Jain Point for First Blind Trocar Insertion: Fellows’ Perspective
Year: 2025
Type: article
Abstract: The essence to learning endoscopic surgeries lies in mastering entry and exit techniques. What happens in between is essentially a matter of patience, perseverance, and planning. The key to a good laparoscopic surgery is a confident entry and hence the need for the present review. Pelvic endoscopy is fraught with various complications. Primary access is often associated with injuries to the gastrointestinal tract and major blood vessels, the reported incidence being 0.4 and 0.2/1000 patients, respectively.[1] The gastrointestinal injuries may be classified as type I (due to the advancement of sharp instruments toward the posterior abdominal wall and encountering anatomically normal but distended bowel) and type II (due to visceral adhesions to the abdominal wall). Some of these injuries such as type II injuries may not be avoided even though the surgeon may be vastly experienced due to plastered bowel on the abdominal wall. This underscores the need for developing an impeccable technique for endoscopic entry into the female pelvis with a short learning curve and which eases the tension from beginner’s mind. Traditionally, we were told that there are two types of entry into the peritoneal cavity which include the closed and the open entry. The closed entry technique involves the insertion of a Veress needle (a needle equipped with a spring-loaded obturator) into the peritoneal cavity. Intraperitoneal insertion of the Veress is then confirmed by aspiration and free instillation of saline followed by Veress intraperitoneal insufflation pressure test. Pneumoperitoneum is created followed by primary trocar insertion. Finally, the laparoscope is passed through the trocar once the obturator is removed. Another variation of the closed technique described involves direct trocar entry without first introducing the Veress needle.[2] Hasson’s technique of first blind entry is described as open technique which involves incising skin, fat, rectus sheath and peritoneum followed by the insertion of a blunt trocar under direct vision, creation of pneumoperitoneum and insertion of laparoscope. The proponents of the technique cite prevention of vascular and visceral injury and avoidance of preperitoneal insufflations as its potential benefits. The point of entry of the Veress needle and primary trocar placement is an important question that requires careful consideration, and the approach has to be individualized depending on patient characteristics and history of previous surgery. Therefore, the surgeon has to be well versed with traditional and alternative entry points. Various points of entry have been described in the literature. The most often used approach is through the umbilicus or just infraumbilical. This entry point may often overlie adherent omentum and bowel in patients with previous surgery, and Veress needle/primary trocar insertion through this point may lead to a catastrophic sequel. Raoul Palmer[3] described an entry point which may be useful in obese or very thin patients, patients with previous midline abdominal incisions, large pelvic mass, anticipated adhesions or failed pneumoperitoneum. The point has been described 3 cm below the costal margin in the midclavicular line.[3] Contraindications to this approach include the presence of hepatomegaly, splenomegaly, portal hypertension, history of previous gastric/splenic surgery, or a palpable gastropancreatic mass. There is a real risk of injury to an overdistended stomach when entering through the Palmer’s point if the nasogastric tube has been placed incorrectly. Lee et al.[4-6] described an alternative entry site in patients with previous midline abdominal surgeries. Positioned midway between the xiphoid process and the umbilicus, this insertion site for the primary trocar provides a central anatomical view, facilitating head-to-foot orientation during surgery. Originally designed for laparoscopic para-aortic lymph node dissection, its application has since expanded to various gynecological laparoscopic procedures. They reported their experience with 188 laparoscopies with this approach of primary port insertion in which 184 surgeries (98.4%) were without any complication. They encountered two omental and one colonic injury during primary port insertion.[7] Agarwala and Liu[8] described their experience of laparoscopic surgeries in 918 patients with previous surgeries and suspected adhesions. They introduced Veress needle through the ninth intercostal space in the anterior axillary line along the superior margin of the lower rib. Pneumoperitoneum was created and primary trocar was then introduced through Palmer’s point. The complications included pneumothorax creation in three cases and one case each of bowel and gastric injury by Veress needle. This method was contraindicated in patients with contraindications to Palmer’s point entry as discussed previously. Ironically, all previous researches kept moving higher up in the abdomen to stave off adhesions. The authors, who are a group of young fellows in their nascent years in gynecologic endoscopy, were keen on learning various points of entry into the abdomen. During discussions, it was brought out that the major challenge was the first blind trocar insertion. The major retroperitoneal vessels (MRVs) beneath the umbilicus and over the sacral promontory were major deterrents in using this site as the first blind port of entry. Similarly, the possibility of injuring the liver, spleen, or overdistended stomach through Palmer’s point and its limitations in patients with hepatosplenomegaly or previous upper abdominal surgery led to search for an alternate entry point.[9] During our training in gynecologic endoscopy at Vardhman Hospital, we have incorporated the Jain point into our surgical practice as a first blind port. The technique[10] includes the insertion of Veress needle through Jain point, which is located in the left paraumbilical region at the level of the umbilicus, in a straight line drawn vertically upward from a point 2.5 cm medial to anterior superior iliac spine (ASIS). After marking the Jain point, the Veress needle is inserted straight, with a finger guard to control depth, without lifting the abdomen. As the needle is passed, two distinct pops are heard. The first pop is heard, when the needle passes through the external oblique aponeurosis. The second pop is heard when it pierces the fused aponeurosis of the internal oblique and transverse abdominis muscle followed by resistance-free passage of needle in the peritoneal cavity. During primary trocar insertion through the umbilicus, the abdominal wall needs to be lifted to avoid hitting the sacral promontory. Moreover, it requires assistance. Furthermore, when the surgeon and the assistant lift the overlying abdominal wall, often the pull is in different directions and the trocar may follow an unintended track. One of the prime benefits of Jain point, which we found of immense help, is that we can do away with lifting of the abdomen. There is also less incidence of complications such as preperitoneal insufflation leading to a more confident entry through the Jain point [Figure 1a and b].Figure 1: (a) Veress needle inserted from Jain point in the patient with previous surgery. (b) Trocar insertion at Jain pointAdditional ports are added under vision, with left lower operating port located approximately 10–12 cm from the Jain point.[10] Furthermore, using Jain point as a working port, we had the convenience of using ipsilateral ports and with ergonomic working for surgeons. While making first blind entry, we always had fear of injuring underlying MRVs, but Jain point, being paraumbilical, has the potential to avoid injury to it. The aorta and inferior vena cava lie in the midline and the iliac vessels are lower down near the pelvic brim. It also avoids superior epigastric and superficial epigastric vessels that are located within 5 cm of the midline. This strategic location alleviates the fear of vascular injury from our minds. Using the Jain point during our surgical procedures and its anatomical location in a nascent area of the abdomen has instilled confidence in us that there is a reduced risk of inadvertently entering any viscera or hollow viscus. As the sigmoid colon is way down at the pelvic brim, the stomach is higher up at the level of the 10th to 12th thoracic vertebrae, the spleen lies near the costal margin at the level of the tenth thoracic vertebra, and the kidneys are deep in the retroperitoneum. This region on the left side of the abdomen from the 12th vertebra till the pelvic brim has been found to be free of bowel adhesions [Figure 2].Figure 2: Trocar inserted at Jain point in the patient with multiple adhesionsDue to the higher and lateral location of the point, the chances of hitting a large pelvic mass during entry were remote. In patients with large masses, we observed that using the Jain point for laparoscopic entry avoids direct entry into the mass. This technique helps prevent undue bleeding from hitting a myoma, obscured vision, and spillage of ovarian cyst contents, which can lead to upstaging of diseases if it is found to be borderline or malignant.[11] Our fellowship experience confirms the ease of primary trocar insertion via the Jain point in cases with multiple previous surgeries[12,13] with some of the bizarre adhesions due to intestinal pathologies, colostomy, and colon pullback with multiple drain sites. Jain point sits outside the surgical area, accommodating scars across the upper, mid, and lower abdomen [Figure 3]. It can also be used in infective pathologies resulting in dense intra-abdominal adhesions like Koch’s, diverticulitis, sequel of septicaemia following T.O. abscess which can give rise to horrendous adhesions even without a previous surgery. Since our center is located in North India, which has the world’s highest prevalence of Koch’s, we have encountered several patients with frozen pelvis and extensive midline scars from the pubic symphysis to the xiphisternum due to previous surgeries where we could make a safe entry through Jain point. These patients typically have high adhesion scores.[14] We saw that in cases with scars on the left side, the mirror image of the Jain point on the right side can be utilized, unlike Palmer’s point, which poses a risk of liver injury on the right side.[10] Since the hospital now has an active urology department, we have seen urologists entering from the right side Jain point routinely.Figure 3: Trocar insertion at Jain Point in patient with multiple adhesions bands with densely adherent ovary and uterus to the anterior abdominal wallImplication of Jain point is not limited to gynecological surgeries alone. We have observed the Jain Point being utilized in concomitant procedures involving general surgical indications along with gynaecological procedures. These include surgeries such as TLH with cholecystectomy, appendectomy, hernia repair, and excision of mesenteric cysts. In these cases, the Jain Point initially serves as a working port during TLH and later functions as an optical port during cholecystectomy. Its adoption across various surgical specialties, including general surgery,[15] urology, gastroenterology, bariatric, oncology,[16,17] and robotic surgery[18] represents a paradigm shift in laparoscopic access, offering an adaptable and ergonomic solution to the challenges posed by previous surgeries in different subspecialties of endoscopy. The Jain point has low documented complications, with a general complication rate of 0.011% and slightly higher at 0.04% in cases of multiple previous surgeries.[9] This was observed by a team in over ten thousand cases over a period of 14 years, which laid the backbone of our learning. Minor issues, like omental emphysema in thin patients due to needle overshoot, were encountered in 2.7% of cases. Preperitoneal insufflation occurred during the learning phase but decreased over time.[13] Jain point has a short learning curve of 8–10 cases which helped us gain confidence in laparoscopic entry at a very early stage.[14] Harry Reich mentioned in his foreword for the book titled “Non-Umbilical Laparoscopic Entry Ports,” that the “Jain Point is the lowest among all entry port and has a prominent bony landmark, ASIS, hence may be best for routine use”.[19] In conclusion, a large case series suggests the safety and efficacy of the Jain point. It offers a reliable alternative, particularly in challenging cases with adhesions or contraindications to traditional entry points. As till now there are no known contraindications, the Jain point emerges as a scientifically validated option either as a first blind entry port or as a working port for novice and experienced surgeons alike. Declaration of Patient consent The authors certify that they have obtained all appropriate patient consent form. In the form, the patient has given her consent for her images and other clinical information to be reported in the journal. The patient understands that her name and initials will not be published and due efforts will be made to conceal identity, but anonymity cannot be guaranteed. Author contributions All authors were involved in carrying out the study. NJ and DG designed the analysis and drafted the manuscript; VJ, SS, BB and PS contributed to the editing and reviewing of the manuscript. All other authors contributed reviewing of the manuscript and approved the submitted version. Data availability statement The data supporting the results of this study are not publicly available due to patient confidentiality. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.
Institutions: Chhatrapati Shahu Ji Maharaj University, Ganesh Shankar Vidyarthi Memorial Medical College, University of Delhi, Kasturba Hospital, Baba Farid University of Health Sciences, M.J.P. Rohilkhand University, Maharashtra University of Health Sciences, King Edward Memorial Hospital and Seth G.S. Medical College, King George's Medical University, Banaras Hindu University, Bangalore Medical College and Research Institute, SMS Medical College, Institute of Medical Sciences, Post Graduate Institute of Medical Education and Research
Language: English
Subfield: Surgery
Field: Medicine
Domain: Health Sciences
Open Access status: diamond
OpenAlex ID: W4408470255