Establishing Pneumoperitoneum: What Is the Safest Technique for Pneumoperitoneum?

Abstract

Since it represents the first step in any laparoscopic procedure, the technique of pneumoperitoneum establishment and optical trocar insertion has long been a subject for study and debate. The main three techniques available are the open laparoscopy (OL), the Veress needle laparoscopy (VN), and the direct trocar insertion (DTI) technique. Several major (vascular and visceral injury, gas embolism, and failed entry) and minor (extraperitoneal insufflation, trocar site bleeding, infection, and hernia) complications may occur. Many retrospective studies, 32 RCTs, 6 systematic reviews, and 2 Cochrane reviews have addressed this topic. However, owing to some methodological limitations (the main of which is the limited samples as compared to the very low complications rate), a significant difference in major complications has not been clearly demonstrated, although it appears reasonable that OL and DTI with optical trocar would allow for a lower complication rate and above all for a quicker recognition of the eventual complication. From the available data, OL and DTI have a significantly lower rate of failed entry and extraperitoneal gas insufflation, while DTI is the faster technique. In this chapter, a comprehensive review of the literature on this topic is presented, together with an organic revision of access techniques and their complications.