To provide clinical direction, based on the best evidence available, on laparoscopic entry techniques and technologies and their associated complications.
OPTIONS: Implementation of this guideline should optimize the decision-making process in choosing a particular technique to enter the abdomen during laparoscopy.
EVIDENCE: English-language articles from Medline, PubMed, and the Cochrane Database published before the end of September 2005 were searched, using the key words laparoscopic entry, laparoscopy access,
pneumoperitoneum, Veress needle, open (Hasson), direct
trocar, visual entry, shielded
trocars, radially expanded
trocars, and laparoscopic complications.
VALUES: The quality of evidence was rated using the criteria described in the Report of the Canadian Task Force on the Periodic Health Examination. RECOMMENDATIONS AND SUMMARY STATEMENT: 1. Left upper quadrant (LUQ, Palmer's) laparoscopic entry should be considered in patients with suspected or known periumbilical adhesions or history or presence of
umbilical hernia, or after three failed insufflation attempts at the umbilicus. (II-2 A) Other sites of insertion, such as transuterine Veress CO(2) insufflation, may be considered if the umbilical and LUQ insertions have failed or have been considered and are not an option. (I-A) 2. The various Veress needle safety tests or checks provide very little useful information on the placement of the Veress needle. It is therefore not necessary to perform various safety checks on inserting the Veress needle; however, waggling of the Veress needle from side to side must be avoided, as this can enlarge a 1.6 mm
puncture injury to an injury of up to 1 cm in viscera or blood vessels. (II-1 A) 3. The Veress intraperitoneal (VIP-pressure </= 10 mm Hg) is a reliable
indicator of correct intraperitoneal placement of the Veress needle; therefore, it is appropriate to attach the CO(2) source to the Veress needle on entry. (II-1 A) 4. Elevation of the anterior abdominal wall at the time of Veress or primary
trocar insertion is not routinely recommended, as it does not avoid visceral or vessel injury. (II-2 B) 5. The angle of the Veress needle insertion should vary according to the BMI of the patient, from 45 degrees in non-obese women to 90 degrees in obese women. (II-2 B) 6. The volume of CO(2) inserted with the Veress needle should depend on the intra-abdominal pressure. Adequate
pneumoperitoneum should be determined by a pressure of 20 to 30 mm Hg and not by predetermined CO(2) volume. (II-1 A) 7. In the Veress needle method of entry, the abdominal pressure may be increased immediately prior to insertion of the first
trocar. The high intraperitoneal (HIP-pressure) laparoscopic entry technique does not adversely affect cardiopulmonary function in healthy women. (II-1 A) 8. The open entry technique may be utilized as an alternative to the Veress needle technique, although the majority of gynaecologists prefer the Veress entry. There is no evidence that the open entry technique is superior to or inferior to the other entry techniques currently available. (II-2 C) 9. Direct insertion of the
trocar without prior
pneumoperitoneum may be considered as a safe alternative to Veress needle technique. (II-2) 10. Direct insertion of the
trocar is associated with less insufflation-related complications such as
gas embolism, and it is a faster technique than the Veress needle technique. (I) 11. Shielded
trocars may be used in an effort to decrease entry
injuries. There is no evidence that they result in fewer visceral and
vascular injuries during laparoscopic access. (II-B) 12. Radially expanding
trocars are not recommended as being superior to the traditional
trocars. They do have blunt
tips that may provide some protection from
injuries, but the force required for entry is significantly greater than with disposable
trocars. (I-A) 13. The visual entry
cannula system may represent an advantage over traditional
trocars, as it allows a clear optical entry, but this advantage has not been fully explored. The visual entry
cannula trocars have the advantage of minimizing the size of the entry
wound and reducing the force necessary for insertion. Visual entry
trocars are non-superior to other
trocars since they do not avoid visceral and
vascular injury. (2 B).