SUBMITTED 20 DEC 22 1 REVISION REQ. 21 FEB 23; REVISION RECD. 1 MAR 23 2 ACCEPTED 22 MAR 23 3 ONLINE-FIRST: MAY 2023 4 DOI: https://doi.org/10.18295/squmj.5.2023.027 5 6 Intraoperative and Postoperative Outcomes of Modified Bidirectional Intra-7 Umbilical versus Infra-Umbilical Incision for Direct Trocar Insertion in 8 Gynecological Laparoscopy 9 A randomized controlled trial 10 *Atef Darwish, Mohammad Tawfik, Amal Gaflan, Dina Darwish 11 12 Department of Obstetrics & Gynecology, Women’s Health University Hospital, Assiut 13 University, Assiut, Egypt. 14 *Corresponding Author’s e-mail: atef_darwish@yahoo.com 15 16 Abstract 17 Objectives: To describe a modified curved deep bidirectional intra-umbilical vertical incision for 18 primary trocar insertion and prospectively compare its intraoperative and postoperative outcomes 19 with infra-umbilical incision in gynecologic laparoscopy. Methods: Between August 2019 and 20 March 2021, 110 patients subjected to direct trocar insertion technique for laparoscopic 21 intervention were classified into two groups. Group A comprised 55 cases of infra-umbilical 22 incision while a modified curved longitudinal bidirectional deep intra-umbilical incision was 23 used in group B (55 cases). Intraoperative and postoperative assessments were performed. 24 Results: There was statistically significant increased numbers of parity, gravidity, and previous 25 cesarean sections; and a smaller number of infertility complaints in group B. Likewise, group B 26 expressed a statistically significant less peri-trocar CO2 leakage (46 patients, 83.6% versus 28 27 patients, 50.9%) and more tightness of the primary portal entry (45 patients, 81.8% versus 30 28 patients, 54.5%) if compared to group A throughout the whole operation. On follow-up after one 29 month, there was a statistically significant (p-value = 0.029) decreased OSAS and PSAS in 30 mailto:dr.abdullahalalawi@gmail.com group B (10.4 ± 4.2 and 11.8 ± 4.3) i.e., better cosmoses when compared to group A (13.3 ± 5.7 31 and 16.0 ± 6.8) respectively. Conclusion: Performing a modified curved deep bidirectional intra-32 umbilical vertical incision for insertion of primary laparoscopic trocar is a simple and fast step 33 that results in elimination of intraoperative gas leakage and trocar slippage without the need of 34 any additional sutures. Aesthetically, it results in a better scar with satisfactory cosmoses if 35 compared to infra-umbilical incision. 36 Keywords: Laparoscopy; Trocar; Entry. 37 38 Advances in Knowledge: 39 • Primary trocar umbilical insertion for laparoscopy is the commonest approach. 40 • Modified technique results in less gas leakage and trocar slippage. 41 • It is more cosmetic if compared to other access techniques. 42 43 Application to Patient Care: 44 • Umbilicus cosmoses is important particularly for females. 45 • The proposed method for laparoscopic entry will help preserve umbilicus cosmoses as it 46 is totally intra-umbilical. 47 48 Introduction 49 Nowadays, laparoscopic surgery is a well-established modern tool for treating many 50 gynecological disorders as it is followed by rapid wound healing, short hospital stay, less 51 postoperative pain, and better aesthetic results.1 Different laparoscopic entry techniques include 52 Veress needle insertion, open laparoscopy, and direct trocar insertion without a statistically 53 significant difference regarding patient safety.2 Nevertheless, direct trocar insertion is gaining 54 popularity.3 Postoperative umbilical scar cosmoses and appearance are important issues for 55 women. As the umbilicus is an important aesthetic component of the abdomen, surgeons are 56 concerned about how to maintain cosmetic appearance of the umbilicus. In addition to 57 psychological upsetting, bad scars may result in pain, tenderness, and itching.4-6 58 Some studies compared different types of primary portal for gynecologic laparoscopy,7-8 59 however, there is no universal agreement on an ideal periumbilical incision for gynecologic 60 laparoscopy. Moreover, there is lack of studies addressing intraoperative outcomes of different 61 periumbilical incisions. This study aims to introduce a modified curved bidirectional deep intra-62 umbilical incision for primary trocar insertion and prospectively compare its intraoperative and 63 postoperative outcomes with infra-umbilical incision in gynecologic laparoscopy. 64 65 Methods 66 This prospective study was performed at the Endoscopy Unit of the Woman’s Health University 67 Hospital between August 2019 and March 2021 on women in the reproductive age subjected to 68 direct trocar insertion of gynecologic laparoscopy for different indications without any history of 69 previous umbilical operation or umbilical hernia. It was approved by the ethics committee of the 70 Faculty of Medicine (17100792) and was registered at The Clinicaltrials.gov (NCT03988348). 71 All women signed consent to participate in this single blinded RCT to enter one of two groups by 72 random allocation. They were assigned according to the 10 mm primary laparoscopic direct 73 trocar entry points (infra or a modified intra umbilical) and incision types (transverse versus 74 curved longitudinal) respectively using sealed envelopes. The allocated envelopes were opened 75 just before surgery. 76 77 The sample size was estimated using epi info version 7.2.5.0. Using 95% confidence interval and 78 power of 80% assuming percent of unexposed with outcome=5, while percent of exposed with 79 outcome =28. The estimated sample size was 96. Adding 15% drop out rate, the total sample size 80 estimated to be 110.9 Allocated 110 cases were divided into two groups. Group A comprised 55 81 cases subjected to infra-umbilical 10 mm transverse incision while group B comprised 55 cases 82 of a modified curved bidirectional longitudinal intra-umbilical incision for primary laparoscopic 83 direct trocar insertion. Exclusion criteria included patients scheduled for 5mm primary trocar 84 insertion, open laparoscopy, Verres needle insertion, patients with previous abdominal surgery 85 and scar, umbilical hernia, umbilical infection e.g. pilonidal sinus disease,10 previous 86 laparoscopy, or previous umbilical surgery, scarred, previously burned or hyperpigmented 87 umbilicus. Prepubertal or postmenopausal patients were also excluded from this study. 88 89 In the operating room, the umbilicus was prepared by removing all debris using copious amounts 90 of povidone iodine gauze and cotton swabs. Preoperatively, the surgeon commented on the shape 91 of the umbilicus11 (Figure 1) and any umbilical fascial defect signifying any tiny hernia, 92 tightness of the abdominal muscles and skin laxity. To avoid skin disfigurement, clamps to 93 elevate the abdominal wall in all cases was not used, but toothed forceps was used to facilitate 94 delicate skin cut to avoid slipping of the scalpel. In group A, a 10 mm infra-umbilical transverse 95 incision was done to allow trocar to be inserted without undue resistance from the skin so that 96 the trocar passed directly through the fascia and the peritoneum with ease. In group B, a 10 mm 97 right-sided modified curved deep bidirectional longitudinal intra-umbilical incision was made. 98 The technique started by grasping the right edge of the umbilicus with a toothed forceps. Then, a 99 curved vertical incision was made as deep as possible. Thereafter, the trocar was inserted inside 100 the incision till the level of the edge of the sleeve passed the skin. At this moment, the trocar was 101 directed transversely (horizontally) on the right side of the umbilicus for one to two centimeters 102 in the subcutaneous tissue. 103 104 The final step was tilting the trocar to the vertical plane to pierce the fascia towards the pelvis 105 (figure 2). By this way the trocar had 2 pathways (bidirectional) until it reached the peritoneal 106 cavity (horizontally then vertically). In both groups, inflation of the peritoneal cavity with CO2 107 was done up to a pressure of 12-15 mm Hg. Surgical procedures were performed using 108 conventional laparoscopic instruments under vision with a rigid 0-degree, 10-millimeter 109 endoscope. Intraoperatively, the surgeon commented on easiness of movement of the trocar and 110 telescope, any leakage of CO2 alongside the primary trocar and any intraoperative slippage of 111 the trocar during forward and backward movement of the telescope. Operative time varied 112 according to the intraperitoneal laparoscopic procedure. This study didn’t report entry site or 113 intraperitoneal complications in both groups. In both groups, the skin incision was sutured using 114 4/0 Monocryl subcuticular stitch. Patients were offered regular post-laparoscopic surgery care as 115 usual at our institution with on-need analgesics till discharge. They were instructed to take care 116 of the sterile dressings and they came back after one week for check-up and wound dressing. 117 Another follow-up visit was scheduled after one month to properly assess the scar as previously 118 consented by the patients. 119 120 We performed both observer scar assessment scale (OSAS) as well as patient scar assessment 121 scale (PSAS)12 which compare the wound to the nearby skin. In both scales, the lower the score 122 the better the scar. Maximal scores of OSAS and PSAS are 50 and 60 respectively. Moreover, 123 the patient was clearly asked if she or her partner can see the scar by naked eye or not to assess 124 effect of the incision on aesthetic appearance of the umbilicus. Primary outcome of this study 125 was to assess intraoperative performance using two different periumbilical incisions as regards 126 easiness of surgery, CO2 leakage and trocar slippage. Secondary outcomes were observer and 127 couple satisfactions using either incision. 128 129 Statistical Program for Social Science (SPSS) version 24 was used to analyze data. Quantitative 130 data were expressed as mean ±SD. Qualitative data were expressed as frequency and percentage. 131 Mean (average) is the central value of a discrete set of numbers, specifically the sum of values 132 divided by the number of values. Standard deviation (SD) is the measure of dispersion of a set of 133 values. A low SD indicates that the values tend to be close to the mean of the set, while a high 134 SD indicate that the values are spread out over a wider range. Independent-samples t-test (T) of 135 significance was used when comparing between two means (for normally distributed data). 136 Mann–Whitney U (MW) test was used when comparing between two means (for abnormal 137 distributed data). Chi-square test (X2) was used when comparing between non-parametric data. 138 Probability (P-value) < 0.05 was considered significant (S), < 0.001 was considered as highly 139 significant (HS) and > 0.05 was considered non-significant (NS). 140 141 Statement of Ethics 142 Authors state that subjects have given their written informed consent. Assiut University Medical 143 School Ethical Review Board approved the study protocol (17100792). 144 145 Results 146 This study comprised 110 patients subjected to 10 mm direct trocar insertion for gynecologic 147 laparoscopic surgery. They were divided into two groups. Group A comprised 55 cases of 148 transverse infra-umbilical incision while group B comprised 55 cases subjected to modified 149 curved deep bidirectional longitudinal intra-umbilical incision. Table 1 shows insignificant 150 difference regarding age, duration of marriage, and history of previous operations, abortion, or 151 duration of infertility between both groups. However, increased numbers of parity, gravidity and 152 previous cesarean sections; and a smaller number of infertility complaints were statistically 153 significant in group B. 154 155 Indications of laparoscopic surgery were variable in both groups. In group A, indications were 156 1ry infertility in 24 patients (43.6%), 2ry infertility in 19 patients (34.56%), hematocolpus and 157 hematometra in 1 patient (1.8%), left ectopic pregnancy in 1 patient (1.8%), missed IUD threads 158 in7 patients (12.7%), Rt. Adnexal cyst in 2 patients (3.6%) and Rt. Ovarian torsion in 1 patient 159 (1.8%). In group B. It was 1ry infertility in 8 patients (14.5%), 2ry infertility in 16 patients 160 (29.1%), 2ry amenorrhea in 1 patient (1.8%), bilateral endometrioma in 1 patient (1.8%), chronic 161 pelvic pain in 2 patients (3.6%), Ewing sarcoma for transposition of ovaries in 1 patient (1.8%), 162 undisturbed tubal ectopic pregnancy in 10 patients (18.1%), missed IUD in 6 patients (10.9%), 163 right disturbed ectopic pregnancy in 1 patient (1.8%), ovarian cyst in 7 patients (12.7%), adnexal 164 hematoma in 1 patient (1.8%) and laparoscopic monitoring of hysteroscopic metroplasty of a 165 uterine septum in 1 patient (1.8%). 166 167 There was insignificant difference between both groups regarding preoperative assessment of the 168 umbilicus including presence of dimple, shape and appearance, index finger test for minute 169 hernia and use of conical trocar end. The most common umbilical shape noted in both groups 170 was vertical (84 cases, 76.3%) followed by transverse umbilicus (21 cases, 19%). However, there 171 was a statistically significant difference between both groups regarding abdominal wall muscle 172 and skin laxity as shown in table 2. 173 174 Group B expressed a statistically significant less peri-trocar CO2 leakage (46 patients, 83.6% 175 versus 28 patients, 50.9%) and more tightness of the primary portal entry (45 patients, 81.8% 176 versus 30 patients, 54.5%) if compared to group A throughout the whole operation as seen in 177 table 3. On follow-up after one month, there was a statistically significant (p-value = 0.029) 178 decreased OSAS and PSAS in group B (10.4 ± 4.2 and 11.8 ± 4.3) when compared to group A 179 (13.3 ± 5.7 and 16.0 ± 6.8) respectively as shown in table 4 and figure 3. Moreover, 47 patients 180 (85.4%) and 23 patients (41.8%) reported failure to see the umbilical scar by naked eye by 181 herself or her partner in group B and A respectively and were satisfied by the aesthetic 182 appearance of the umbilicus. 183 184 Discussion 185 Primary umbilical trocar insertion is a procedural step of critical importance.13 Despite the 186 widespread use of advanced gynecologic laparoscopic surgeries, many surgeons give little 187 attention to skin incisions after lengthy and tedious operations and leave young staff to close 188 abdominal wall incisions. Most of gynecologic patients are young and very concerned about 189 aesthetic appearance of their belly. The umbilicus is very essential to the aesthetic appearance of 190 the abdomen14 and umbilical incisions directly affect female cosmoses. 191 192 This study included patients in the reproductive age with exclusion of young girls and 193 postmenopausal cases to eliminate age-related factors of wound healing.15 To minimize study 194 bias, direct trocar insertion was only used in this study with exclusion of cases of open 195 laparoscopy and Veress needle insertion. Surgical trocars may be bladed (safety) or bladeless, 196 disposable, or reusable, or spiral (corrugated) or non-spiral. Trocar end may be pyramidal or 197 conical without a significant difference in literature. An animal study demonstrated that using 198 conical and pyramidal trocars resulted in similar force, deformation, time, and distance of 199 exposed blade if they were of the same size.16 200 201 In this study, trocar type was standardized as bladeless reusable non-spiral with conical end to 202 eliminate the effect of these variables on the incision. Incision sites for primary trocar insertion 203 may be infra-umbilical, supra-umbilical, or trans-umbilical.16 Supraumbilical incision was 204 excluded as it is seldom used by gynecologists. In a review of laparoscopic practice by general 205 surgeons, approximately half of the laparoscopists preferred the infra-umbilical route and 35.7% 206 the supraumbilical area for entry.6 Vertical incision is usually preferred for initial intraperitoneal 207 access as it offered superior cosmetic effects than transverse incision.17 The infra-umbilical 208 incision cuts through the skin, the subcutaneous fat, and the fascia. In contrast, the intra-209 umbilical incision is a linear incision from the skin to the fascia, extending only the length of the 210 umbilical ring. An intra-umbilical incision may take less time, is easier to perform, and is 211 theoretically less traumatic as only the skin and fascia need to be divided. 212 213 Nowadays, the intra-umbilical incision is being used more frequently, with the increasing cases 214 of single incision laparoscopic surgery (SILS), which has recently been proven to be a feasible 215 alternative for conventional laparoscopic surgery with better cosmetic outcome.18 In a 216 retrospective comparison of gynecologic laparoscopy cases, intra-umbilical incision, and peri-217 umbilical incision (longitudinal/transverse oblique/arc incision according to the bellybutton 218 natural skin folds) were compared. They concluded that intra-umbilical incision should be 219 promoted in gynecologic laparoscopy.19 220 221 Postpartum sterilization using intra-umbilical skin incision was more efficient regarding aesthetic 222 concerns and operation time in a RCT.8 What’s new in the current prospective RCT is to assess 223 the impact of modifications of the intra-umbilical incision on intraoperative and postoperative 224 outcomes (Darwish laparoscopic entry). Making the incision as deep as possible aims to make it 225 invisible and less liable to cause pain on touch using the maximal benefit of the natural umbilical 226 dimple. Addressing this important point would fulfil the requirements of the aesthetic appearance 227 of the umbilicus as the scar was not seen in 47 patients (85.4%) using this modified technique if 228 compared to 23 patients (41.8%) if infra-umbilical incision was made. Since most of the 229 umbilical shape of human being is vertical oval (in this study it was seen in 84 cases, 76.3%), 230 vertical incision used in this study in group B is more anatomic than transverse incision used in 231 group A. 232 233 Another additional advantage of the modified technique was making a curved intra-umbilical 234 incision (Figure 2) to be adapted with the natural curve of the umbilical dimple. In this study, 235 umbilical dimple was present in 95 cases (86.3%) in both groups, so selection of a curved 236 incision in group B was more anatomic. Importantly, the surgeon did not use any instrument to 237 elevate the anterior abdominal wall unlike others who usually use pointed towel forceps or 238 Kocher forceps11 or other traumatic instruments that may leave a scar and hyperpigmentation 239 adding more disfigurement and psychological upset to the patients. Not only does aggressive 240 elevation of the skin around the umbilical region injurious and non-aesthetic, but also it doesn’t 241 add any surgical benefit because the skin and fascia at the umbilicus are in direct contact that is 242 why it is the preferred site for primary entry. This proximity can be explained by the absence of 243 subcutaneous fat and muscle at the umbilicus that makes the midline dissection plane bloodless 244 to the peritoneum.5 245 246 All these technical tricks resulted in a better aesthetic appearance of the umbilicus and lower 247 OSAS and PSAS scales (better cosmoses) using this modified technique if compared to the 248 transverse infra-umbilical incision group. This study incorporated patient impressions and 249 comments on all issues of umbilical incision including their comment on the visibility of the scar 250 by herself or her partner which is considered one of the best aesthetic evaluation variables. This 251 step is commonly used after liposuction operations which may affect the appearance and shape 252 of the umbilicus.20 253 254 Intraoperative benefits of the modified intra-umbilical to the surgical procedures are many. 255 Insertion of the trocar horizontally for one to two centimeters then its direction vertically 256 (bidirectional) adds an advantage of maintaining an airtight seal to avoid gas leakage alongside 257 the trocar and avoiding trocar slippage throughout the operation. This is simply explained by the 258 making fascial perforation away from the alignment with skin incision. Trocar dislodgment 259 occurs frequently during laparoscopic surgery particularly in some lean women, those with weak 260 anterior abdominal wall muscle or fascia and those with lax redundant skin. The best example is 261 multiparous or malnourished women. 262 263 The results of this study supported these concepts as the modified bidirectional technique was 264 more successful than classic infra-umbilical technique even in women with increased parity or 265 gravidity who were prone to weak anterior abdominal wall and lax skin (Table 2). Frequent 266 slippage of the trocar and abdominal deflation is a real distressing problem. Abdominal wall 267 emphysema can occur besides the risky prolongation of the surgical procedure.21 To overcome 268 this problem, some authors take a stitch at the fascia and encircle the trocar throughout the 269 procedure.22 Others use spiral trocars whether disposable or reusable.23 Disposable spiral trocars 270 are very expensive if compared with reusable trocar and cannot be afforded by healthcare 271 authorities in many hospitals particularly developing countries with limited resources. Reusable 272 spiral trocar may require more force for insertion that may carry a risk of unintentional injury24 273 due to repeated resistance to the corrugations along the whole shaft. Moreover, despite lack of 274 sufficient supporting studies, using 10 spiral trocars with force may be a risk factor for 275 subsequent umbilical trocar-site hernia as previously reported25 due to repeated tears of the 276 fascia. On post-operative follow-up of all cases of this study, using ordinary reusable conical 10 277 mm trocar, there was no case of trocar-site hernia in either group. 278 279 Despite being a prospective RCT, this study has some limitations. Small sample size is a definite 280 limitation. Including all types of umbilici in either group would carry a bias as some umbilici are 281 already inverted with a definite dimple while others are protruding which may affect scar 282 appearance and pain scoring. Moreover, comments on easiness of movement of trocar and 283 telescope, leakage of CO2 and intraoperative slippage of trocar were all subjectively assessed. 284 Theoretically, more accurate tools of assessment would be more informative. Nevertheless, in 285 some situations, intraoperative observations particularly by expert surgeons would be as accurate 286 and clinically informative as some sophisticated time-consuming tests. In modern statistics, 287 subjectivity is respected and is replaced by awareness of multiple perspectives and context 288 dependence.26 A larger sample size and a multicentre study is needed to achieve a definite 289 conclusion in this respect. 290 291 Conclusion 292 From this study, it is concluded that performing curved deep bidirectional longitudinal intra-293 umbilical incision for insertion of primary laparoscopic trocar (Darwish laparoscopic entry) is a 294 simple and fast step that results in elimination of intraoperative gas leakage and trocar slippage 295 without the need of any additional sutures. Aesthetically, it results in a better scar with 296 satisfactory cosmoses if compared to infra-umbilical incision. 297 298 Conflicts of Interest 299 The authors declare no conflict of interests. 300 301 Funding 302 No funding was received for this study. 303 304 Authors’ Contribution 305 AD is the principal investigator who conceptualized the study, refined the study protocol, 306 performed many operations, and wrote the full paper. MT conceived the idea, wrote the protocol, 307 performed many operations, supervised the candidate and reviewed the thesis and the full paper. 308 AG was the active candidate who made the interviews, collected data and made all statistical 309 analyses with the aid of a statistician. DD reviewed the paper and made some corrections. All 310 authors approved the final version of the manuscript. 311 312 References 313 1. Pitkin RM, Parker WH. Operative laparoscopy: a second look after 18 years. Obstet 314 Gynecol 2010; 115: 890-891. 315 2. 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Trokarhernien Eine seltene, potenziell gefährliche Komplikation 391 nach laparoskopischen Eingriffen [Trocar site hernias. A rare but potentially dangerous 392 complication of laparoscopic surgery]. Chirurg. 2002 Sep;73(9):899-904. German. doi: 393 10.1007/s00104-002-0525-2. PMID: 12297955. 394 26. Gelman A, Hennig C. Beyond subjective and objective in statistics. Journal of the Royal 395 Statistical Society Series A, 2017, vol. 180, issue 4, 967-1033. 396 397 398 Figure 1: Different shapes of umbilicus in studied cases. A) Vertical oval umbilicus, B) 399 Transverse funnel-shaped umbilicus, C) Outie projecting umbilicus, D) button-like transverse 400 bulging umbilicus. 401 402 403 Figure 2: Steps of modified intra-umbilical direct trocar insertion. A) deep curved longitudinal 404 intra-umbilical incision, B) insertion of a 10 mm trocar till disappearance of sleeve edge, C) 405 Transverse insertion of the trocar for 1-2 cm in horizontal plane in the subcutaneous tissue, D) 406 rotation of the trocar 90 degrees to the vertical plane followed by penetration of the fascia). 407 408 Table 1: Sociodemographic and obstetric data of the studied groups. 409 Group A (N = 55) Group B (N = 55) Stat. test P-value Age (years) Mean 28.5 29.1 T = 0.46 0.643 NS ±SD 7.1 6.8 Duration of marriage (years) Mean 7.2 9.0 MW = 1237.5 0.457 NS ±SD 3.7 7.0 Gravidity Mean 1.4 2.2 MW = 1048.5 0.004 HS ±SD 1.9 1.9 Parity Mean 0.8 1.7 MW = 947 < 0.001 HS ±SD 1.4 1.6 Abortions Mean 0.6 0.5 MW = 1494 0.895 NS ±SD 0.9 0.8 No. of CS Mean 0.5 0.9 MW = 1211 0.038 S ±SD 0.7 1.2 Previous operation No 54 98.2 % 52 94.5% X2 = 1.03 0.308 NS Yes 1 1.8% 3 5.5% Infertility No 12 21.8 % 29 52.7% X2 = 11.2 0.001 HS Yes 43 78.2 % 26 47.3% Infertility duration Mean 5.2 4.5 MW = 464.5 0.351 NS ±SD 3.2 3.1 410 411 Table 2: Intraoperative assessments of umbilicus and abdominal wall in both groups. 412 Group A (N = 55) Group B (N = 55) X2 P-value Shape Vertical oval 52 94.5% 47 85.5% 2.5 0.112 NS Horizontal oval 3 5.5% 8 14.5% Appearance Inverted 48 87.3% 46 83.6% 0.29 0.589 NS Everted (protruded) 7 12.7% 9 16.4% Dimple Absent 6 10.9% 9 16.4% 0.69 0.405 NS Present 49 89.1% 46 83.6% Index finger test for hernia Negative 55 100% 55 100% ---- ---- Abdominal skin laxity No Yes 41 14 74.5% 29 26 52.7% 5.6 0.017 S 25.4% 47.2% Abdominal muscles Weak 16 29.1% 32 58.1% 9.4 0.002 HS Strong 39 70.9% 23 41.8% Trocar tip Conical 55 100% 55 100% ---- ---- Umbilical incision Transverse 55 100% 0 0% 110 < 0.001 HS Longitudinal 0 0% 55 100% 413 414 Table 3: Comparisons of intra-operative assessments of umbilicus between studied groups. 415 Group A (N = 55) Group B (N = 55) Stat test P-value Easy trocar and telescope movement No 6 10.9% 3 5.5% X2 = 1.08 0.297 NS Yes 49 89.1% 52 94.5% leakage of CO2 No 28 50.9% 46 83.6% X2 = 13.4 < 0.001 HS Yes 27 49.1% 9 16.4% Tightness Tight 30 54.5% 45 81.8% X2 = 9.4 0.002 s Loose 25 45.5% 10 18.2% 416 417 418