Hindawi Publishing Corporation Diagnostic and Therapeutic Endoscopy Volume 2012, Article ID 305428, 7 pages doi:10.1155/2012/305428

Review Article Comparison of Two Entry Methods for Laparoscopic Port Entry: Technical Point of View

Adriana Toro, Maurizio Mannino, Giovanni Cappello, Andrea Di Stefano, and Isidoro Di Carlo

Department of Surgical Sciences, Organ Transplantation, and Advanced Technologies, University of Catania, Cannizzaro Hospital, Via Messina 829, 95126 Catania, Italy

Correspondence should be addressed to Isidoro Di Carlo, [email protected]

Received 27 February 2012; Accepted 5 April 2012

Academic Editor: Andrea Tinelli

Copyright © 2012 Adriana Toro et al. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Laparoscopic entry is a blind procedure and it often represents a problem for all the related complications. In the last three decades, rapid advances in laparoscopic surgery have made it an invaluable part of general surgery, but there remains no clear consensus on an optimal method of entry into the peritoneal cavity. The aim of this paper is to focus on the evolution of two used methods of entry into the peritoneal cavity in laparoscopic surgery.

1. Introduction patients but also for the increasing rate. In the last three decades, rapid advances in laparoscopic surgery have made Access into the abdomen is the one challenge of laparoscopy it an invaluable part of general surgery, but there remains no that is particular to the insertion of surgical instruments clear consensus as an on optimal method of entry into the through small incisions. Laparoscopy is currently widely peritoneal cavity. used in the practice of medicine, for both diagnostic and There are two methods for creating a pneumoperi- therapeutic purposes. The minimally invasive approach has toneum, the closed technique and the open technique. become the method of choice for treating most benign Although there is no consensus regarding the best method of abdominal diseases that require surgery. However, it is obvi- gaining access to the peritoneal cavity to create a pneu- ous that laparoscopic procedures are not risk free. Laparo- moperitoneum, the Veress needle insertion is the most fre- scopic entry is a blind procedure, and it represents a problem quently used technique. for all the related complications. Complications arising Aim of this paper is to focus on the evolution of the from laparoscopic surgery are rare and commonly occur most used methods of entry into the peritoneal cavity in when attempting to gain access to the peritoneal cavity laparoscopic surgery with particular attention to patients [1]. Creation of the pneumoperitoneum is the first and submitted to previous surgery without comorbidities. most critical step of a laparoscopic procedure because that access is associated with injuries to the gastrointestinal 2. Most Used Methods of Entry tract and major blood vessels and at least 50% of these major complications occurs prior to commencement of the Classic closed technique (Verres needle) [4] and open classic intended surgery. This complication rate has remained the technique (Hasson technique) [5] are the common most same during the past 25 years [2]. procedures used in laparoscopy to entry into the peritoneal The number of vascular injuries in laparoscopy is 2 in cavity. 10.000 procedures and a serious complication associated with mortality occurs in 3.3 per 100.000 [3]. Finding a safe 2.1. Verres Needle. The Verres needle is the oldest method, entry technique is a priority not only for the life of the developed by Dr. Verres in 1938 and it is the most used 2 Diagnostic and Therapeutic Endoscopy technique especially in gynecological procedures. The users angling of the needle [11], the saline drop test [12], the of this technique describe this entry as easy and quick. spinal needle test [13], imaging (CT and MRI), and the direct Commercially available Verres needles vary from 12 to measuring of the distance [14]. 15 cm in length, with an external diameter of 2 mm. A bezel- One of the major challenge in port entry is the shaped tip enables the needle to pierce the tissues of the small bowel lesions. Usually adhesions of small bowel can abdominal wall. Upon entering the peritoneal cavity, the be detected by ultrasound. Characteristics of preoperative resistance generated from the abdominal wall is overcome, abdominal ultrasound in predicting infraumbilical adhe- which permits the exposure of the interior needle with sions have been determined in a study. The results were its blunt atraumatic mandril [6]. This system affords a that prevalence of infraumbilical bowel adhesions was 12%. degree of safety and efficacy, making the puncture of the A visceral slide threshold <1 cm to predict adhesions had peritoneal cavity with a Verres needle an easy, fast, and sensitivity = 86%, specificity = 91%, positive predictive effective technique. Once the peritoneal cavity is inflated value = 55%, and negative predictive value = 98%. Measuring by this technique, the first trocar can be inserted without visceral slide improves preoperative prediction of both problems, minimizing intraoperative gas leakage and saving presence and absence of bowel adhesions in patients with surgical time. previous abdominal operations of infections; this technique Nevertheless, despite this safety device, incorrect insuf- may assist in avoiding iatrogenic bowel injury [15]. flations occur. Injuries to major vessels are the leading This study has been integrated by test with technique intraoperative cause of death associated with laparoscopic of periumbilical ultrasound-guided saline infusion (PUGSI). procedures [7]. The classic location of the Verres needle The technique as described below is one of the most used. puncture is the midline of the abdomen near the umbilical The presence or absence of visceral slide is demonstrated scar. Due to the short distance between the anterior abdom- using exaggerated inspiration/expiration after intubation. inal wall and the retroperitoneal vascular structures in this Visceral slide in this investigation is defined in accor- region, less than two centimetres in thin people, puncture dance with Kodama’s original definition as the longitudinal poses risks of injury to these large vessels [8]. The abdominal distance the intestines or omentum travels as visualized aorta, the inferior vena cava, and the common iliac vessels by ultrasound during an exaggerated inspiration/expiration are especially vulnerable to lesions during puncture with the cycle [16]. Verres needle in proximity of the umbilical scar. An abnormal test for the visceral slide is considered The needle relies on the ability of the blunt outer sheath a movement of viscera less than 1 cm. A normal test for to retract while passing through tissue and to spring forward the viscera is movement equal to or greater than 1 cm. in order to cover the sharp needle tip when tissue resistance Immediately after the visceral slide measurement, the PUGSI diminishes. The length of the Verres needle that should be test is conducted. A sterile 19-gauge spinal needle on a inserted in the abdominal cavity is not specified in any syringe is advanced through the skin and subcutaneous layers scientific report. The use of a click sound associated with under ultrasound guidance at a 90◦ angle. Once beyond the springing forward of the blunt stylet is recommended to the peritoneum, 8–10 mL of sterile normal saline is injected determine when to stop advancing the needle. Unfortunately under real-time ultrasound visualization. A normal test for the quality of the sound is not always reliable because it PUGSI is defined as dispersion of the infused saline without depends on many factors including ambient noise and the fluid loculation. The formation of a fluid pocket or localiza- extent of recoil in the needle spring function. The judgement tion indicated an abnormal test and suggests the presence of is subjective and it is neither quantifiable nor taught in obliterating subumbilical adhesions. An inconclusive test is training. There are two important factors in the insertion of defined as one in which the physician is unable to definitively a Verres needle. First the insertion should be not excessive to determine the normality or abnormality of the test. In case avoid the risk of vascular injury. Second it should be adequate of difficulties to well understand the PUGSI results the to avoid extraperitoneal insufflation, because this will lead physician uses his clinical judgment to make decisions related to failure of the pneumoperitoneum with an associated to the best method of entry. The PUGSI test was able to detect operative difficulty due to inappropriate distension of the all case of obliterating subumbilical adhesions, demonstrat- anterior abdominal wall and postoperative pain. ing sensitivity, and specificity of 100%. Use of both tests Tests can be performed before insufflation to verify preoperatively appears to be helpful in identifying patients whether the Verres needle is correctly positioned, thus at risk for visceral injury during laparoscopic surgery [17]. avoiding injury. Patients with previous abdominal surgery are more Traditional texts recommend an insertion angle of 45◦ prone to visceral injury caused by the Verres needle. This from horizontal in patients with a body mass index smaller is due to peritoneal adhesions, which typically grow where than 30 kg/m2 to avoid a vascular injury. Some Authors the incision of the parietal peritoneum was made [18]. report not having a problem with a vertical orientation of Autopsy studies have found adhesions in 74% to 95% of the Vessel needle, provided that the umbilicus is significantly patients with previous abdominal surgery. Midline incisions elevated and the needle is only inserted a distance of approx- greatly increase the risk of adhesions in the umbilical region. imately 2 to 3 cm or until a negative pressure is encountered Even incisions made away from the umbilicus may lead [9]. to adhesion formation in the periumbilical region. On the Different methods are reported in literature to improve other hand, insertion of the Verres needle into the left the safety, for example the palpation of aorta [10], the hypochondrium has been reported as safe, with reduced Diagnostic and Therapeutic Endoscopy 3 risk of iatrogenic injury [19]. The stomach is immediately Some authors believe that trocar injuries to abdominal below the anterior abdominal wall at the site where the viscera occur (a) when the viscera are unusually close to the left hypochondrium puncture is made. If the stomach is point of trocar insertion or (b) where the trocar penetrates accidentally perforated, its contents will not necessarily leak. too far into the abdominal cavity as it is inserted. The former This is due to the protection provided by the three layers of can be anticipated when the patient has undergone a surgery gastric muscle, which tend to close the puncture. previously [2]. A stomach perforation is easy to diagnose upon initial In this case for avoiding visceral injury can be used the inspection of the peritoneal cavity and can be repaired by open Hasson technique or if the closed technique is used laparoscopic suture. to place the first trocar at a site remote from the previous Recently another procedure has been developed to incision.The concept in the open technique is to create a calculate the length of the needle in order to avoid vascular tiny incision, directly incise the layers of the abdominal wall, lesions when it is introduced into the peritoneal cavity. A directly cut the peritoneum and enter the abdomen. Since gas monogram has been developed to determine the length of can escape around the incision, an olive is placed over the end the Verres needle that could be safely introduced to achieve of the trocar to occlude the incision, and sutures are placed the pneumoperitoneum reducing or eliminating the risk on the abdominal fascia and attached to the cannula [2]. of vascular injuries of the retroperitoneal vessels during The benefits of this method of entry are the prevention laparoscopic entry. Axial images of the magnetic resonance of bowel injury caused of blind puncture with a needle imaging (MRI) have been used to measure the vertical and subsequent trocar, gas embolism, avoid preperitoneal distance between umbilicus and retroperitoneal vessels to insufflation and to have certainty of establishing a pneu- develop this procedure [20]. moperitoneum, a very low incidence of vascular injuries, and Twoverticalmeasurementshavebeencalculated.The furthermore a correct anatomical repair of the abdominal first is the vertical distance from the skin at the pit of umbili- wall incision. cus to rectus sheath (STP). The second measurement is the Reasons for limiting the use of the open technique vertical distance from the skin at the pit of umbilicus to the include greater time needed for performance, difficulty with anterior surface of retroperitoneal vessel on the image (STR). the technique, obese patients, and difficulty in maintenance The abdominal cavity depth has been defined as the ver- of the pneumoperitoneum. tical distance from rectus sheath at the level of umbilicus to Open procedures are commonly employed for high-risk the anterior surface of retroperitoneal vessels (the difference patients, like those with a previous abdominal surgery, in between the STP and STR). Two independent observers have particular midline incisions or obesity [22]. An additional confirmed all measurements [20]. factor might be the higher incidence of complications early Using the mean regression line for STP (skin to peri- on in the surgical learning curve. Safe access depends toneum) a safe insertion distance has been identified and a critically on adhering to well-recognized principles of trocar monogram has been developed which can be used to predict insertion, knowledge of abdominal anatomy, and recognition objectively the depth of the peritoneal cavity. of the hazards imposed by previous surgery. Specific measures for the correct insertion and for the Widespread use of this technique has been limited to reduction of the risk of injury of obese and thin patients patients with previous lower abdominal surgery, pregnant have to be improved. The Verres needle insertion at 45◦ from women, children, and very thin patients where little space the umbilicus means that needle has to traverse a distance exists between the abdominal wall and the spine [2]. of 12–16 cm, which increases the risk of extraperitoneal In experienced hands the open technique for to access the insufflation. This method using this nomogram gives a abdominal cavity is necessary about three to ten minutes. measure of the safe distance in obese patients for vertical The open laparoscopic entry is considered particularly insertion and it improves the success and safety of the safe in patients with previous abdominal surgery, especially umbilical insufflation. The nomogram is also helpful in thin midline incisions. Vascular injuries are nearly entirely pre- patients as this reminds surgeon to be aware of the very short vented by the open entry technique, with anecdotal cases distance (+2 cm) between umbilical skin and major vessels. of aortic laceration being reported. These injuries have been The only controversy of this technique is the need of MRI attributed to an insufficient elevation of the abdominal wall, for each patients, and its related time and cost. with the skin incision passing directly through skin, fascia, The safe laparoscopic entry guidance should be dis- and into the underlying vessels [21, 23]. A factor accounting seminated widely but not necessarily negate the risk of for some of this disparity could be patient selection bias. laparoscopic entry-related injury, nor would it protect the In literature are reported fewer injury of bowel and major clinician against any ruling of negligence should a compli- vascular injury using this technique than the Verres needle cation occur. Unless practice concurs with recommended technique. guidance, patients undergoing laparoscopy will be exposed A meta-analysis of 760,890 closed laparoscopy and to increased unnecessary operative risk [21]. 22,465 open laparoscopy cases reported that the incidence of vascular injury rate in closed laparoscopy was 0.44% compared with 0% in open laparoscopy. The incidence 2.2. Hasson Technique. Hasson first described open laparo- of bowel injury was 0.7% compared to 0.5%, respectively. scopy in 1971 and it remains the favourite entry method for The authors concluded that the open (Hasson) technique many laparoscopic surgeons [5]. eliminates the risk of vascular injury and gas embolism and 4 Diagnostic and Therapeutic Endoscopy reduces the risk of bowel injury and recommend the open point on the abdominal wall where the peritoneum is tightly technique to be adopted for primary laparoscopic entry [24]. fused and allows direct entry to the peritoneal cavity in the Penfield noted a 0.06% incidence of bowel injury, but the majority of the cases, while the abdominal wall is kept tented injuries were mostly partial and were recognised immediately and away from the underlying viscera at all times [31]. because of the proximity of the bowel to the wound [25]. Probably the safest initial entry site in high-risk patients Patients with previous abdominal surgery and those is the left upper quadrant, better known as Palmer’s point. known to have peritoneal adhesions present a higher risk This site (3 cm below the left costal margin in the mid- for peritoneal entry complication [26]. In this case the high- clavicular line) is rarely affected by adhesions, and with risk patients must be preoperative informed of the possibility splenomegaly and stomach distension being excluded it has of alternate entry method or the likelihood of conversion been shown to be safe [32, 33]. Molloy et al. in a meta- to laparotomy. General surgeons in Canada use the open analysis of 51 studies on techniques and complications of primary entry technique, with the Hasson trocar and cannula primary port entry, the authors found that risks associated applied periumbilically to establish a pneumoperitoneum with open entry are similar to those with direct entry. Left for laparoscopic surgery [27]. In a review of 2010 patients upper quadrant entry is available but is more complicated in the Authors confirm previous reports of the low risk of obesepatientsandcarriesitsownrisksaswell[34]. enterotomy, absence of fatal vascular injury, and comparable rates of umbilical infection/hernia associated with an open entry technique. The rapid recognition of enterotomy with 3. Discussion this entry technique and the utility of this technique in obese patients or those with previous abdominal procedures are Over the last two decades, rapid advances have made additional advantages [28]. laparoscopic surgery a well-established procedure. However, Hasson report his experience on 5,284 women who were because laparoscopy is relatively new, it still arouses contro- subjected to open technique for laparoscopic surgery and versy, particularly with regard to the best method for the have developed complications related to primary access. creation of the pneumoperitoneum. Twenty-one patients had minor wound infections, four had To establish the pneumoperitoneum, access to the peri- minor haematomas, one developed an umbilical hernia that toneal cavity can be gained through minilaparotomy and required surgery, and one had an inadvertent injury to insertion of a laparoscopic trocar or Hasson trocar. Alter- the small bowel that was repaired intraoperatively without natively, an optical trocar can be blindly inserted into the adverse outcome [29]. peritoneal cavity, or a Verres needle may be inserted through A new technique emphasizes the identification and the the abdominal midline. The latter is the most frequently used incision of the point where the midline abdominal fascia technique. is fused with the base of the umbilicus. The importance of In literature are reported various cases of injury to the the application of counter traction directly at the point of great vessels caused by the Verres needle. A report illustrates insertion has been described in literature [30]. This method the difficulty in correctly diagnosing this complication, allows the penetration under the direct vision with minimal which is mainly due to the retroperitoneal position of the controlled axial force and without the requirement of fascial vessels. sutures or other cumbersome aspects of the traditional open technique. Major vascular injuries caused by the insertion of the Knowledge application of the anatomy of the umbilicus is Verres needle into the abdominal midline occur even in the critical to this method of access. The use of a lateral incision hands of experienced surgeons. Schafer¨ et al. analyzed 26 to the umbilicus allows ideal delineation of the umbilical major vascular injuries and reported that only four of them junction with the midline fascia, and a left-sided incision is (15%) had been caused by inexperienced surgeons (surgeons preferentially employed as this minimizes interference from who had performed fewer than 50 laparoscopic procedures). the falciform ligament. The success of this method depends The other 22 injuries (85%) had been caused either by on identifying the single point where the umbilical fascia and experienced surgeons (those who had performed between the peritoneum are fused. The Incision with suture scissors 51 and 100 procedures) or very experienced surgeons (over of this point provides a rapid, safe, and easy access to the 100 procedures performed) [35]. Thus, it is essential that the peritoneal cavity. This technique has been used for more position of the needle tip after insertion be determined as than 1000 consecutive laparoscopic procedures over a 4-year accurately as possible. period and there was only one intraabdominal injury to In addition, analysis of intraperitoneal pressure and the small bowel in a patient with multiple previous midline volume of gas insufflated at different time points during laparotomies and a prosthetic mesh closure [30]. insufflation is essential to prevent gas insufflation into sites Another technique consists in a transverse supra- or other than the peritoneal cavity. It has been established that subumbilical incision showing the umbilical cicatrix pillar intraperitoneal pressure levels and the total volume of gas and the junction of the pillar with the linea alba. After insufflated into the peritoneal cavity at given time points can the incision (1 cm) at the junction of the umbilical cicatrix be predicted, provided that the tip of the Verres needle is in pillar with the linea alba is possible to have the peritoneal fact in the peritoneal cavity during insufflation [36]. cavity opened [31]. This technique is safe, effective, easy to No vascular injury was reported in a study investigating learn, and quick to perform. The method clearly displays the 3,041 patients submitted to blind insertion of the first trocar Diagnostic and Therapeutic Endoscopy 5 through a midline incision at the umbilicus under intraperi- way for ten seconds, test was considered negative (needle toneal pressure of 25–30 mmHg [37]. This corroborates the incorrectly positioned inside the peritoneal cavity or ob- hypothesis that elevated intraperitoneal pressure protects the struction of its side hole). intraabdominal structures from injury caused by the first The five tests evaluated in this study are adequate to guide trocar. No injury caused by blind insertion of the first trocar surgeons with regard to the correct positioning of the Verres was reported in a study involving 1,150 patients submitted needle for creation of pneumoperitoneum. These tests may to laparoscopy under intraperitoneal pressure of 25 mmHg avoid iatrogenic injury and insufflation of gas into the wrong [38]. No clinical complications have been shown to arise site [41]. from transitory elevation of intraperitoneal pressure [37, 38]. Although these tests and techniques may be helpful in However, it is known that extremely high levels of accessing the peritoneal cavity, the fact that visceral and intraperitoneal pressure for longer periods of time can cause vascular injuries occur shows that they are not foolproof. physiological and structural changes, directly related to the A study reported that complication rates during intro- tension levels caused by the high pressure. Studies have duction of Verres needle are one attempt 0.8–16.3%, two demonstrated that patients submitted to high intraperitoneal attempts 16.31–37.5%, three attempts 44.4–64%, and more pressure for longer periods of time can present decreased car- than three attempts 84.6–100%. The complications associ- diac output, decreased venous return, increased mean arte- ated were extraperitoneal insufflation, omental and bowel rial pressure, increased systemic vascular resistance, altered injuries, and failed laparoscopy [42]. renal perfusion and glomerular filtration rate, and ischemia- Merlin et al. reported on a systematic review that the reperfusion injury of intraabdominal organs [39]. Therefore, most common of the major complications associated with most authors have proposed that intraperitoneal pressure access were bowel injuries [43]. The risk of bowel injury remains at 12 mmHg and never above 15 mmHg during in nonrandomized studies was higher with the open tech- laparoscopic procedures. nique than with closed technique, although bias introduced The Verres needle is typically inserted through the through patient selection may have been a factor. The abdominal midline, at the umbilicus. Albeit effective, inser- evidence on the comparative safety and effectiveness of the tion of the Verres needle through the midline poses danger. different access methods was not definitive, but trends in the All injuries to the great vessels caused by the Verres needle data merit further exploration. reported in the literature resulted from midline punctures in Chapron et al. reported on a nonrandomized comparison the umbilical region [40]. Azevedo et al. claim that insertion of open versus closed laparoscopic entry practised by uni- of the Verres needle into the left hypochondrium has been versity affiliated hospital teams. The bowel and major vessel reported as safe and effective and potential injuries are less injury rates were 0.04% and 0.01% in the closed technique severe [38]. Nevertheless, it is essential that the position of and 0.19% and 0% in the open technique, respectively. They the needle after insertion be determined as accurately as concluded that open laparoscopy does not reduce the risk of possible. Needle-positioning tests prior to insufflation have major complications during laparoscopic access [44]. been evaluated and considered adequate to guide surgeons Catarci et al. analysed a multicenter questionnaire survey with regard to the correct positioning of the Veress needle of general surgeons (57% responding) reported a relatively for creation of the pneumoperitoneum [41]. high incidence of major injuries; the highest with optical The objective of the study of Azevedo was to evaluate trocars (0.27%), the second highest with the closed technique five tests that are used to confirm the correct position of the (0.18%, used 82% of the time), and the lowest with the Verres needle inside the peritoneal cavity. The tests were (1) open technique (0.09%). Until 1997, no case of major aspiration test: aspiration using a 5 mL syringe with a Verres retroperitoneal vessel injury had been reported with the use needle. This test was considered positive when no material of a blunt Hasson’s cannula, which therefore was considered was aspirated and negative when material was aspirated; (2) to be absolutely safe, while the rate of vascular injury was injection test: injection of 5 mL of saline solution through from 0.02% to 0.24% for closed technique. The rate of the Verres needle. This test was considered positive when visceral injury with closed technique varied from 0.03% to moderate resistance to liquid flow was observed and negative 0.15% with prevalence of injury to the gastrointestinal tract when increased resistance to liquid flow was observed; (3) (80%) greater than that for urinary tract (20%). With the recovery test: after injection of 5 mL of saline solution, aspi- open technique, the same figure varied from 0% to 0.12%. ration was performed, this test was considered positive when High rates of morality related to major injury (10–50%) the liquid injected was not recovered and negative when the actually were reported in gynaecologic series, associated liquid was not recovered; (4) saline drop test: saline solution mainly with delayed diagnosis and treatment [45]. was poured into the needle. Liquid flow was observed. This Jansen et al. in clinical trials that compared closed test was considered positive when the liquid disappeared and open entry techniques, the complication rates were immediately and negative when the liquid remained inside 0.07% and 0.17% for the closed and open techniques, the needle; (5) initial intraperitoneal pressure test. This respectively. The number of entry-related complications with test was considered positive (needle correctly positioned the open technique was significantly higher than with the inside the peritoneal cavity with unobstructed side hole) closed technique. Hasson et al. [5]conclude“Thereisno when initial intraperitoneal pressure was 8 mmHg or lower evidence to support abandoning the closed entry technique during the first ten seconds of insufflation. When initial in laparoscopy; however, the selection of patients for an open intraperitoneal pressure was over 8 mmHg and remained this or alternative procedure is still recommended” [46]. 6 Diagnostic and Therapeutic Endoscopy

Meta-analysis failed to reveal any safety advantage of an [6] J. G. Chandler, S. L. Corson, and L. W. Way, “Three spectra open technique when compared with a closed method of of laparoscopic entry access injuries,” Journal of the American entry, in terms of both visceral and major vascular injury. College of Surgeons, vol. 192, no. 4, pp. 478–491, 2001. It must be noted that the included randomised controlled [7] H. B. Peterson, J. R. Greenspan, and H. W. Ory, “Death follow- trials had insufficient power to effectively demonstrate an ing puncture of the aorta during laparoscopic sterilization,” advantage [47]. Obstetrics and Gynecology, vol. 59, no. 1, pp. 133–134, 1982. The rate of carbon dioxide embolism was 0.001% in [8] G. C. Roviaro, F. Varoli, L. Saguatti, C. Vergani, M. Maciocco, a review of 489 335 closed laparoscopies [48]. Several case and A. Scarduelli, “Major vascular injuries in laparoscopic reports have detailed fatal or near-fatal coronary, cerebral, surgery: still of interest?” Surgical Endoscopy and Other Inter- ventional Techniques, vol. 16, no. 8, pp. 1192–1196, 2002. or other gas embolism. Such a complication has not been reported at open laparoscopy. [9] T. T. Vellinga, S. de Alwis, Y. Suzuki, and J. I. Einarsson, “Laparoscopic entry: the modified alwis method and more,” Tinelli et al. present a modified direct optical entry Reviews In Obstetrics And Gynecology, vol. 2, no. 3, pp. 193– (DOE) in patients previously undergone abdominal pelvic 198, 2009. surgery, compared with the classical open laparoscopy. The [10] D. Polyzos, N. Papadopoulos, L. Chapman et al., “Where is the authors suggest that DOE is as safe as open laparoscopy aorta? Is it worth palpating the aorta prior to laparoscopy?” and can be used in patients with previous abdomino-pelvic Acta Obstetricia et Gynecologica Scandinavica, vol. 86, no. 2, surgery [49]. pp. 235–239, 2007. The use of Hasson technique has not cost due to the [11] M. P. Milad and M. F. Terkildsen, “The spinal needle test complete surgical procedure do not need any disposable effectively measures abdominal wall thickness before cannula device. On the opposite Verres needle has the cost of the placement at laparoscopy,” Journal of the American Association Verres disposable device permitting only one use. The cost of of Gynecologic Laparoscopists, vol. 9, no. 4, pp. 514–518, 2002. complications varies depending on the type of complication. [12] W. H. Hurd, R. O. Bude, J. O. L. DeLancey, J. M. Gauvin, and The major complications are vascular injury and bowel A. M. Aisen, “Abdominal wall characterization with magnetic injury. The complete amount of the complication depends resonance imaging and computed tomography: the effect of from the operating room cost, the hospitalization duration obesity on the laparoscopic approach,” Journal of Reproductive cost, and from the supplementary devices utilized for the Medicine for the Obstetrician and Gynecologist, vol. 36, no. 7, complication. The cost of operating room per hour is about pp. 473–476, 1991. 300C, while the cost of hospitalization is estimated at about [13]F.Nezhat,A.I.Brill,C.H.Nezhat,A.Nezhat,D.S.Seidman, 600C a day. In case of vascular injury the possible use of and C. Nezhat, “Laparoscopic appraisal of the anatomic rela- tionship of the umbilicus to the aortic bifurcation,” Journal of prosthesis must be added, while in the case of intestinal the American Association of Gynecologic Laparoscopists, vol. 5, injury the possible use of the stapler should be added. no. 2, pp. 135–140, 1998. In our personal experience based on 750 laparoscopic [14] M. R. Cohen and B. Scoccia, “Double laparoscopy: an alterna- surgical procedure, 50 patients were previously undergone to tive two-stage procedure to minimize bowel and blood vessel abdominal surgery. Between these patients only one reported injury,” Journal of Gynecologic Surgery, vol. 7, no. 4, pp. 203– a minor intestinal injury during Verres procedure repaired 206, 1991. during the laparoscopic procedure injury. [15]F.F.Tu,G.M.Lamvu,K.E.Hartmann,andJ.F.Steege, In conclusion between two techniques was analysed the “Preoperative ultrasound to predict infraumbilical adhesions: Hasson technique that could be preferred in case of operated a study of diagnostic accuracy,” American Journal of Obstetrics patients without comorbidities. and Gynecology, vol. 192, no. 1, pp. 74–79, 2005. [16] I. Kodama, L. A. Loiacono, B. Sigel et al., “Ultrasonic detection of viscera slide as an indicator of abdominal wall adhesions,” References Journal of Clinical Ultrasound, vol. 20, no. 6, pp. 375–380, 1992. [1] R. Varma and J. K. Gupta, “Laparoscopic entry techniques: [17] C. Nezhat, J. Cho, V. Morozov, and P. Yeung, “Preoperative clinical guideline, national survey, and medicolegal ramifica- periumbilical ultrasound-guided saline infusion (PUGSI) as tions,” Surgical Endoscopy and Other Interventional Techniques, a tool in predicting obliterating subumbilical adhesions in vol. 22, no. 12, pp. 2686–2697, 2008. laparoscopy,” Fertility and Sterility, vol. 91, no. 6, pp. 2714– [2] S. Krishnakumar and P. Tambe, “Entry complications in 2719, 2009. laparoscopic surgery,” Journal of Gynecological Endoscopy and [18] S. G. Levrant, E. Bieber, and R. Barnes, “Risk of anterior Surgery, vol. 1, no. 1, pp. 4–11, 2009. abdominal wall adhesions Increase whith number and type of [3] D. C. Wherry, M. R. Marohn, M. P. Malanoski, S. P. Hetz, previous laparotomy,” Journal of the American Association of and N. M. Rieh, “An external audit of laparoscopic cholecys- Gynecologic Laparoscopists, vol. 1, no. 4, p. S19, 1994. tectomy in the steady state performed in medical treatment facilities of the Department of Defense,” Annals of Surgery, vol. [19] A. Rohatgi and A. L. Widdison, “Left subcostal closed (Veress 224, no. 2, pp. 145–154, 1996. needle) approach is a safe method for creating a pneumoperi- [4] D. N. Patel, M. N. Parikh, M. S. Nanavati, and M. J. Jus- toneum,” Journal of Laparoendoscopic and Advanced Surgical sawalla, “Complications of laparoscopy,” Asia-Oceania Journal Techniques A, vol. 14, no. 5, pp. 278–280, 2004. of Obstetrics and Gynaecology, vol. 11, no. 1, pp. 87–91, 1985. [20] Y. Afifi, A. Raza, M. Balogun, K. S. Khan, and R. Holders, “New [5] H. M. Hasson, “A modified instrument and method for nomogram for safe laparoscopic entry to reduce vascular laparoscopy,” American Journal of Obstetrics and Gynecology, injury,” Journal of Obstetrics and Gynaecology, vol. 31, no. 1, vol. 110, no. 6, pp. 886–887, 1971. pp. 69–72, 2011. Diagnostic and Therapeutic Endoscopy 7

[21] R. M. Hanney, K. M. Alle, and P. C. Cregan, “Major vascular [37] H. Reich, S. C. Ribeiro, C. Rasmussen, J. Rosenberg, and A. injury and laparoscopy,” Australian and New Zealand Journal Vidali, “High-pressure trocar insertion technique,” Journal of of Surgery, vol. 65, no. 7, pp. 533–535, 1995. the Society of Laparoendoscopic Surgeons, vol. 3, no. 1, pp. 45– [22] M. Ito, Y. Asano, A. Horiguchi et al., “Cholecystectomy using 48, 1999. single-incision laparoscopic surgery with a new SILS port,” [38] J. Tsaltas, S. Pearce, A. Lawrence, A. Meads, J. Mezzatesta, Journal of Hepato-Biliary-Pancreatic Sciences,vol.17,no.5,pp. and S. Nicolson, “Safer laparoscopic trocar entry: it’s all about 688–691, 2010. pressure,” Australian and New Zealand Journal of Obstetrics [23] R. M. Hanney, H. L. Carmalt, N. Merrett, and N. Tait, “Use and Gynaecology, vol. 44, no. 4, pp. 349–350, 2004. of the hasson cannula producing major vascular injury at [39] O. H. M. Hypolito,J.L.M.C.Azevedo,F.M.S.De´ laparoscopy,” Surgical Endoscopy, vol. 13, no. 12, pp. 1238– Lima Alvarenga Caldeira et al., “Creation of pneumoperi- 1240, 1999. toneum: noninvasive monitoring of clinical effects of elevated [24] M. Larobina and P. Nottle, “Complete evidence regarding intraperitoneal pressure for the insertion of the first trocar,” major vascular injuries during laparoscopic access,” Surgical Surgical Endoscopy and Other Interventional Techniques, vol. Laparoscopy, Endoscopy and Percutaneous Techniques, vol. 15, 24, no. 7, pp. 1663–1669, 2010. no. 3, pp. 119–123, 2005. [40] J. L. M. C. Azevedo, O. C. Azevedo, S. A. Miyahira et al., [25] A. J. Penfield, “Critical decisions in 22 years of outpatient “Injuries caused by Veress needle insertion for creation of laparoscopy,” Journal of the American Association of Gyneco- pneumoperitoneum: a systematic literature review,” Surgical logic Laparoscopists, vol. 1, no. 4, pp. S28–S29, 1994. Endoscopy and Other Interventional Techniques, vol. 23, no. 7, [26] A. String, E. Berber, A. Foroutani, J. R. Macho, J. M. Pearl, pp. 1428–1432, 2009. and A. E. Siperstein, “Use of the optical access trocar for safe [41] O. C. de Azevedo, J. L. M. C. Azevedo, A. A. Sorbello, G. P. and rapid entry in various laparoscopic procedures,” Surgical S. Miguel, J. L. Wilson, and A. C. De Godoy, “Evaluation of Endoscopy, vol. 15, no. 6, pp. 570–573, 2001. tests performed to confirm the position of the Veress needle [27] C. Compeau, N. T. McLeod, and A. Ternamian, “Laparoscopic for creation of pneumoperitoneum in selected patients: a entry: a review of Canadian general surgical practice,” Cana- prospective clinical trial,” Acta Cirurgica Brasileira, vol. 21, no. dian Journal of Surgery, vol. 54, no. 5, pp. 315–320, 2011. 6, pp. 385–391, 2006. [28]J.B.Long,D.L.Giles,J.L.Cornella,P.M.Magtibay,R. [42] R. E. Richardson and C. J. G. Sutton, “Complications of M. C. Kho, and J. F. Magrina, “Open laparoscopic access first entry: a prospective laparoscopy audit,” Gynaecological technique: review of 2010 patients,” Journal of the Society of Endoscopy, vol. 8, no. 6, pp. 327–334, 1999. Laparoendoscopic Surgeons, vol. 12, no. 4, pp. 372–375, 2008. [43] T. L. Merlin, J. E. Hiller, G. J. Maddern, G. G. Jamieson, A. [29] H. M. Hasson, “Open laparoscopy as a method of access in R. Brown, and A. Kolbe, “Systematic review of the safety and ff laparoscopic surgery,” Gynaecological Endoscopy, vol. 8, no. 6, e ectiveness of methods used to establish pneumoperitoneum pp. 353–362, 1999. in laparoscopic surgery,” British Journal of Surgery, vol. 90, no. [30] J. L. Antevil, S. Bhoyrul, M. E. Brunson, M. A. Vierra, and 6, pp. 668–679, 2003. N. D. Swadia, “Safe and rapid laparoscopic access. A new [44] C. Chapron, L. Cravello, N. Chopin, G. Kreiker, B. Blanc, approach,” World Journal of Surgery, vol. 29, no. 6, pp. 800– and J. B. Dubuisson, “Complications during set-up procedures 803, 2005. for laparoscopy in gynecology: open laparoscopy does not [31] P. Lal, A. Vindal, R. Sharma, J. Chander, and V. K. Ramteke, reduce the risk of major complications,” Acta Obstetricia et “Safety of open technique for first-trocar placement in laparo- Gynecologica Scandinavica, vol. 82, no. 12, pp. 1125–1129, scopic surgery: a series of 6,000 cases,” Surgical Endoscopy, vol. 2003. 26, no. 1, pp. 182–188, 2012. [45] M. Catarci, M. Carlini, P. Gentileschi, and E. Santoro, “Major [32] J. Mayol, J. Garcia-Aguilar, E. Ortiz-Oshiro, J. A. De-Diego and minor injuries during the creation of pneumoperi- Carmona, and J. A. Fernandez-Represa, “Risks of the minimal toneum: a multicenter study on 12,919 cases,” Surgical Endo- access approach for laparoscopic surgery: multivariate analysis scopy, vol. 15, no. 6, pp. 566–569, 2001. of morbidity related to umbilical trocar insertion,” World [46] F. W. Jansen, W. Kolkman, E. A. Bakkum, C. D. De Kroon, Journal of Surgery, vol. 21, no. 5, pp. 529–533, 1997. T. C. M. Trimbos-Kemper, and J. B. Trimbos, “Complications [33] R. Palmer, “Safety in laparoscopy,” Journal of Reproductive of laparoscopy: an inquiry about closed- versus open-entry Medicine for the Obstetrician and Gynecologist, vol. 13, no. 1, technique,” American Journal of Obstetrics and Gynecology, vol. pp. 1–5, 1974. 190, no. 3, pp. 634–638, 2004. ff [34]D.Molloy,P.D.Kaloo,M.Cooper,andT.V.Nguyen, [47] G. Ahmad, J. M. N. Du y, K. Phillips, and A. Watson, “Laparo- “Laparoscoic entry a literature review and analysis of tech- scopic entry techniques,” Cochrane Database of Systematic niques and complications of primary port entry,” Australian Reviews, no. 162, Article ID CD006583, 2008. ff and New Zealand Journal of Obstetrics and Gynaecology, vol. [48] H. J. Bonjer, E. J. Hazebroek, G. Kazemier, M. C. Giu rida, W. 42, no. 3, pp. 246–254, 2002. S. Meijer, and J. F. Lange, “Open versus closed establishment of [35] M. Schafer,¨ M. Lauper, and L. Krahenb¨ uhl,¨ “Trocar and Veress pneumoperitoneum in laparoscopic surgery,” British Journal needle injuries during laparoscopy,” Surgical Endoscopy, vol. of Surgery, vol. 84, no. 5, pp. 599–602, 1997. 15, no. 3, pp. 275–280, 2001. [49] A. Tinelli, A. Malvasi, M. Guido et al., “Laparoscopy entry in [36] J. L. M. C. Azevedo, O. C. Azevedo, A. A. Sorbello et al., patients with previous abdominal and pelvic surgery,” Surgical “Intraperitoneal pressure and volume of gas injected as effec- Innovation, vol. 18, no. 3, pp. 201–205, 2011. tive parameters of the correct position of the veress needle during creation of pneumoperitoneum,” Journal of Laparoen- doscopic and Advanced Surgical Techniques,vol.19,no.6,pp. 731–734, 2009. Copyright of Diagnostic & Therapeutic Endoscopy is the property of Hindawi Publishing Corporation and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.