Laparoscopic Entry Techniques

Clinical Case

The first step in most abdominal laparoscopic procedures is insufflation of the intraperitoneal space with CO2 gas and the introduction of the videoscope system. For this, we have different options: close and open techniques.  Open/Hasson Technique: This is a technique for entering the abdomen under direct vision. This technique can be used to enter any quadrant of the abdomen, but is most commonly employed at the central umbilical site. A vertical or transverse skin incision approximately 10 to 12 mm long is made just below or above the umbilicus. The subcutaneous fat and tissues are bluntly dissected apart using small narrow finger retractors or a Kelly hemostat. The white linea alba is visualized and grasped on either side with hemostats. The linea alba is elevated with the hemostats and a vertical 10mm incision is made through the fascia . Further dissection with a hemostat will reveal the thickened white peritoneum, with is grasped with a pair of laterally placed hemostats. The peritoneum is elevated and opened cautiously with a scalpel. A dark, empty peritoneal space is seen and a pair of lateral stay sutures are placed. These sutures incorporate the perineum and linea alba and are later used to secure the Hasson port , and can be used to close this incision.  The next step is to verify that the intraperitoneal space has been entered freely and the Hasson port with its blunt, rounded-tip obturator is introduced into the abdomen. Veress Needle technique: The Veress needle is a close technique . It is a good technique for an unoperated abdomen, because if the patient has previous surgery, can have adhesions and is posible to make a bowel injury. In that case we preferred the open technique or make the incision for the Veress in the palmer point (subcostal left). A vertical or horizontal incision is made in the umbilicus or lateral wall, and is grasped by the surgeon so as to elevated the abdominal wall. A Veress needle is held like a pencil by the surgeon who inserts it up to the peritoneum where a characteristic popping sensation is felt. An unobstructed free intraperitoneal position of the Veress needle is verified by easy irrigation of clear saline in and out of the peritoneal space. If the needle is free we started the pneumoperitoneum. Another option in laparoscopic entry techniques is direct visualization by bladeless trocar. This kind of tracers are used in laparoscopic procedures to create and maintain a port of entry. The trocar may be used with or without visualization for primary and secondary insertions. It is a very secure laparoscopic entry technique because we can visualize with the optic all the layers of the abdominal wall up to the cavity.  In conclusion there is insufficient evidence to recommend one laparoscopic entry technique over another and an open-entry technique is associated with a reduction in failed entry when compared to a closed-entry technique, with no evidence of a difference in the incidence of visceral or vascular injury.