Laparoscopic entry and complications

It is 03:15, and the bleep goes. You are the gynaecology registrar, and the consultant is still in clinic. The patient is a 32-year-old BMI 38 booked for laparoscopic cystectomy. You have two entry options. The anatomy is hostile from the umbilicus. Which line of action would you take and why?^[1]

Entry techniques for gynaecological laparoscopy are not equal.^[1][2] In a hostile-umbilicus patient (BMI 38, prior midline incision) the Veress-needle first-choice approach is not appropriate — the failure rate of pneumoperitoneum at the umbilicus in the obese or previously operated abdomen is 5–10% (Ahmad 2012), and multiple insertion attempts raise the risk of bowel and vascular injury. The Palmer-point entry (Palmer 1974) is the consultant-level response: a 3-cm transverse incision 3 cm below the left subcostal margin in the midclavicular line, opening the peritoneum under direct vision. It is the first choice when the umbilicus is hostile.^[4] The open Hasson approach is an alternative but with similar BMI limitations.

^{[1] [2]}

Overview and definition

Laparoscopic entry into the peritoneal cavity is the highest-risk step in gynaecological laparoscopy, accounting for a disproportionate share of major complications.^[1][2] The three principal entry techniques (Veress-needle closed entry, open Hasson, and direct trocar insertion) are not equivalent in safety or suitability. Patient factors (BMI, prior abdominal surgery, intra-abdominal adhesions), operator experience, and equipment (sharp vs optical Veress, bladed vs blunt trocar) determine the choice. The aim is to enter the peritoneal cavity with a controlled pneumoperitoneum, avoid vascular and visceral injury, and have a defined rescue plan when the entry is uneventful and when it is not.

References6ShowHide

1. [1]Ahmad G, Baker J, Finnerty J, Phillips K, Watson A Laparoscopic entry techniques Cochrane Database Syst Rev, 2019.PMID 30657163
2. [2]Ahmad G, Gent D, Henderson D, et al. Laparoscopic entry techniques Cochrane Database Syst Rev, 2015.PMID 26329306
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]Marchand GJ, Masoud A, King A, et al. Systematic review and meta-analysis of Veress needle entry versus direct trocar entry in gynecologic surgery BMJ Surg Interv Health Technol, 2022.PMID 35865828
5. [5]Douketis JD, Spyropoulos AC Perioperative Management of Patients Taking Direct Oral Anticoagulants: A Review JAMA, 2024.PMID 39133476
6. [8]Giacobbe V, Rossetti D, Vitale SG, Rapisarda AM, Padula F, Laganà AS, Palmara VI Otorrhagia and Nosebleed as first signs of Intravascular Absorption Syndrome During Hysteroscopy: From Bench to Bedside. Kathmandu Univ Med J (KUMJ), 2016.PMID 27892449