Safe Technique for Laparoscopic Entry into the Abdominal Cavity

Tips and Tricks in Laparoscopic Surgery in Light of 172 Patients, From A Gynecological Point of View in Turkey

“…Roy GM et al reported that elevating the abdominal wall using towel clips provides the greatest distance between parietal peritoneum and the underlying viscera, thus enabling the maximum margin of safety during entry [16]. Our results were in similar range with this study.…”

“…Severe complications in laparoscopy are usually encountered during initial abdominal entry, currently there are a number of techniques described in order to minimize entry-related injuries including the Veress-pneumoperitoneum-trocar, "classic" or closed entry [2] the open (Hasson) technique [3] direct trocar insertion without pneumoperitoneum [4] use of shielded disposable trocars [5,6] optical Veress needle [7,8] optical trocars, [9,10] radially expanding trocars [11,12] and a trocarless reusable, visual access cannula [13,14], yet none of them are proven to be safer than the other. Abdominal wall elevation by hand or using towel clips during Veress needle entry or primary trocar insertion is considered to be an effective safety measure by many surgeons [15,16]. In a study using a suprapubic port for measurement to compare the efficacy of manual abdominal wall elevation below the umbilicus and of towel clips placed within and 2 cm from the umbilicus it was reported that only towel clips proved a significant peritoneal elevation during primary trocar insertion [16].…”

“…Abdominal wall elevation by hand or using towel clips during Veress needle entry or primary trocar insertion is considered to be an effective safety measure by many surgeons [15,16]. In a study using a suprapubic port for measurement to compare the efficacy of manual abdominal wall elevation below the umbilicus and of towel clips placed within and 2 cm from the umbilicus it was reported that only towel clips proved a significant peritoneal elevation during primary trocar insertion [16]. Even after an ideal operating field is established an endoscopic surgeon has various other challenges to overcome, especially in advanced procedures, including but not limited to; avoiding bladder and ureter injury, avoiding bowel injury and proper suturing and knot tying, the latter which can be stressful at times.…”

Laparoscopic entry techniques: clinical guideline, national survey, and medicolegal ramifications

“…However, fusion of the parietal peritoneum and linea alba at the pit of the umbilicus logically dictates that a vertical (90°to the horizontal abdomen) Veress insertion represents the shortest skin-toperitoneum anatomic distance to enable direct peritoneal entry. According to computed tomography (CT) abdominal mapping [111,112,145] and actual laparoscopy [113,146,147], this skin-to-peritoneum distance at the umbilical pit is consistently no greater than 2 cm, irrespective of abdominal obesity. Nevertheless, it is suggested that the Veress angle of entry should vary (45°in nonobese women and 90°in obese women) because CT abdominal imaging [112]) and visualization at laparoscopy [113] have shown that the location of the underlying aortic bifurcation (which may be prone to Veress injury) tends to be directly under the umbilicus in nonobese women or 2-3 cm caudal to the umbilicus in obese women.…”

“…An IAP of 25 mmHg has been shown to achieve a maximum safe distance between the anterior abdominal wall and underlying abdominal contents without compromising cardiorespiratory function [156,157]. A two-handed, screwing manner-controlled vertical (90°) entry of only the primary trocar tip uses the safe CO 2 bubble depth afforded through an IAP of 25 mmHg and is highly unlikely to injure underlying vessels according to actual laparoscopy [113,146,147] and abdominal vasculature CT mapping studies [111,112,145]. Although there is no direct supporting evidence, an initial check for bowel and vascular injury immediately after primary trocar insertion is recommended to avoid missing this complication and exposing the women to serious morbidity.…”