Steps to Insert Laparoscopy Tools into the Abdomen
The safest approach to laparoscopic abdominal entry involves selecting an appropriate entry site (typically umbilicus or left upper quadrant), followed by either Veress needle insufflation, direct trocar insertion under visualization, or open (Hasson) technique—with no single method demonstrating universal superiority, making surgeon experience the primary determinant of technique selection. 1
Pre-Procedure Assessment
Patient Evaluation
- Assess for previous abdominal surgery or peritonitis history, as these substantially increase risk of abdominal wall adhesions and visceral injury during trocar insertion 2
- Consider preoperative ultrasonography of the parietal wall to detect peritoneal adhesions (100% sensitivity, 88.5% diagnostic accuracy) to identify adhesion-free zones for safe entry 2
- Evaluate for contraindications including hemodynamic instability, respiratory compromise, or severe coagulopathy 3
Anesthesia Preparation
- General anesthesia with balanced technique (intravenous and inhalational agents plus muscle relaxants) provides optimal cardiovascular stability and rapid recovery 3
- Alternative options include regional anesthesia or local anesthesia with intravenous sedation for select cases, though general anesthesia remains standard 3, 4
Entry Site Selection
Primary Entry Points
- Umbilicus is the most common entry site among gynecologic surgeons 1
- Left upper quadrant (Palmer's point) serves as alternative, particularly in patients with suspected periumbilical adhesions 1
- Choose adhesion-free areas based on surgical history and preoperative imaging when available 2
Three Main Entry Techniques
1. Veress Needle Technique (Most Commonly Used)
Step-by-step insertion:
- Apply local anesthetic at chosen entry site 5
- Make small skin incision (typically 2-5mm) 6
- Insert Veress needle at 45-90 degree angle depending on patient body habitus 1
- Perform "safe track" maneuver: advance needle while aspirating with plunger to confirm no blood or bowel contents 6
- Confirm intraperitoneal placement through saline drop test or pressure readings 1
- Insufflate abdomen with CO2 to create pneumoperitoneum (standard pressure 12-15 mmHg, though 3-5 mmHg sufficient for microinvasive procedures) 3, 4
- Insert primary trocar through same incision after adequate insufflation 1
2. Direct Trocar Insertion (Underutilized but Effective)
Key advantages and technique:
- Faster than Veress technique with potentially fewer failed entries 1
- Insert trocar directly through abdominal wall without prior pneumoperitoneum 1
- Requires confident, controlled insertion with immediate laparoscopic visualization 1
- No high-quality evidence suggests this method is less safe than Veress needle 1
3. Open (Hasson) Technique
Preferred situations and steps:
- Best choice for patients with suspected intra-abdominal adhesions from previous surgery 1
- Make 1-2 cm incision at entry site 1
- Dissect down to fascia under direct visualization 1
- Incise fascia and peritoneum under direct vision 1
- Insert blunt-tipped Hasson trocar and secure with fascial sutures 1
- More technically challenging but provides direct visualization of all layers 1
Critical Safety Measures
Verification Steps
- Perform "safe track technique" before trocar entry: pass small-bore needle with anesthetic while pulling back on plunger to ensure no interposed bowel loops 6
- For endoscopic procedures, confirm gastric/peritoneal puncture through visual inspection and air aspiration 6
- Verify "one-to-one" finger indentation endoscopically to ensure no overlying bowel loops or liver 6
Pneumoperitoneum Management
- Standard insufflation pressure: 12-15 mmHg for conventional laparoscopy 3
- Lower pressure (3-5 mmHg) feasible for microinvasive procedures under local anesthesia 4
- During COVID-19 or infectious concerns, use constant pressure insufflators and central aspirator systems to minimize aerosol leakage 6
- Empty pneumoperitoneum completely before trocar removal to prevent gas embolism 6
Secondary Trocar Placement
Technique for Additional Ports
- Place under direct laparoscopic visualization 1
- Insert lateral to rectus muscles to avoid epigastric vessels 1
- Transilluminate abdominal wall to identify vascular structures when possible 6
- Maintain adequate spacing between trocars for instrument triangulation 1
Common Pitfalls and Complications
Recognition and Prevention
- Major entry complications are rare but critical—surgeon must be familiar with troubleshooting failed entries and managing vascular or bowel injury 1
- Failed entry occurs more commonly with Veress needle technique; consider switching to open technique 1
- Visceral injury risk highest during first trocar insertion, especially with prior abdominal surgery 2
- In patients with ascites, drain fluid before entry to improve visualization and reduce infection risk 6