What are the safest techniques for laparoscopic entry?

Safest Techniques for Laparoscopic Entry

The safest techniques for laparoscopic entry include the open (Hasson) technique, Veress needle technique, direct trocar insertion, and left upper quadrant entry, with no single method demonstrating clear superiority in preventing major complications. Each technique has specific advantages and safety considerations that should guide selection based on patient factors and clinical circumstances.

Primary Entry Techniques

Open (Hasson) Technique

• Creates direct visualization of peritoneal entry
• Particularly recommended for:
  • Patients with previous midline incisions 1
  • Suspected periumbilical adhesions 2
  • Presence of umbilical hernia 2
  • Pregnant women in second and third trimester 1
• Technically more challenging but provides visual confirmation of safe entry 3

Veress Needle Technique

• Most commonly used among gynecologists 3
• Key safety considerations:
  • Intraperitoneal pressure ≤10 mmHg indicates correct placement 2
  • Avoid waggling the needle side-to-side (can enlarge a 1.6mm puncture to a 1cm injury) 2
  • Insertion angle should vary with BMI (45° in non-obese to 90° in obese patients) 2
  • Increase abdominal pressure (20-30 mmHg) immediately before first trocar insertion 2, 1
  • Perform safety checks during insertion 1

Direct Trocar Insertion

• Safe alternative to Veress needle technique 2
• Associated with fewer insufflation-related complications (e.g., gas embolism) 2
• Faster technique than Veress needle 2
• Can be performed under laparoscopic visualization 3

Left Upper Quadrant (Palmer's Point) Entry

• Should be considered when:
  • Suspected or known periumbilical adhesions 2
  • History or presence of umbilical hernia 2
  • After three failed insufflation attempts at umbilicus 2
  • Strongly recommended for patients with previous midline incision laparotomy 1

Special Considerations for Safe Entry

Pregnancy

• Adapt insertion level based on uterine volume 1
• Second trimester: Use open (Hasson) or left upper quadrant technique 1
• Third trimester: Use open technique above the level of uterine fundus 1

COVID-19 Precautions

When performing laparoscopy during COVID-19 pandemic:

• Use closed suction systems 4
• Create suitable incisions for leak-free trocars (balloon trocars if available) 4
• Aspirate pneumoperitoneum before making auxiliary incisions or removing trocars 4
• Keep intraoperative pneumoperitoneum pressure and CO2 ventilation at lowest possible levels 4
• Reduce Trendelenburg position time 4
• Minimize electrocautery/ultrasonic scalpel use to reduce surgical smoke 4

Specialized Entry Devices

Visual Entry Systems/Optical Trocars

• Allow clear optical entry but advantage not fully explored 2
• Not superior to other trocars in avoiding visceral and vascular injury 2
• Should not be used as first-line technique due to insufficient evaluation 1
• May be useful in patients prone to access injuries 5

Radially Expanding Trocars

• Not recommended as superior to traditional trocars 2
• Require significantly greater force for entry despite blunt tips 2
• Should not be used as first-line technique due to insufficient evaluation 1

Shielded Trocars

• May be used to decrease entry injuries 2
• No evidence they result in fewer visceral and vascular injuries 2

Common Pitfalls and Complications

• Major entry complications are rare but can be life-threatening 3
• Surgeon familiarity with entry-failure troubleshooting is essential 3
• Elevation of anterior abdominal wall during Veress or primary trocar insertion is not routinely recommended as it doesn't prevent visceral or vessel injury 2
• No specific technique has been proven superior in preventing vascular and visceral complications 5

Algorithm for Technique Selection

1. Assess patient risk factors:

   • Previous abdominal surgery? → Consider open (Hasson) technique
   • Midline incisions? → Use left upper quadrant entry
   • Pregnancy? → Adapt technique based on trimester
   • Suspected adhesions? → Open technique or left upper quadrant entry

2. If no specific risk factors:

   • Any of the four main techniques (Veress needle, open Hasson, direct trocar, or left upper quadrant) can be safely used 1
   • Select based on surgeon experience and comfort

3. If initial entry attempt fails:

   • After three failed umbilical attempts → Switch to left upper quadrant entry 2
   • Consider alternative sites if both umbilical and LUQ insertions fail 2