Fundamentals of Peritoneal Access

Abstract

The art of laparoscopic surgery is anticipating requirements for completing contemplated procedures. Patient safety and technical efficacy are inextricably linked to how carefully the patient is evaluated preoperatively. Choosing the best method for accessing the peritoneal cavity depends on patient phenotype, abdominal wall morphology, and anatomic configuration of underlying vital anatomy. Since no particular method is necessarily the safest approach for every patient, it is incumbent on every laparoscopic surgeon to be well-versed in alternative procedures for insufflation and entry into the peritoneal cavity. The laparoscopic surgeon must be forever mindful that most life-threatening surgical accidents to small and large bowel as well as to retroperitoneal vessels occur during insertion of the Veress needle and primary cannula. Review of a nationwide analysis of access-related complications in Finland revealed 256 complications during more than 70,000 laparoscopic procedures performed over 4 years; the frequency of bowel perforation was 0.1%, including 20 small and 16 large bowel injuries caused by either an umbilical trocar or Veress needle. 1 Injury to iliac vessels and aorta occurred in five patients. Complications during 1033 laparoscopic surgeries performed at one center over 6 years had an overall rate of 3%, of which 23.5% occurred during Veress needle or first trocar insertion. 2 A group in Switzerland prospectively followed 14,243 patients over 2 years and found 22 trocar and 4 Veress needle injuries (0.18%), including 19 injuries to large and