What is the safest entry technique, Veress (pneumoperitoneum needle), Hassan (open laparoscopy), or Optiview (visual entry), for a general adult population undergoing elective laparoscopic surgery?

Safest Laparoscopic Entry Technique

No single entry technique—Veress needle, Hassan (open), or Optiview (visual entry)—demonstrates universal superiority in preventing major vascular or visceral injuries, and the choice should be guided by patient-specific risk factors and surgeon experience rather than a blanket recommendation. 1, 2

Evidence Quality and Limitations

The available evidence does not support one technique as definitively safest across all clinical scenarios. Multiple guidelines and systematic reviews consistently conclude that high-quality randomized controlled trials fail to demonstrate clear superiority of any single method for preventing the most catastrophic complications—major vascular and bowel injuries. 1, 2, 3

Technique-Specific Considerations

Veress Needle Technique

• Most commonly used among gynecologists (61.5% of surgeons), facilitating primary trocar placement with established familiarity. 1, 4
• The Veress intraperitoneal pressure (VIP ≤10 mmHg) is a reliable indicator of correct intraperitoneal placement; attach the CO₂ source immediately upon entry rather than performing multiple safety checks. 2
• Angle of insertion should vary by BMI: 45 degrees in non-obese patients to 90 degrees in obese patients. 2
• Traditional safety tests (saline drop test, aspiration test) provide minimal useful information and are not necessary. 2
• Critical pitfall: Avoid waggling the Veress needle side-to-side, as this can enlarge a 1.6mm puncture to a 1cm injury in viscera or vessels. 2

Hassan (Open) Technique

• May be preferred in patients with suspected periumbilical adhesions, history of umbilical hernia, or multiple previous laparotomies (>4 prior surgeries). 5, 2, 3
• Can be more technically challenging and time-consuming compared to other methods. 1, 6
• Does not demonstrate superior safety compared to closed techniques in preventing major injuries. 2, 3
• Recommended for pregnant patients beyond 14 weeks gestation using trans-umbilical or supra-umbilical routes depending on uterine size. 3

Optiview (Visual Entry/Direct Optical Entry)

• Appears to have the lowest complication rate in comparative studies but remains the least commonly used technique. 4
• Allows clear optical visualization during entry, minimizing entry wound size and reducing insertion force. 2, 4
• In patients with previous abdominopelvic surgery, direct optical entry demonstrates statistically significant advantages over open laparoscopy: shorter entry time (P<0.01) and less blood loss (P<0.01), with no difference in vascular or bowel injury rates. 6
• May be underutilized despite potential safety advantages, likely due to surgeon unfamiliarity and equipment availability. 1, 4
• Does not completely eliminate risk of visceral or vascular injury. 2

Direct Trocar Insertion (Without Pneumoperitoneum)

• Safe alternative to Veress technique with faster entry time and fewer insufflation-related complications (including gas embolism). 2
• Blind trocar technique has the greatest number of complications despite being commonly used. 4

Risk-Stratified Approach

Standard Risk Patients (No Prior Surgery, Normal BMI)

• Any of the four main techniques (Veress, Hassan, direct trocar, or Optiview) can be used based on surgeon experience. 2, 3
• Optiview may offer marginal safety advantage if available and surgeon is trained. 4

High-Risk Patients

• Previous midline laparotomy or periumbilical adhesions: Consider left upper quadrant (Palmer's point) entry, open technique at distance from scars, or micro-laparoscopy in LUQ. 2, 3
• Slim patients: Exercise extreme caution with trans-umbilical entry (blind or open) due to proximity of great vessels. 3
• Obesity: Adjust Veress needle angle to 90 degrees; consider direct optical entry for improved visualization. 2
• Pregnancy >14 weeks: Contraindicate trans-umbilical Veress; use open laparoscopy (trans/supra-umbilical) or LUQ micro-laparoscopy with maximum insufflation pressure of 12 mmHg. 3
• Multiple prior surgeries (>4 laparotomies): Avoid laparoscopic entry due to high risk of iatrogenic injury; consider open technique or alternative entry sites. 5, 7

Critical Safety Measures

• Left upper quadrant entry should be considered after three failed umbilical insufflation attempts or in patients with known periumbilical pathology. 2
• Adequate pneumoperitoneum is determined by pressure (20-30 mmHg), not predetermined CO₂ volume. 2
• Elevation of the anterior abdominal wall during Veress or trocar insertion is not routinely recommended as it does not prevent visceral or vessel injury. 2
• Maintain operating pressure at 12 mmHg during procedures. 8
• Shielded and radially expanding trocars do not demonstrate superiority in preventing injuries and are not recommended as first-line options. 2

Complication Rates

Overall laparoscopic entry complications remain low across all techniques: total intra-operative complication rate 3.3%, open conversion rate 0.33%, transfusion rate 1.13%, and post-operative complication rate 2.53%. 4 The rarity of major complications makes definitive comparative studies challenging, but when they occur, rapid recognition and management are lifesaving. 1