Laparoscopic Entry: A Review of Techniques, Technologies, and Complications

Abstract

ObjectiveTo provide clinical direction, based on the best evidence available, on laparoscopic entry techniques and technologies and their associated complications. OptionsThe laparoscopic entry techniques and technologies reviewed in formulating this guideline include the classic pneumoperitoneum (Veress/trocar), the open (Hasson), the direct trocar insertion, the use of disposable shielded trocars, radially expanding trocars, and visual entry systems. OutcomesImplementation of this guideline should optimize the decision-making process in choosing a particular technique to enter the abdomen during laparoscopy. EvidenceEnglish-language articles from Medline, PubMed, and the Cochrane Database published before the end of September 2005 were searched, using the key words laparoscopic entry, laparoscopy access, pneumoperitoneum, Veress needle, open (Hasson), direct trocar, visual entry, shielded trocars, radially expanded trocars, and laparoscopic complications. ValuesThe quality of evidence was rated using the criteria described in the Report of the Canadian Task Force on the Periodic Health Examination. Recommandations et déclaration sommaire1.Left upper quadrant (LUQ, Palmer’s) laparoscopic entry should beconsidered in patients with suspected or known periumbilicaladhesions or history or presence of umbilical hernia, or after threefailed insufflation attempts at the umbilicus. (II-2 A) Other sites ofinsertion, such as transuterine Veress CO2 insufflation, may beconsidered if the umbilical and LUQ insertions have failed or havebeen considered and are not an option. (I-A)2.The various Veress needle safety tests or checks provide very littleuseful information on the placement of the Veress needle. It istherefore not necessary to perform various safety checks oninserting the Veress needle; however, waggling of the Veressneedle from side to side must be avoided, as this can enlarge a1.6 mm puncture injury to an injury of up to 1 cm in viscera orblood vessels. (II-1 A)3.The Veress intraperitoneal (VIP-pressure ≤ 10 mm Hg) is a reliableindicator of correct intraperitoneal placement of the Veress needle;therefore, it is appropriate to attach the CO2 source to the Veressneedle on entry. (II-1 A)4.Elevation of the anterior abdominal wall at the time of Veress orprimary trocar insertion is not routinely recommended, as it doesnot avoid visceral or vessel injury. (II-2 B)5.The angle of the Veress needle insertion should vary according tothe BMI of the patient, from 45˚ in non-obese women to 90˚ inobese women. (II-2 B)6.The volume of CO2 inserted with the Veress needle shoulddepend on the intra-abdominal pressure. Adequatepneumoperitoneum should be determined by a pressure of 20 to30 mm Hg and not by predetermined CO2 volume. (II-1 A)7.In the Veress needle method of entry, the abdominal pressure maybe increased immediately prior to insertion of the first trocar. Thehigh intraperitoneal (HIP-pressure) laparoscopic entry techniquedoes not adversely affect cardiopulmonary function in healthywomen. (II-1 A)8.The open entry technique may be utilized as an alternative to the Veress needle technique, although the majority of gynaecologists prefer the Veress entry. There is no evidence that the open entry technique is superior to or inferior to the other entry techniquescurrently available. (II-2 C)9.Direct insertion of the trocar without prior pneumoperitoneum maybe considered as a safe alternative to Veress needle technique. (II-2)10.Direct insertion of the trocar is associated with less insufflation-related complications such as gas embolism, and it is a faster technique than the Veress needle technique. (I)11.Shielded trocars may be used in an effort to decrease entryinjuries. There is no evidence that they result in fewer visceral andvascular injuries during laparoscopic access. (II-B)12.Radially expanding trocars are not recommended as beingsuperior to the traditional trocars. They do have blunt tips that mayprovide some protection from injuries, but the force required forentry is significantly greater than with disposable trocars. (I-A)13.The visual entry cannula system may represent an advantage overtraditional trocars, as it allows a clear optical entry, but thisadvantage has not been fully explored. The visual entry cannulatrocars have the advantage of minimizing the size of the entrywound and reducing the force necessary for insertion. Visual entrytrocars are non-superior to other trocars since they do not avoidvisceral and vascular injury. (2B)