Different procedures to create pneumoperitoneum have been described over time but a recently updated Cochrane review does not offer the possibility of recommending one technique over another on the basis of related (very low) major complication rates. Although trocar and Veress needle are the instruments causing most bowel injury during laparoscopy, major vascular injuries are related to the trocar insertion in more than half of cases compared to Veress needle when a closed-entry technique is performed. We describe and discuss the Open Veress Assisted (OVA) technique for laparoscopic entry that is routinely used in our surgical practice.
Open technique involves skin and subcutaneous layer incision up to cutting down the peritoneum. Once in the peritoneal cavity, a blunt trocar is placed under direct visualization. Gas insufflation is provided and the laparoscope is inserted.
Closed technique starts with the insertion of a Veress needle into the peritoneal cavity, after a little incision of the skin. The needle is pushed in until it gives a double click, ensuring that it is in the intraperitoneal space. Once into peritoneal cavity, gas insufflation is provided. After the incision of the skin, the first trocar is placed through the abdominal wall up to cutting down muscular layers and the peritoneum with blunt manoeuvres.
Modification of standard techniques
The OVA technique allows a safe first trocar insertion, in a previously tested abdominal wall site, after the creation of pneumoperitoneum using Veress needle in the upper left quadrant.
After a little incision of the skin with a scalpel, a Veress needle is placed in the left hypochondrium two or three cm below the costal margin, laterally to the rectus abdominis muscles [Figures 1 and 2].
A gas tube is connected to the needle and CO2 insufflation starts with high flow.
When intra-abdominal pressure reaches 12 mmHg, the insertion site of the first trocar is checked with the aspiration test: the needle of a 10 mL syringe containing 3 mL of saline is introduced perpendicularly into the abdominal cavity with simultaneous suction manoeuvres [Figure 3].
This hydro-pneumatic test can detect a free intra-peritoneal area when CO2 backs into the syringe, whereas evidence of resistance, blood or stools show a no safe zone.
In the chosen area, a 10-mm full-thickness incision of abdominal wall including the peritoneum is performed [Figure 4]. The gas leakage confirms access so that the first trocar can be inserted into the abdominal cavity without any effort, avoiding potential vascular or visceral injuries [Figure 5].
The procedure ends with the check of Veress needle position by optics and its removal.
This method differs from the closed technique for a full-thickness incision of the abdominal wall at the first trocar site, avoiding the blind application of potentially dangerous insertion-related forces. Compared with the open technique, OVA laparoscopic entry provides a smaller muscular fascia incision because there is no need for layer-by-layer abdominal wall dissection. This could affect trocar site incisional hernia development.
OVA technique is also applicable to obese patients. Furthermore, it is advantageous in previously operated patients because of the risk of adhesions under the midline laparotomy scar and in the operations that need to place optical trocar outside the umbilicus.
Between December 2018 and July 2021, OVA technique was used in a total of 324 surgical procedures categorised in 259 laparoscopic colorectal resection and 24 subtotal or total gastrectomies. A total of 125 procedures were performed in previously operated patients. No vascular or visceral injuries occurred after Veress or first trocar insertion. Likewise, there were not abdominal wall seromas or haematomas in the post-operative period.
OVA technique can be considered a safe alternative procedure for laparoscopic entry. By avoiding potentially dangerous insertion-related forces, even in previously operated patients, when the first trocar needs to be positioned away from the umbilicus or abdominal scar, we consider the technique safe and most advantageous.
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Conflicts of interest
There are no conflicts of interest.
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