It appears that open method is relatively safer technique as major complications are rare so in learning and beginning phase of the laparoscopic procedure this technique may be adopted. There is no safety mechanism in the Verres needle or primary trocar to prevent bowel injuries in case of sub umbilical adhesions. The safety of Verres needle or primary trocar entry in closed technique mostly depends on proper selection of cases, skill of the surgeon and must be considered as the utmost important part of the laparoscopic operation.