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Abdominal access techniques used in laparoscopic surgery

Abdominal access techniques used in laparoscopic surgery
Aurora Pryor, MD, MBA
Andrew T Bates, MD
Section Editor:
Jeffrey Marks, MD
Deputy Editor:
Wenliang Chen, MD, PhD
Literature review current through: Dec 2022. | This topic last updated: Feb 07, 2022.

INTRODUCTION — Laparoscopic techniques have revolutionized the field of surgery with benefits that include decreased postoperative pain, earlier return to normal activities following surgery, and fewer postoperative complications (eg, wound infection, incisional hernia) compared with open techniques [1]. However, unique complications are associated with gaining access to the abdomen for laparoscopic surgery. Inadvertent bowel injury or major vascular injury is uncommon, but both are potentially life-threatening complications that are most likely to occur during initial access [2-6].

The techniques for access to the peritoneal cavity, choice of access technique, placement locations, and port placement for single-incision surgery will be reviewed here. Complications of laparoscopic access are discussed in a separate topic review. (See "Complications of laparoscopic surgery".)

ABDOMINAL WALL ANATOMY — Knowledge of the anatomy of the abdominal wall is essential for the safe insertion of laparoscopic access devices. These devices traverse the skin, subcutaneous fat, variable myofascial layers, preperitoneal fat, and parietal peritoneum.

Access locations — The fascial and muscular layers of the abdominal wall are variable depending upon specific location. Anatomy at typical laparoscopic access sites and related intra-abdominal anatomy are discussed below. Detailed anatomy of the abdominal wall is discussed elsewhere. (See "Anatomy of the abdominal wall".)

Midline abdomen — The midline abdominal wall is devoid of important vessels and nerves and is a preferred initial access site for many laparoscopic procedures. (See 'Advanced access techniques' below.)

The layers of the abdominal wall in the midline include skin, subcutaneous fat, and a fascial layer (the linea alba) that is a coalescence of the anterior and posterior rectus sheath (figure 1). The round ligament of the liver running within the falciform ligament attaches to the posterior aspect of the right rectus muscle in the upper midline abdominal wall as low down as the umbilicus.

Midline intra-abdominal structures from cranial to caudal include the liver, stomach, transverse colon, omentum, small intestine, sigmoid colon, and bladder. Decompression of the stomach with a nasogastric or orogastric tube and bladder decompression with a Foley catheter can maximize the view of the upper abdominal and pelvic operating fields and minimize risk for injury. Previous midline abdominal incision can be associated with significant underlying adhesions. Alternative access sites should be chosen. (See 'Special considerations for access' below.)

Umbilicus — Transumbilical access is the most common location for establishing pneumoperitoneum with either the Veress needle or open (Hasson) technique. (See 'Closed (Veress needle)' below.)

The umbilicus is a fusion of fascial layers and is devoid of subcutaneous fat. The median umbilical ligament (ie, obliterated urachus) and paired medial umbilical ligaments (ie, obliterated umbilical arteries) are peritoneal folds that join together at the inferior margin of the umbilicus, forming a tough layer. A defect in the umbilical fascia with or without the presence of a mass suggests an umbilical hernia (picture 1). Anomalies of the urachus may also exist (figure 2). If an umbilical hernia or urachal anomaly is suspected, alternative access sites may need to be considered. (See 'Special considerations for access' below.)

Medial costal margin — Laparoscopic access at the costal margin can be useful for a variety of upper abdominal laparoscopic procedures. The abdominal wall is better supported nearer the muscular attachments to the ribcage as the access needle or port passes during entry [7]. This typically provides less deformation of the abdominal wall during access. (See 'Multiple port placement' below.)

Along the medial costal margin, the layers of the abdominal wall include the skin, subcutaneous fat, anterior rectus fascia, rectus muscle, posterior rectus fascia, transversalis fascia, transversus abdominis muscle, preperitoneal fat, and parietal peritoneum (figure 1). The superior epigastric artery runs along the underside of the rectus muscle in its midline. The region where the external oblique, internal oblique, and transversalis fascia fuse immediately lateral to the rectus muscle (linea semilunaris) contains no vessels.

The liver descends below the rib margin 1 to 3 cm on the right, and a prominent left lateral segment may also be present on the left. The body of the stomach and transverse colon are in proximity. Decompression of the stomach with a nasogastric tube or orogastric tube should be performed to maximize the view of the upper abdomen. The presence of a subcostal incision(s) (eg, Kocher, chevron) is likely to be associated with significant underlying adhesions.

Lateral abdomen/flank — Lateral abdominal and flank access sites are commonly used for the placement of retracting instruments. (See 'Multiple port placement' below.)

Palmer's point is located 3 cm below the left costal margin, just lateral to the rectus muscle in the midclavicular line. Like the left ninth intercostal location, Palmer's point can also be used as a site for initial insufflation of the abdomen with a Veress needle when a transumbilical site cannot be used or is not preferred [8]. A right-sided approach can be used as well. (See 'Special considerations for access' below.)

Lateral to the rectus muscle, the layers of the abdominal wall include the skin, subcutaneous fat, fascia and muscle of the external oblique, internal oblique, transversus abdominis (outward to inward), preperitoneal fat, and parietal peritoneum (figure 1 and figure 3). The deep nerves and vessels of the abdominal wall run parallel to each other traveling along the posterior surface of the internal oblique (figure 4 and figure 5).

Ninth left intercostal space — The ninth left intercostal space is another, although uncommon, site that is useful for primary insufflation of the abdomen when other sites are not available. (See 'Special considerations for access' below.)

The intercostal space is accessed in the anterior axillary line close to the superior margin of the tenth rib. This site approximates the inferior margin of the posterior spleen. The splenic flexure of the colon is also in proximity, making this access point more challenging than more medial sites.

Hypogastrium — Access sites in the hypogastric region are used for laparoscopic surgery on pelvic structures. (See 'Multiple port placement' below.)

Many arteries and nerves traverse the hypogastric region to supply the abdominal wall, including the inferior and superficial epigastric arteries, superficial and deep iliac circumflex arteries, and iliohypogastric and ilioinguinal nerves (figure 4 and figure 5). The location of port sites in the lower abdomen should be chosen to avoid these vessels and nerves. If the vessels are not obvious prior to laparoscopic access, the laparoscope can be used to transilluminate the abdominal wall and identify the vessels. Access just medial and superior to the anterior superior iliac spine avoids these structures [9].

PERITONEAL ACCESS — Before any laparoscopic procedure can begin, the peritoneal cavity needs to be accessed, first to establish pneumoperitoneum and subsequently to place a port for the laparoscope and add the placement of additional ports for various laparoscopic instruments. When choosing sites, previous surgical incisions, particularly sites with mesh placement, should be noted. Sites that have not been previously instrumented are preferred for initial access, and mesh should be avoided. If this is not possible, it is important to close the port site, including the edges of any mesh, with permanent suture at the end of the procedure.

Laparoscopic entry can be performed with an open (ie, Hasson) or closed (eg, Veress needle, optical entry trocar) technique. Each method has advantages and disadvantages, and neither is suitable as an all-purpose method for laparoscopic access. Different approaches can be used for primary and secondary port placement during the same procedure. (See 'Choice of technique' below.)

Prior to peritoneal access, we decompress the stomach and/or bladder to minimize the likelihood of bowel or bladder injury, depending on the point of entry. (See "Complications of laparoscopic surgery", section on 'Bladder puncture'.)

Open (Hasson) — The Hasson technique refers to an open method in which an incision (usually periumbilical) is made through the abdominal wall under direct vision [10]. The advantage of the open technique is the direct visualization of all layers of the abdominal wall during entry [11].

This technique generally adds to the length of the procedure, taking longer to perform at the beginning and the end of the procedure compared with a closed (Veress needle) technique. It also tends to create a larger fascial defect to close at the completion of the procedure. Even though the Hasson technique is most commonly used in the periumbilical region, this method can be used anywhere on the abdominal wall and is particularly useful when there is a concern for abdominal wall adhesions in a patient with a prior laparotomy. (See 'Choice of technique' below.)

Procedure — To access the abdomen using an open technique:

Make an incision in the skin.

Bluntly dissect the subcutaneous fat with a clamp (tonsil, Kelly).

Cauterize, or ligate and divide, any vessels that are encountered.

Place Kocher clamps on the fascia or umbilical stalk (if utilizing periumbilical region).

Incise the fascia until a small amount of preperitoneal fat is identified. Place stay sutures in the fascial edges.

The stay sutures aid with retraction of the abdominal wall and can be used to secure the port to the fascia, preventing its displacement during the surgery.

Bluntly dissect the preperitoneal fat, if present, and bring the peritoneum up into the wound with a hemostat.

Open the peritoneum sharply, sweep the underside of the abdominal wall with the index finger to clear omentum or bowel, and confirm the absence of adhesions in the region of the incision.

Place a blunt-ended trocar (ie, Hasson) through the incision, and secure it with the stay sutures or by inflating a balloon-tipped trocar, if used.

Attach the gas (typically carbon dioxide) to the port and insufflate the abdomen. (See 'Establishing pneumoperitoneum' below.)

At the end of the procedure, remove the stay sutures, or, alternatively, use them to close the fascial defect. (See 'Fascial closure' below.)

Closed (Veress needle) — The Veress needle technique refers to a closed method in which the Veress needle (named for Janos Veres) is used to puncture through the layers of the abdominal wall. This technique was popularized by Raoul Palmer in the mid-20th century [8]. The Veress needle, originally developed to give patients with tuberculosis iatrogenic pneumothorax without damaging the underlying lung parenchyma, is a small-bore (2 mm) needle with a spring-loaded protective obturator that recoils to cover the end of the needle, allowing entry into a body cavity without traumatizing the underlying organs (picture 2). When the needle enters the peritoneal cavity, the clinician usually feels or hears the protective sheath/obturator "click" when it recoils, indicating that the needle tip no longer has resistance against its tip. This click generally indicates that the peritoneal cavity has been entered; however, this click can also be felt if the tip of the device is within a hollow viscus inadvertently, and one of several confirmatory techniques is generally used before insufflating through the needle.

The most common insertion site for the Veress technique is the umbilicus because there is no fat or muscle between the skin and peritoneum at this location. Transumbilical insertion is contraindicated when umbilical abnormalities (eg, umbilical hernia) are present or there is a concern for underlying adhesions from a prior surgery. (See "Overview of gynecologic laparoscopic surgery and non-umbilical entry sites", section on 'Candidates for non-umbilical access'.)

The Veress needle technique allows for a quick entry into the peritoneal cavity since direct cutdown to the fascia level and suture closure of the access site are not needed, provided a ≤12 mm trocar is used. There may also be a reduced risk for access site hernia with this technique [12]. (See "Complications of laparoscopic surgery", section on 'Hernia'.)

A disadvantage of closed umbilical access is an increased risk of major vascular complications compared with the open technique [2,4,13-20]. The distance between the base of the umbilical stalk and the aorta is generally less than 4 cm and as little as 2 cm in thin individuals. For this reason, some surgeons advocate using a site other than the umbilicus if the Veress technique for abdominal insufflation is chosen. If the midline is used, upward retraction is imperative to provide resistance and limit the amount of downward force exerted on the needle. (See "Complications of laparoscopic surgery", section on 'Vascular injury' and 'Choice of technique' below.)

Alternative sites to establish pneumoperitoneum when the umbilicus cannot be used or is not preferred for closed access include other points in the midline, the medial costal margin, the ninth left intercostal space, the lateral border of the rectus muscle 3 cm below the left costal margin (ie, Palmer's point), and the lateral border of the rectus muscle at the level of the iliac crest. (See 'Access locations' above and 'Special considerations for access' below.)

Procedure — To access the abdomen with a closed approach using a Veress needle:

Estimate the length of Veress needle needed to reach the peritoneal cavity.

Make a 5 mm incision in the skin and the subcutaneous tissue.

Place the needle through the incision to the level of the fascia, mark the depth on the needle, then remove the needle.

Grasp the fascia (eg, manually, Kocher clamp) and elevate the abdominal wall, unless a subcostal site is used [21,22]. It is important to note that grasping only the skin while not including the fascia may increase the rate of failed entry [2].

Grasp the Veress needle just above the previously marked site and insert it through the incision at a 45 degree angle toward the hollow of the pelvis, or away from fixed viscera, with care not to deviate in laterally.

Feel for two "pops." The first occurs when the needle passes through the abdominal fascia and the second as it passes through the parietal peritoneum. More lateral access sites may have additional "pops" if more than one layer of fascia is traversed.

When the needle enters the peritoneal space, the displaced hub of the needle will "click" as the protective sheath recoils to cover the end of the needle. An intra-abdominal needle will also move more freely than a needle within the abdominal wall.

Several methods are available for confirming Veress needle placement; however, no trials are available to suggest the use of one method over another. These include one of the following [23]:

Saline aspiration and injection:

Attach a 10 mL syringe containing 4 mL of normal saline to the Veress needle hub.

Aspirate with the syringe. If there is no content return, an intraperitoneal location of the tip of the needle is presumed. If blood or enteric contents are returned upon aspirating the syringe, an inadvertent vascular or visceral injury may have occurred. Under this circumstance, leave the needle in place and obtain abdominal access at a site to assess the original site for potential injury. The initial access needle should only be removed under direct visualization. (See 'Failed entry' below.)

Inject saline into the presumed peritoneal space if there was no return of blood or bile. If saline injects freely without resistance, an intraperitoneal location of the tip of the Veress needle is assumed. If there is high pressure to resistance, the needle is generally still within one of the layers of the abdominal wall.

Remove the syringe and drip saline into the open Veress needle hub. If saline flows freely without resistance, an intraperitoneal location is assumed.

Hanging drop method:

Place a drop of saline into the open Veress needle hub.

Elevate the abdominal wall.

An intra-abdominal location for the needle is suggested if the drop of water is drawn into the needle because of the negative intra-abdominal pressure generated.

Measurement of intraperitoneal pressure:

Measure intra-abdominal pressure by attaching the Veress needle to the laparoscopic insufflator.

An intra-abdominal position of the needle is suggested for intra-abdominal pressure ≤10 mmHg. In one large observational study, confirmation of low intraperitoneal pressure was the most reliable method to confirm Veress needle placement [23].

Once an intra-abdominal position of the needle is verified, initiate gas insufflation (typically carbon dioxide). A properly placed Veress needle will allow free flow of gas. Tympany should be appreciated with percussion of the abdomen in the right upper quadrant. (See 'Establishing pneumoperitoneum' below.)

To place the primary port:

Once the abdomen is insufflated, remove the Veress needle.

Place the primary port into the Veress needle track or alternative site. A visual entry port is most commonly used and allows early recognition and immediate management if a vascular or gastrointestinal injury has occurred [15].

Avoid a trocar direction or depth that could result in injury to the aorta or iliac arteries. Holding the trocar shaft rather than its top during insertion may help prevent uncontrolled depth or speed of penetration. (See 'Visual entry technique for primary and secondary port placement' below.)

If visual entry devices are not available or not preferred, blind insertion of the primary trocar can also be performed once the abdomen has been properly insufflated. We prefer a disposable, shielded trocar because it tends to be sharper than reusable trocars and requires less force upon insertion [17]. An alternative device is a radially dilating trocar, which has no cutting mechanism. Introduce the trocar perpendicular to the skin for a distance of 2 to 3 cm, and then increase the angle of introduction to between 45 degrees and approximately 60 degrees in the direction of the area of interest within the abdomen. Control of the force and depth of trocar/port should be maintained at all times. Excessive pressure to overcome skin or fascial resistance can lead to uncontrolled trocar entry, which increases the risk of injury to bowel or other abdominal or retroperitoneal structures. One useful technique is to gently twist the trocar while exerting firm downward pressure. We prefer to bluntly enlarge a narrow incision or, alternatively, to change to an open (Hasson) method, rather than increasing the force placed upon the instrument. Yet another approach is to use a trocar system designed to maintain the Veress needle track. Commercially available Veress needles with a radially dilating expandable sleeve are available (eg, Versa Step). After the pneumoperitoneum has been established, the Veress needle is removed from the sleeve (which maintains the track). A blunt, dilating trocar/obturator system can then be inserted along the sleeve track without change in direction from the initial needle entry. (See 'Open (Hasson)' above.)

Listen for a rush of gas from the peritoneal cavity, which indicates that the proper trocar depth has been reached. Withdraw the trocar slightly and advance the port cannula 1 to 2 cm to ensure placement within the abdominal cavity. Insert the laparoscope (picture 3) into the port and the abdomen, and confirm that no inadvertent injury has occurred.

Entry complications may be reduced by hyperdistending the abdomen when blind trocar insertion following Veress needle insufflation is used. Hyperdistention elevates the abdominal wall off the abdominal organs and provides better support for the trocar. This technique is useful for very thin patients and patients with obesity [24]. Clinically significant adverse effects on cardiopulmonary function have not been observed with brief periods of hyperdistention, provided the patient is not in Trendelenburg position [25-27]. (See 'Special considerations for access' below.)

Visual entry technique for primary and secondary port placement — The visual entry technique accesses the abdominal cavity with a specialized optical trocar/port that has a transparent tip, allowing each layer of the abdominal wall to be seen with a 0 degree laparoscope as it is being traversed. Commercially available optical trocar/ports include Optiview, Kii optical access system, and Visiport. The manner in which each of these devices affects tissue dissection as the tip advances differs in minor ways.

These devices are typically used for primary port placement after Veress needle abdominal insufflation or secondary port placement after pneumoperitoneum has already been established. (See 'Closed (Veress needle)' above and 'Open (Hasson)' above.)

Some surgeons advocate use of an optical trocar/port as a means to establish initial pneumoperitoneum [28]. The left upper quadrant (1 cm caudal to the subcostal margin in the midclavicular line) is a safe location for this approach; however, right upper quadrant and left epigastric locations are also commonly used. Optical access ports specifically designed to establish pneumoperitoneum are now commercially available (eg, Kii Fios First Entry). (See 'Lateral abdomen/flank' above and 'Choice of technique' below.)

Procedure — Once pneumoperitoneum has been established using either the open Hasson or Veress needle technique, optical/trocar port placement is performed as follows:

Make an incision (0.5 to 1 cm) in the skin at an appropriate port site. (See 'Access locations' above and 'Multiple port placement' below.)

Advance the laparoscope (typically 0 degree) to the end of the optical trocar/port and place into the incision perpendicular to the abdominal wall.

Apply gentle downward pressure on the abdominal wall.

Advance the optical trocar by creating large semicircular twists of the handle while applying downward pressure on the abdominal wall.

Stop advancing the optical trocar/port when a rush of gas is heard from the abdominal cavity. Seeing the omentum (midline access) or a dark space confirms correct placement of the device in the abdominal cavity. If the abdomen has been pre-insufflated, a large black space will also be seen as the peritoneum dilates around the device tip. This is visual confirmation of entry. If the abdomen has not been insufflated, you will see a meniscus of peritoneum on one-half of the view and visceral fat/bowel on the other half, which should appear to move independently if the optical trocar is moved left and right.

Remove the camera, withdraw the trocar slightly, and advance the cannula 1 to 2 cm. Then, remove the trocar and reinsert the laparoscope.

Advanced access techniques — More advanced approaches are currently under investigation as alternative access techniques for laparoscopic surgery. These include single-incision laparoscopic surgery (SIS).

Single-incision surgery — Single-incision surgery refers to a laparoscopic access technique that uses a single incision, usually at the umbilicus. There is no consensus on the nomenclature for this approach, and this technique has been published under many different names, including SILS (single-incision laparoscopic surgery), SPA (single port access), SSL (single-site laparoscopy), OPUS (one-port umbilical surgery), SLAPP (single laparoscopic port procedure), SPLS (single-port laparoscopy), SLIT (single laparoscopic incision transabdominal surgery), SIMPL (single-instrument port laparoscopic surgery), and LESS (laparoendoscopic single-site surgery). SILS and LESS are the most commonly used terms and were introduced by industry. Laparoendoscopic single-site surgery (LESS) was introduced as standard terminology for academic publications in 2008 by the Laparoendoscopic Single-Site Surgery Consortium for Assessment and Research [29], although this has not been universally adopted.

The concept of single-incision surgery is not entirely new. In one report in 1969, "single trocar operative laparoscopy" was performed using a 12 mm operative laparoscope with one operative channel [30,31]. In 1991, the first hysterectomy by a single trocar technique was reported by Pelosi et al [32]. Despite these pioneering efforts, laparoscopic surgeons did not embrace single-incision surgery, primarily related to challenges inherent to the technique.

The indications and contraindications for a laparoscopic single-site approach are the same as for conventional laparoscopic surgery. The only specific contraindication for laparoendoscopic single-incision surgery is prior mesh placement at the intended access site. Whether to choose a single-incision or multiple port approach for laparoscopy is discussed below. (See 'Single incision port versus multiple ports' below.)

Compared with conventional laparoscopy, single-incision laparoscopy is more challenging due to several technical factors, including loss of triangulation and depth perception because the camera and working instruments are parallel with each other, reduced range of motion for the instruments, limited extra-abdominal working space with creation of a "hand clashing" problem, and decreased field of view due to suboptimal instrument or camera position [29]. Specialized training is needed to overcome these challenges; however, surgical training has not uniformly incorporated single-incision techniques into surgical residency programs. For surgeons experienced with standard laparoscopic techniques, adopting single-incision techniques is feasible and safe provided accepted safety practices are maintained [33-37]. In evaluating the learning curve for single-incision surgery procedures, the authors of one study reported that the most significant improvement in operative time occurred after 10 completed cases, and lesser improvements were seen after 20 cases [38]. Specialized instrumentation and advances in laparoscopic techniques have helped minimize some of the problems inherent to single-incision surgery. Some of these include improved optics for laparoscopic cameras, roticulating instruments and cameras, and techniques such as crossing the hands or using different-length instruments [39-43]. (See "Instruments and devices used in laparoscopic surgery", section on 'Laparoscopes for single-incision surgery' and "Instruments and devices used in laparoscopic surgery", section on 'Instruments for single-incision laparoscopy'.)

Single-incision surgery techniques are in development in many abdominal and pelvic surgery fields (eg, general surgery, gynecology, urology) [44,45]. A systematic review identified 4595 single-site operations performed at predominantly six institutions [46]. Single-incision cholecystectomy was the most commonly reported procedure, representing 24 percent of the 4595 operations. Single-incision nephrectomy was the second most common procedure. Technical success rates were high, with conversion to a standard approach required in 0 to 10 percent of patients [47-51]. Similarly, in a systematic review of single-incision laparoscopic colectomy, the overall conversion rate was 7 percent [52]. Of the 378 cases, 6 (1.6 percent) were converted to a hand-assisted laparoscopic procedure, 14 (4.0 percent) were converted to conventional (multiport) laparoscopic colectomy, and 6 cases (1.6 percent) required conversion to open colectomy. Robotic assistance or other novel devices may be useful when performing single-incision surgery. Initial data from animal and human procedures in urology appear promising [43,53-55].

Alternative sites used in gynecologic laparoscopy — In gynecologic laparoscopy, Veress needle insertions through the uterine fundus [56] and posterior vaginal fornix [57] have also been used. (See "Overview of gynecologic laparoscopic surgery and non-umbilical entry sites", section on 'Non-abdominal sites'.)

Establishing pneumoperitoneum — Once peritoneal access is established, the abdomen is insufflated, typically with carbon dioxide (CO2) gas. Other gases have also been tried, including nitrous oxide and helium; however, the safety of these agents has yet to be established [58]. CO2 gas can be administered cold or heated, with or without humidification. Compared with cold gas, heated gas led to only a minimal, clinically insignificant rise in core body temperature of 0.31° Celsius (95% CI 0.09-0.53), without any meaningful improvement in patient outcomes or ease of surgery. Thus, the extra cost of heating and/or humidifying gas used in laparoscopy cannot be justified, according to a Cochrane review of 22 randomized trials [59].

The rate of CO2 gas flow is set low initially. However, a Veress needle will only allow a maximum flow rate of 3L/min if this is the technique used. After abdominal, and not extraperitoneal, insufflation is confirmed, the gas flow can be increased to its full flow rate while the intra-abdominal pressure is monitored. The pressure will initially be <10 mmHg but will slowly increase. The preset intra-abdominal pressure of 12 to 15 mmHg should be reached. The gas is left on but flows into the abdomen only if the abdominal pressure falls below the preset pressure. Pressures lower than 12 mmHg have been used successfully in laparoscopic cholecystectomy without apparent increases in complications or conversion rates, but with lower rates of shoulder pain [60]. (See 'Minimizing access-related pain' below.)

The necessary volume of gas needed for insufflation is dependent upon the depth of anesthesia, use of neuromuscular blockade, and the patient's size. Visual and manual examination (ie, tympany upon palpation) of the abdomen confirms that adequate pneumoperitoneum has been achieved.

If the pressure rapidly increases to 12 to 15 mmHg, then the needle/port may be displaced or occluded. The abdominal wall should be grasped and gently elevated. This will dislodge any omentum or bowel that may be blocking the opening of the needle or port. Changing the angle or rotating the trocar or Veress needle can also help free the opening. Ensure that the stopcock on the port is in the correct "open" position and that there are no severe kinks in the insufflation tubing. If none of these maneuvers reduce the increased pressure to an acceptable level, the needle or port should be removed and replaced.

During insufflation, increased intra-abdominal pressure stimulates the neurohumoral vasoactive systems, resulting in increased heart rate, mean arterial pressure, and systemic and pulmonary vascular resistance while decreasing vital capacity, venous return, preload, and cardiac output [21]. In otherwise healthy patients, American Society of Anesthesiologists (ASA) class 1 or 2, these physiologic effects are not detrimental if intra-abdominal pressure does not exceed 15 mmHg and diminish as the patient's physiology accommodates.

The CO2 gas causes hypercapnia and respiratory acidosis due to absorption of the gas across the peritoneal surface. Endogenous buffering systems and accelerated elimination of CO2 via the lungs prevent clinically significant acidosis under normal circumstances. Monitoring end-tidal CO2 concentration is mandatory, and minute volume should be increased to maintain a normal CO2 level [21]. Arrhythmias are a potentially serious consequence of hypercarbia. Renal parenchymal compression and decreased renal blood flow may result in temporary oliguria, which typically resolves upon release of pneumoperitoneum [61].

Fascial closure — If a port was placed with the open (Hasson) technique or a port ≥12 mm is used, the fascia should be closed with suture to reduce the risk of developing a port-site hernia [12]. Port sites established in a region of prior mesh should be closed with permanent suture. However, closure of the fascial defect does not guarantee that a hernia will not develop at that site. Port sites created with a radially dilating trocar (as opposed to cutting trocars) do not generally require closure unless larger than 12 mm in size, or if manually dilated during specimen removal. (See "Complications of laparoscopic surgery", section on 'Hernia'.)

Fascial reapproximation can be accomplished in a variety of ways. Ideally, the fascia is directly visualized with the aid of retractors. The fascial edges are grasped and sutured closed with interrupted or continuous suture.

A number of specialized instruments have been devised for port site fascial closure (eg, Grice suture needle, Carter-Thomason needle-point suture passer, Endo Close instrument, Reverdin suture needle) [62,63]. The benefit of these devices has yet to be proven.

CHOICE OF TECHNIQUE — There continues to be controversy over which of the two principal techniques, Hasson or Veress needle technique, provides safer access to the peritoneum for laparoscopic surgery [4,11,13-15,19,21,64-70]. A systematic review of randomized trials comparing these entry techniques found no significant differences in overall complication rates but noted that the available trials were small and results were underpowered to detect uncommon complications such as vascular or gastrointestinal injury and postoperative hernia [2]. Retrospective reviews suggest that the risk of major complications is reduced with open access techniques or placement of trocars with visual confirmation (direct vision or visual entry devices) [2,4,13-20].

The conclusions drawn from the systematic review are as follows:

Radially expanding trocars reduce port site bleeding (odds ratio [OR] 0.13, 95% CI 0.05-0.37) compared with cutting trocars.

Not elevating the abdominal wall compared with elevating it when using a Veress needle technique was found to have lower incidence of failed entry without an increase in the risk of complications. We feel that specifically elevating the fascia, as opposed to the bulky abdominal wall, may facilitate Veress needle placement; however, there are limited data available to support this conclusion.

A direct-entry technique or use of a radially expanding trocar reduced extraperitoneal insufflation (OR 0.16, 95% CI 0.08-0.29) and failed entry (OR 0.25, 95% CI 0.11-0.53) compared with use of the Veress needle alone.

Access for insufflation — Surgeons should adhere to the technique with which they have the most experience but should be familiar with alternative techniques. Surgeon preference and experience likely plays a role in minimizing the risk of injury.

Each technique should be used selectively depending upon proposed port location, the intended function of the port, and patient factors, such as prior surgery (ie, likelihood of adhesions) and body habitus. For access in the region of the umbilicus, either Hasson or Veress techniques can be used. A third alternative of blind trocar access without insufflation has been described, but there are inadequate data to support its use.

A variety of trocar/port combinations are commercially available for laparoscopy. Each combines a tube with a sealing mechanism to maintain pneumoperitoneum and may be nondisposable or disposable. The most common trocars cut the myofascial layers with a blade, divide tissues with nonbladed flanges, or have radially dilating outer sheaths to facilitate insertion. The dilating trocars may minimize bleeding and risk of hernia [12].

Primary port placement — Following a Veress needle insufflation, the primary port can be placed either through the Veress needle track (except ninth rib approach) or elsewhere in the abdomen with either a simple (blind) trocar or visual entry trocar. It is our practice to place a Veress needle in a left upper quadrant location for most foregut cases and to upsize to a 5 mm trocar at the same site. If a subcostal port is not needed for the procedure, we usually obtain access with a periumbilical open technique, or Veress technique with clamps elevating the fascia [6].

Secondary port placement — Secondary ports can be placed with either a nondisposable trocar, shielded disposable trocar, or visual entry trocar, but always with the abdomen insufflated with direct observation with the laparoscope of the trocar entering the abdomen. Ports should be placed to facilitate operating in-line with the camera while maintaining triangulation and adequate spacing between the hands.

Special considerations for access

Umbilical hernia — In patients with a small umbilical hernia undergoing a laparoscopic procedure, open access into the hernia and a finger sweep to clear adhesions ensure safe access to the abdomen. The hernia can then be closed primarily at the completion of the case if the defect is small (<2 cm). Larger defects may be associated with significant adhesions and will likely require mesh hernia repair to minimize the risk of recurrence. Under this circumstance, access away from the umbilicus is suggested (eg, subcostal location) to facilitate visualization of the hernia and to perform lysis of adhesions, if needed. The management of umbilical hernias is discussed in detail elsewhere. (See "Management of ventral hernias", section on 'Surgical management of ventral hernias'.)

Prior abdominal surgery — Prior abdominal or pelvic surgery is associated with an increased risk for access site complications [71]. (See "Complications of laparoscopic surgery", section on 'Risk factors'.)

In patients with prior surgery, surgeons should avoid prior surgical incisions when obtaining their initial access if possible. If port placement is necessary at the site of a previous incision, open access should be performed.

Even when the initial access is away from prior incisions, it is still possible for visceral structures to be adhesed to the abdominal wall in areas away from incisions. Therefore, care should be taken when placing the initial port. There is interest in using bedside ultrasound imaging to detect abdominal wall areas free from critical adhesions in order to facilitate port placement in laparoscopic surgery [72]. However, this technique requires further study before it can be recommended for general use.

Once the abdomen is insufflated and the primary port placed, the peritoneum should be inspected to determine whether adhesiolysis is needed prior to the placement of additional ports.

Obesity — In patients with obesity, longer trocars and Veress needles may be needed due to the thickness of the abdominal wall. With the open technique, a larger skin incision may be necessary to adequately expose of the fascia.

With a Veress needle technique, entry location should be based upon bony landmarks and not the location of the umbilicus, since it can be displaced several centimeters inferiorly. The pannus can be retracted caudally, for better positioning and to thin the abdominal wall [73]. Skin folds on the abdominal wall should be avoided. During Veress needle placement, a 90 degree insertion angle is used to maximize the available needle length. The use of dilating trocars may reduce the incidence of postoperative hernia [12]. (See 'Choice of technique' above.)

Instrument mobility may also be limited depending upon the depth of the subcutaneous fat. Care must be taken during trocar placement to align them as needed for the procedure. Occasional repositioning of trocars may be necessary if procedures involve multiple abdominal quadrants.

Pregnancy — The gravid uterus may displace many intra-abdominal organs. Initial access is chosen to avoid contact with the uterus. Open access is often advocated in pregnant patients [74,75]. Laparoscopic surgery in pregnant patients is discussed in detail elsewhere. (See "Laparoscopic surgery in pregnancy".)

Single incision port versus multiple ports — The main theoretical advantage of single-incision laparoscopy is a potentially "scarless" abdomen when the incision is placed within or around the umbilicus. Randomized trials comparing conventional laparoscopic surgery with single-incision surgery have been performed for cholecystectomy, appendectomy, and nephrectomy [47-50,76-80]. These trials have found similar or longer operative times, similar or shorter mean length of hospital stay, and pain scores that are better or worse for the single-incision surgery group. Where cosmetic scores were reported, they have been consistently better for the single-incision group compared with conventional laparoscopy, even when patients are followed to a time of full wound healing [81]. However, one prospective study comparing a single-incision versus conventional laparoscopy for cholecystectomy found a significantly increased rate of postoperative hernia for the single-incision versus traditional four-port cholecystectomy approach (8.4 versus 1.2 percent) [81]. This study and other similar findings have led to a decline in this technique.

MULTIPLE PORT PLACEMENT — The port locations for various laparoscopic surgeries depend upon the location in the abdomen where the majority of the surgical procedure is to take place. Typically, the operating surgeon should be standing opposite this location. Multiple access sites are chosen to maintain a comfortable operating position for the surgeon, with triangulation of the instruments around the surgical focal point within the abdomen, while minimizing restricted motion due to collision of the port with the patient's body (bony prominences, thigh) or the operating table.

Depending upon the largest instrument needed for a particular port, the appropriate-sized trocar should be used. A ≥12 mm trocar is needed for surgical staplers, and a ≥10 mm trocar is needed for other specialized surgical instruments (eg, Endo Stitch). In general, the smallest size port possible that still permits a safe operation should be used to minimize the risk of subsequent incisional hernia, seroma, and pain. (See "Complications of laparoscopic surgery", section on 'Hernia'.)

Typical port placements and the role of the operating and assistant surgeon in utilizing these ports are presented for various general laparoscopic procedures in this section. Different clinicians may use alternative port locations based on training, personal preference, or individual patient anatomy.

Cholecystectomy — We use an open technique to enter the peritoneal cavity for acute indications but a Veress technique for elective procedures to place a 5 to 12 mm trocar at or near the umbilicus. The laparoscope is introduced through this port, and three additional 5 mm ports are placed under direct visualization 1 to 2 cm inferior to the right subcostal margin (figure 6). The surgeon operates from the patient's left side using the subxiphoid and one of the subcostal ports. The surgeon manipulates the infundibulum to provide counter-retraction with the left hand and uses a dissector with the right hand through the subxiphoid port (figure 7). The assistant works from the patient's right side using the right lateral port and umbilical port. The assistant uses the left hand to retract the fundus for exposure and operates the camera with their right hand. (See "Laparoscopic cholecystectomy".)

Alternatively, one of the 5 mm ports can be placed halfway between the xiphoid and umbilical ports. In this case, the surgeon retracts the infundibulum of the gallbladder through the midline port and uses the dissector through the subxiphoid port (shown in red) (figure 8). The assistant retracts the fundus of the gallbladder cephalad through the right lateral port and operates the laparoscope via the periumbilical port.

Appendectomy — We use an open or Veress technique to enter the peritoneal cavity and place a 5 to 12 mm trocar at the umbilicus. The laparoscope is introduced through this port, and two additional 5 mm ports are placed under direct vision in the left lower abdomen (figure 9). The first is placed lateral to the left rectus muscle and medial to the anterior superior iliac spine, and the second is placed in the suprapubic region at least two fingerbreadths superior to the pubic tubercle. (See "Appendectomy", section on 'Laparoscopic technique'.)

Both the surgeon and the assistant stand on the patient's left side. The surgeon operates through the two 5 mm ports, and the assistant operates the laparoscope. One 12 mm port is required to pass a surgical stapler to transect the appendix. The appendix is removed through the periumbilical port site, usually with a specimen bag (figure 10).

Alternatively, the two 5 mm ports can be placed in the "bikini line" (figure 11). The surgeon retracts the appendix using a grasper through a right lower quadrant port and dissects using the periumbilical port site while the assistant operates the laparoscope through a left lower quadrant port.

Inguinal hernia surgery — Access for inguinal hernia repair can be totally extraperitoneal (TEP) or transabdominal preperitoneal (TAPP). Laparoscopic inguinal hernia repair is discussed in detail elsewhere. (See "Laparoscopic inguinal and femoral hernia repair in adults".)

For TEP access, a large balloon dissector is placed via a periumbilical incision through the rectus sheath into the preperitoneal inguinal space (figure 12). As the balloon is inflated, the peritoneum is dissected from the abdominal wall. Additional ports are placed in a preperitoneal location for subsequent hernia repair.

For the TAPP approach, access is typically via a transumbilical approach, with subsequent trocars placed lateral to the rectus muscles bilaterally and into the peritoneal space (figure 13).

Foregut surgery — Laparoscopic foregut cases include Heller-type myotomy, hiatal hernia repair, gastroesophageal fundoplication procedures, gastrectomy, and bariatric procedures (eg, Roux-en-Y gastric bypass, sleeve gastrectomy). (See "Laparoscopic Roux-en-Y gastric bypass" and "Laparoscopic sleeve gastrectomy".)

We use a Veress needle technique in the left upper quadrant to insufflate the peritoneal cavity; a 5 mm port is placed through the Veress tract, and a laparoscope is placed. Four additional ports are placed under direct vision (figure 14). A 5 mm port is placed in the subxiphoid region for a laparoscopic liver retractor to aid in exposing the gastroesophageal junction. Right and left subcostal ports (5 mm) are placed, and two additional ports are placed midway between these subcostal ports and the umbilicus. One of the midabdominal ports is used to pass the surgical stapler (12 mm), curved needles for freehand suturing, and/or special suturing instruments, such as the Endo Stitch (11 mm).

The surgeon stands on the patient's right side using the dissector and stapler through the right-sided ports. The assistant stands on the patient's left side, operating the laparoscope with their left hand through the 5 mm midabdominal port site and providing countertraction for the surgeon through the left subcostal port site. For some complex cases, an additional 5 mm port may be added in the left midabdomen to allow the assistant two operative hands.

Alternatively, the patient can be placed in a split leg or low lithotomy ("French") position, and the surgeon operates from a position between the legs. For this approach, the larger port may be placed in the patient's left upper quadrant to facilitate right-handed suturing. For complicated foregut procedures, an additional left abdominal port may be added.

Colectomy — To enter the peritoneal cavity, we use an open technique at the umbilicus and place a 5 to 12 mm Hasson trocar.

The port sites for right colectomy are similar to those for laparoscopic appendectomy (figure 9) with the addition of one or more 5 mm ports in the upper midline region (figure 15). Both the surgeon and the assistant stand on the patient's left side. A 5 mm upper midline port is useful during mobilization of a difficult hepatic flexure. Once the colon is mobilized, the umbilical port site is extended to a mini-laparotomy incision and extracorporeal bowel resection and ileocolic anastomosis performed through a wound protector. The mini-laparotomy incision is closed according to standard principles. (See "Principles of abdominal wall closure".)

For left colectomy and sigmoid colectomy, the port sites are almost a mirror image of right colectomy port sites (figure 16). Both the surgeon and the assistant stand on the patient's right side. Either the suprapubic port or the right lower quadrant port can be used to introduce the surgical stapler (12 mm) for transection of the sigmoid colon at the peritoneal reflection. The upper midline port is useful for mobilizing the splenic flexure. The resected sigmoid colon can be removed through a mini-laparotomy at the umbilicus, similar to the right colectomy, transrectally or through a small Pfannenstiel incision. (See "Minimally invasive techniques: Left/sigmoid colectomy and proctectomy".)

Splenectomy — The patient is placed in a right lateral decubitus position (60 to 90 degrees) with a bean bag for support. The patient's abdomen is hyperextended by using the table break and kidney rest to open the space between the patient's left iliac crest and left subcostal margin.

We use an open technique to enter the peritoneal cavity at the umbilicus (enlarged spleen) or in a subcostal location (normal-sized spleen) and place a 5 to 12 mm Hasson trocar (figure 17). Review of preoperative imaging in cases of splenomegaly can be of great value in helping the surgeon determine the best location for initial port placement.

A port is placed in the left flank region in the anterior axillary line between the left subcostal margin and the left iliac crest under direct vision. This port is used to pass a stapler (12 mm) to transect the hilar vessels after dissection has been completed. Two other 5 mm ports are placed for dissection and countertraction.

After the hilum has been transected and the perisplenic attachments are divided, the spleen is captured into a large laparoscopic bag placed through the primary port site and is removed by morcellation (crushing and tearing with ring forceps). Alternatively, if the integrity of the spleen is important for pathologic analysis, a mini-laparotomy is performed.

Adrenalectomy — The patient is positioned in a decubitus position (with the right side down for a left-sided procedure and vice versa for a right-sided procedure) in a 60 to 90 degree reverse Trendelenburg position using a bean bag for support. The patient's abdomen is hyperextended to extend the space between the patient's left iliac crest and left subcostal margin.

We access the peritoneal cavity with a Veress technique through a midclavicular subcostal site. The port site placements for the left and right adrenal gland are mirror images of one another (figure 18A-B). Three additional ports are placed under direct vision, including a flank port in the midaxillary line between the subcostal margin and the iliac crest, an epigastric port, and a medial subcostal port. An additional port may be needed for the right adrenalectomy to retract the liver to expose the right retroperitoneum.

Once the adrenal gland is resected, it is captured in a laparoscopic bag placed through the 12 mm subcostal port site and removed by extending this incision, as needed, to maintain the integrity of the adrenal gland for pathologic analysis. (See "Adrenalectomy techniques".)

Ventral hernia repair — For ventral hernia repair, the ideal placement of the access port(s) is away from the hernia defect to allow for adequate mesh overlap and fixation (figure 19). Large defects may require bilateral port placement. A reasonable location for initial access is laterally within the quadrant furthest from the site of the hernia. At least one trocar ≥10 mm is needed to pass the mesh. (See "Laparoscopic ventral hernia repair".)

Pelvic surgery — A variety of laparoscopic procedures are performed in the pelvis, including ovarian cystectomy, hysterectomy, and tubal ligation, among others. Primary access is obtained at the umbilicus using an open (Hasson) or Veress needle technique. For manipulation of pelvic structures, ports are placed, bilaterally as needed, in the lower quadrants, or, occasionally, lateral to the rectus muscle low in the abdomen at the level of the umbilicus (figure 20).

SINGLE-INCISION PORTS AND PLACEMENT — A specially designed single multichannel port provides access for the laparoscope as well as several other laparoscopic instruments. Multiple co-located trocars can also be used. In general, these devices are all placed with an open technique.

A variety of dedicated port systems and instruments are available for single-incision laparoscopy. Port systems vary in diameter, which determines the length of fascial incision needed (1.2 to 7 cm), and in the number of channels and their diameters (three to four channels, ranging from 5 to 15 mm). Multiport systems include TriPort and QuadPort, AirSeal, SILS Port and other SILS procedure kits and access devices, GelPort, and the Cuschieri Endocone. Complete single-incision platforms are also available (eg, Single Port Instrument Delivery Extended Reach [SPIDER]).

The single-incision port is typically at the umbilicus through a single 2 to 3 cm incision (figure 21 and picture 4). The length of the incision is dictated by the diameter of the device, and the choice of a transverse versus vertical incision depends upon the anatomy of the umbilicus. The surgeon should select the orientation to maximize incision length within the umbilicus. To improve cosmesis, the incision should be kept within the umbilical ring as much as possible.


Failed entry — If bile, enteric contents, or blood returns at placement of the Veress needle, the needle should be left in place and alternative access gained immediately. Alternative access can be laparoscopic unless the bleeding is significant, in which case open laparotomy is warranted.

Any failed entry site should be inspected to assess for any associated injury, which, when identified, is appropriately repaired. If entry fails but there is no complication, access can be reattempted at the same site.

Leaking port — If a port or single-site device leaks during a procedure, it is usually due to the fascial defect being too large or excess port angulation. Balloon-tipped trocars can be helpful. Leaks can also be mitigated with additional sutures or the placement of a towel clamp to cinch the tissue closed around the trocar. Petrolatum-coated gauze may also be used to reduce the flow of any air leak.

Loss of port position — If a port is sliding within the abdominal wall, the port may need to be repositioned and/or secured with additional sutures. Even ports not specifically designed to be sutured in place (ie, no rings or suture stays) can be easily secured using a drain or "sandal"-type stitch. The use of longer or larger-diameter trocars or balloon/expandable-tip trocars may also be helpful. Many Hasson trocars have an adjustable plug that permits the cannula to be secured to various depths with a lock mechanism to prevent the port from changing position.

Bleeding port — The vessels of the abdominal wall can be injured during the access procedure. Access sites are carefully chosen to avoid these vessels. (See 'Access locations' above.)

Bleeding from the abdominal wall may not become apparent until after the port is removed, because the port may tamponade muscular or subcutaneous bleeding. In addition to visually inspecting the access site upon its creation, the site should also be inspected during and following removal of the port. Bleeding points can usually be identified and managed with electrocautery. On occasion, the skin incision may need to be enlarged to control the bleeding.

If persistent bleeding continues, a Foley catheter can also be inserted, inflated, and gentle traction applied to tamponade the site. If this maneuver fails, U-stitches can be placed into the abdominal wall under direct laparoscopic visualization using a suture passer with absorbable braided suture. Care must be taken to suture proximal and distal to the injured portion of the vessel. A number of specialized instruments have been devised for port site fascial closure, and these may also be useful for managing abdominal wall bleeding. (See 'Fascial closure' above.)

Loss of pneumoperitoneum — Under some circumstances, the established pneumoperitoneum may need to be temporarily released (eg, patient intolerance, hemodynamic instability, for portions of some surgical procedures) or is lost due to a leaking port or equipment malfunction. Most trocars have stopcock valves to easily release pneumoperitoneum if this is required. To reinstitute pneumoperitoneum, the stopcock can be turned back in line with the gas flow. To troubleshoot inadvertent loss of pressure, all potential loss sites should be assessed, including the gas supply, insufflation tubing, insufflator, valves, and port sites (eg, extraperitoneal trocar, leak around trocar at fascial level).

Extraperitoneal insufflation — Subcutaneous, preperitoneal, or omental insufflation can occur with any access technique. Some authors suggest that direct access without insufflation minimizes the incidence; however, these data are limited. Any benefit of preventing erroneous insufflation is offset by the potential for bowel or vascular injury by placing a trocar prior to insufflation. (See "Complications of laparoscopic surgery", section on 'Related to pneumoperitoneum'.)

Intraperitoneal placement of the Veress needle or Hasson trocar may have initially been confirmed. However, if the device is inadvertently withdrawn out of the peritoneum, subcutaneous insufflation of CO2 gas will occur and insufflation pressure will quickly rise to ≥15 mmHg. The abdominal wall distends but is not tympanitic, and crepitus instead will be noted in the subcutaneous tissues.

Subcutaneous CO2 insufflation may increase the end-tidal CO2, and anesthesia personnel should be notified if extraperitoneal insufflation has occurred. Small amounts of extraperitoneal air are usually quickly resorbed once intraperitoneal insufflation is achieved. In older adults, and patients with compromised tissue integrity (eg, collagen, vascular, or mixed connective tissue disorders), subcutaneous CO2 insufflation can progress rapidly, quickly reaching the chest wall, neck, and face.

Minimizing access-related pain — Postoperative shoulder pain is not uncommon after laparoscopic surgery. It is generally considered a referred pain due to irritation of the diaphragm (by fluid, blood, or the carbonic acid created from the mixing of carbon dioxide gas and intraperitoneal water) or stretching of the phrenic nerves during the procedure [82].

Pain from trocar placement is expected but can be minimized by using the least number of ports required to perform the procedure safely, minimizing the number of large ports (ie, ≥10 mm), and injecting local anesthetic at the port sites either before or at the end of the procedure [21].

The primary measure to reduce access-related pain relating to insufflation is to reduce the initial insufflation rate and insufflation pressure [60]. A systematic review identified 22 trials comparing low-pressure pneumoperitoneum with standard-pressure pneumoperitoneum in patients undergoing laparoscopic cholecystectomy (n = 1263) [83]. The low-pressure group had significantly lower pain scores and a lower incidence of shoulder pain among the 10 studies that reported this outcome. No significant differences in the need to convert to open surgery or complication rates were identified between low-pressure and standard-pressure groups. In a later trial (PAROS), patients who underwent laparoscopic colectomy at a pressure of 7 versus 12 mmHg had less pain, lower analgesic requirements, and shorter hospital stay [84].

Other measures include warming and humidifying the CO2 gas and removing residual CO2 gas at the end of the procedure (facilitated by placing the patient in Trendelenburg position) [85-94]. The displacement of trapped CO2 gas may be improved with the instillation of normal saline, or by using pulmonary recruitment maneuvers, which involve multiple manual pulmonary inflations by the anesthesiologist (increases intra-abdominal pressure) [86,89-95].

Methods for more fully evacuating pneumoperitoneum were compared in a trial that randomly assigned 158 women undergoing gynecologic laparoscopic surgery to one of three groups to evaluate the effectiveness of these treatments in preventing postoperative laparoscopy-induced abdominal or shoulder pain [89]. After pneumoperitoneum was released, the abdomen was either filled with normal saline, pulmonary recruitment maneuvers were used, or no additional procedure was used (control). The incidence of postoperative shoulder pain was significantly decreased in the saline group (41 versus 65 and 73 percent at 24 hours after surgery, respectively; 24 versus 51 and 55 percent at 48 hours after surgery, respectively) compared with the pulmonary recruitment group or control group. Upper abdominal pain was improved for both treatment groups compared with the control group.

In one randomized trial, patients who underwent a maneuver to remove excess carbon dioxide compared with those who did not had significantly less postoperative shoulder pain (pain scores at 12 hours were 16 versus 30) [86]. The maneuver was performed prior to wound closure and with laparoscopic port valves open, the patient was placed in Trendelenburg position (30 degrees), and the anesthesiologist was asked to provide positive pressure pulmonary inflation five times.

Two randomized trials found that intraperitoneal irrigation with local anesthetic reduced shoulder pain compared with normal saline; preparations used were 50 mL of 0.5% lidocaine (pain scores 24 versus 44) [87] or 10 mL of 0.5% bupivacaine in 500 mL saline (42 versus 4 percent reported shoulder pain) [88].

A 2019 Cochrane systematic review and meta-analysis of 32 studies found the following interventions to be associated with reduced shoulder pain after gynecological laparoscopic procedures [96]:

A specific technique for releasing the pneumoperitoneum

Intraperitoneal fluid instillation

An intraperitoneal drain

Local anesthetic applied to the peritoneal cavity (not subdiaphragmatic)

Subdiaphragmatic intraperitoneal local anesthetic and warmed and humidified gas did not make a difference to shoulder pain. Gasless laparoscopy actually increased the severity of shoulder pain.

Inadequate exposure — If exposure or dissection is difficult or unsafe, additional trocars should be added to maintain patient safety. This is particularly important during single-site procedures, which should be abandoned in favor of a multiport technique if a good view of the operative field cannot be established.

COMPLICATIONS — The majority of access-related fatalities following laparoscopic surgery are due to a vascular or gastrointestinal injury [16]. Complications related to abdominal access are discussed in detail elsewhere. (See "Complications of laparoscopic surgery".)

SOCIETY GUIDELINE LINKS — Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: Laparoscopic and robotic surgery".)


Laparoscopic techniques have revolutionized the field of surgery. Before any laparoscopic procedure can begin, the peritoneal cavity needs to be accessed to establish pneumoperitoneum and place ports for the laparoscope and various laparoscopic instruments. (See 'Introduction' above.)

Initial laparoscopic access can be performed with open (ie, Hasson) or closed (eg, Veress needle) techniques. The Hasson technique refers to an open method in which an incision is made through the abdominal wall and a blunt trocar/port (ie, Hasson cannula) is placed under direct vision after sharply dividing the myofascial layers. The Veress needle technique is a closed method in which a Veress needle is used to puncture through the abdominal wall. Once the needle is confirmed in place, the abdomen is insufflated. The needle is subsequently removed, and a trocar/port is placed through the Veress needle tract. (See 'Peritoneal access' above.)

Initial access for abdominal insufflation is most commonly performed at the umbilicus. Open access techniques can be performed anywhere on the abdominal wall. Alternative sites for Veress needle insufflation include the lateral border of the rectus muscle 3 cm below the left costal margin (ie, Palmer's point) and the lateral border of the rectus muscle at the level of the iliac crest. (See 'Midline abdomen' above and 'Lateral abdomen/flank' above and 'Hypogastrium' above.)

The locations for multiple ports in laparoscopic surgery are chosen to triangulate the camera and instruments around a focal point within the abdomen, thereby maintaining optimal access for manipulation of the instruments and providing comfortable positions for the surgeon and assistant. (See 'Multiple port placement' above.)

Advanced approaches under investigation as alternative access techniques for laparoscopic surgery include single-incision surgery (SIS). (See 'Advanced access techniques' above and 'Single incision port versus multiple ports' above and 'Single-incision ports and placement' above.)

For initial peritoneal access, we suggest that surgeons should adhere to the technique with which they have the most experience (Grade 2C). Overall complication rates for laparoscopic access are not significantly different between the Hasson and Veress needle techniques for abdominal insufflation when performed by experienced surgeons; however, the surgeon should be familiar with alternative techniques (see 'Choice of technique' above). Conditions that may require an alternative approach for laparoscopic access include the presence of umbilical hernia, prior abdominal surgery, obesity, and pregnancy. (See 'Special considerations for access' above.)

We suggest not using blind trocar techniques for peritoneal access, wherever possible, but particularly prior to insufflation of the abdomen (Grade 2C). Blind trocar entry is associated with a greater risk of severe complications, including vascular and gastrointestinal injury. Strict adherence to proper technique minimizes the risk of injury with Veress needle insufflation, and visual entry devices are readily available for the placement of primary trocars. Secondary trocars should always be placed under direct laparoscopic vision. The negligible benefit of a quicker entry does not justify the risk of a potentially lethal complication. (See 'Choice of technique' above.)

Access-related issues, including failed entry, extraperitoneal insufflation, leaking or bleeding ports, and loss of port position or pneumoperitoneum, are unique to laparoscopic surgery. Troubleshooting these issues should be approached in a systematic manner to minimize the loss of time and prevent the development of other complications. (See 'Troubleshooting access issues' above.)

ACKNOWLEDGMENT — The editorial staff at UpToDate acknowledge Gerald Gracia, MD, who contributed to an earlier version of this topic review.

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