Operative laparoscopy — entry, energy, port placement and complications

You are the registrar on a quiet Tuesday list. The first case is a diagnostic laparoscopy for pelvic pain in a thin 24-year-old. The Veress is in, the gas is running, and within ten seconds the anaesthetist says her pressure has dropped and the end-tidal CO2 has fallen. Laparoscopy is the most common operation you do, and the moments that end careers happen in the first ninety seconds of it. This topic is your rehearsal for those ninety seconds, and for the days that follow.^[8][11]

Overview and definition

Laparoscopy is a closed endoscopic operation of the abdomen and pelvis, and in gynaecology it spans everything from a diagnostic look to total laparoscopic hysterectomy, single-port (LESS) surgery and robot-assisted procedures. What unites them is the same first problem: you must get into the peritoneum safely, and you must do it largely blind.^[2][6]

Three primary entry strategies define the field, and you should name them in that order:^[1][2]

• Closed entry — Veress needle to create the pneumoperitoneum, then a trocar to enter.
• Open (Hasson) entry — a mini-laparotomy cut-down to the peritoneum under direct vision, then a blunt port.
• Direct entry — direct trocar insertion, with or without optical guidance, before insufflation.

Around these sit the technologies that modify each: disposable shielded trocars, radially expanding (STEP) trocars, and visual entry systems such as the trocarless threaded visual cannula.^[2][5]

References16ShowHide

1. [1]Ahmad G, Baker J, Finnerty J, Phillips K, Watson A Laparoscopic entry techniques Cochrane Database Syst Rev, 2019.PMID 30657163
2. [2]Vilos GA, Ternamian A, Dempster J, Laberge PY No. 193-Laparoscopic Entry: A Review of Techniques, Technologies, and Complications J Obstet Gynaecol Can, 2017.PMID 28625296
3. [3]Elnaggar AA, Diab KR, El-Hangour BA, Kamel IS, Farhat AM, Abdelsattar AT, Zarad MS Direct trocar insertion vs. Veress needle technique in laparoscopic surgeries. A systematic review and meta-analysis J Visc Surg, 2023.PMID 36842955
4. [4]Granata M, Tsimpanakos I, Moeity F, Magos A Are we underutilizing Palmer's point entry in gynecologic laparoscopy? Fertil Steril, 2010.PMID 20452584
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6. [6]Varma R, Gupta JK Laparoscopic entry techniques: clinical guideline, national survey, and medicolegal ramifications Surg Endosc, 2008.PMID 18401653
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8. [8]Sandadi S, Johannigman JA, Wong VL, Blebea J, Altose MD, Hurd WW Recognition and management of major vessel injury during laparoscopy J Minim Invasive Gynecol, 2010.PMID 20656569
9. [9]Hu H, Choi JDW, Edye MB, Aitken T, Kapurubandara S Gastric Injury at Laparoscopy for Gynecologic Indications: A Systematic Review J Minim Invasive Gynecol, 2022.PMID 36184063
10. [10]Corson SL, Chandler JG, Way LW Survey of laparoscopic entry injuries provoking litigation J Am Assoc Gynecol Laparosc, 2001.PMID 11509771
11. [11]Wind J, Cremers JE, van Berge Henegouwen MI, Gouma DJ, Jansen FW, Bemelman WA Medical liability insurance claims on entry-related complications in laparoscopy Surg Endosc, 2007.PMID 17410401
12. [12]Law KS, Abbott JA, Lyons SD Energy sources for gynecologic laparoscopic surgery: a review of the literature Obstet Gynecol Surv, 2014.PMID 25503110
13. [13]Vilos GA, Rajakumar C Electrosurgical generators and monopolar and bipolar electrosurgery J Minim Invasive Gynecol, 2013.PMID 23659748
14. [14]Jaiswal A, Huang KG Energy devices in gynecological laparoscopy - Archaic to modern era Gynecol Minim Invasive Ther, 2017.PMID 30254903
15. [15]Owens M, Barry M, Janjua AZ, Winter DC A systematic review of laparoscopic port site hernias in gastrointestinal surgery Surgeon, 2011.PMID 21672662
16. [16]Wattiez A, Soriano D, Cohen SB, Nervo P, Canis M, Botchorishvili R, Mage G, Pouly JL, Mille P, Bruhat MA The learning curve of total laparoscopic hysterectomy: comparative analysis of 1647 cases J Am Assoc Gynecol Laparosc, 2002.PMID 12101332