Fellowship Minimal Access Surgery Training

Laparoscopic Port and Trocar Techniques and Complications

Laparoscopic surgery, a minimally invasive procedure, involves examining the abdominal cavity and its contents through small incisions, typically requiring the insertion of a cannula and the establishment of pneumoperitoneum (distension of the abdominal cavity with gas). While laparoscopy offers benefits such as improved cosmetic results and fewer complications compared to traditional open surgery, the initial step of gaining access to the abdomen is critical and is often cited as the “Achilles’ heel” of the procedure. Approximately half of all observed complications in laparoscopic surgeries occur during the creation of pneumoperitoneum and the primary trocar insertion. These entry-related injuries can include gastrointestinal tract perforation, sub-cutaneous or sub-fascial insufflation, major or minor vessel injury, and gas embolism.

To minimise these risks, various laparoscopic entry techniques, instruments, and approaches have been developed and studied. There remains an ongoing debate, spanning decades, regarding the safest entry technique, with no universal consensus or international guideline recommending one method over others. Consequently, the choice of entry method often depends on the surgeon’s training, experience, and the availability of resources.

The primary laparoscopic entry techniques discussed in the sources include:

1. Veress Needle (Closed Entry)

The Veress needle technique, also known as the closed entry method, typically involves making a small skin incision, establishing pneumoperitoneum by insufflating CO2 gas into the abdomen, and then inserting a sharp trocar and cannula system.

Prevalence: This is the most established and widely adopted technique, particularly among gynaecologists globally, with one Canadian survey indicating that 96.3% of respondents always induce pneumoperitoneum prior to primary trocar insertion.
Insertion Sites: The umbilicus is the most frequent insertion site due to its shallow distance to the peritoneum and cosmetic appeal. Alternative sites include the left upper quadrant (LUQ), also known as Palmer’s point, which is recommended for patients with suspected periumbilical adhesions, umbilical hernia, or after three failed insufflation attempts at the umbilicus. Other less common sites include transuterine and the ninth or tenth intercostal space.
Safety Checks: While several “safety tests” (such as the double click sound, aspiration test, hanging drop test, hiss sound test, and syringe test) have been described, current evidence suggests they provide very little useful information on correct needle placement and are not necessary to perform. Surgeons are, however, advised to avoid waggling the Veress needle from side to side, as this can enlarge a puncture injury.
Reliable Indicator: An initial intraperitoneal pressure of ≤ 10 mm Hg is a reliable indicator of correct Veress needle placement.
Abdominal Wall Elevation: Elevating the anterior abdominal wall during Veress or primary trocar insertion is not routinely recommended, as it has not been shown to prevent visceral or vessel injury and can even lead to omental perforations.
Insertion Angle: The angle of insertion should vary based on the patient’s body mass index (BMI), from 45 degrees in non-obese women to 90 degrees in obese women.
Pneumoperitoneum Adequacy: Adequate pneumoperitoneum should be determined by intra-abdominal pressure (e.g., 20 to 30 mm Hg), rather than a predetermined CO2 volume. Higher pressures (25-30 mm Hg) create a deeper CO2 bubble, which can help prevent the trocar tip from touching abdominal contents when force is applied.
Complications: Complications associated with the Veress needle include sub-cutaneous or sub-fascial insufflation, gas embolism, bowel or visceral insufflation, and failure of pneumoperitoneum. Extraperitoneal insufflation is a common complication that can lead to procedure abandonment. The risk of complications increases with the number of insertion attempts. A recent meta-analysis found that the Veress needle method carried a significantly higher risk of omental injury, failed entry, and extraperitoneal insufflation compared to the direct trocar method. It also showed a higher risk of omental injury, extraperitoneal insufflation, and incisional hernia compared to the open method.

2. Direct Trocar Insertion (DTI)

Direct trocar insertion involves directly inserting a sharp trocar into the abdomen without first establishing pneumoperitoneum. The anterior abdominal wall should be adequately elevated during insertion.

Advantages: This technique is considered faster than other methods and involves only one blind step (the trocar insertion) compared to the three blind steps (Veress needle, insufflation, and trocar) of the conventional method. It is also associated with fewer insufflation-related complications, such as gas embolism and extraperitoneal insufflation.
Studies and Outcomes: Dingfelder first described DTI in 1978 as a safe and effective technique. A prospective observational study involving 1913 patients undergoing various laparoscopic procedures (predominantly cholecystectomy, with some appendectomies and ovarian cystectomies) found DTI to be 100% successful without any major or minor intra-abdominal or visceral injuries or gas leakage. The main complications observed were abdominal wall haemorrhage (1.4%) and wound infection (1.9%).
Comparative Superiority: A meta-analysis published in 2023 concluded that the direct trocar method may be preferred over both the Veress needle and open methods.
- Compared to Veress needle, DTI showed a significantly lower risk of omental injury, failed entry, and extraperitoneal insufflation. It was also found to be significantly faster.
- Compared to the open method, DTI was associated with a significantly lower risk of visceral injury and trocar site infection, and was also significantly faster.
Safety Profile: DTI is considered a safe, efficient, rapid, and easily learned alternative method for reducing laparoscopic procedure-related complications. It has been reported to be safe in a wide range of patients, including young, old, obese, and non-obese individuals, and can be quicker than classical techniques.

3. Hasson Open Technique

The Hasson open technique involves making a small incision (essentially a mini-laparotomy), dissecting through the abdominal wall under direct vision, and then inserting a blunt-tipped cannula or port. Stay sutures are often used to secure the port and create a gas seal.

Rationale: This technique is favoured by general surgeons who emphasize direct visualisation of anatomical structures. It is suggested to prevent gas embolism and preperitoneal insufflation.
Indications: It is often considered for patients with a history of previous abdominal surgery, especially those with longitudinal abdominal wall incisions, where adhesions might be a concern.
Complications and Comparisons:
- Early reviews suggested that the open technique had lower rates of bowel and vascular injuries compared to the closed (Veress needle) technique.
- However, a more recent meta-analysis reported a higher rate of bowel injuries with open laparoscopy (0.11%) compared to Veress/trocar (0.04%) and direct entry (0.05%). This could be due to patient selection bias, where higher-risk patients are chosen for the open method.
- Despite its rationale, major vascular injuries can still occur with the open technique.
- The latest meta-analysis found that the open method was the slowest among the compared techniques. It also showed that the Veress needle method had a significantly higher risk of incisional hernia compared to the open method, while the direct trocar method had a significantly lower risk of visceral injury and trocar site infection compared to the open method.
Current Standing: There is no definitive evidence that the open entry technique is superior or inferior to other available entry techniques.

4. Other Entry Techniques

Other specialized devices and techniques aim to improve safety or ease of access:

Shielded Trocars: These disposable trocars have a shield that retracts to expose the sharp tip during insertion and then springs forward to cover the tip upon entering the abdominal cavity. Despite their design, studies indicate no evidence that they result in fewer visceral and vascular injuries, as injuries can still occur. The FDA even requested manufacturers to remove safety claims from their labelling due to lack of clinical data.
Radially Expanding Trocars: These systems use an expanding polymeric sleeve and a blunt obturator to create a tract in the abdominal wall. While their blunt tips might offer some protection, they require significantly greater force for entry compared to disposable trocars (e.g., 14.2 kg vs. 4-6 kg). They are not recommended as superior to traditional trocars.
Visual Entry Systems (Optical Trocars): These systems integrate a laparoscope within the trocar, allowing for real-time visual monitoring as the trocar passes through abdominal wall layers. They can minimize wound size and reduce insertion force. However, even with visual guidance, they do not eliminate the risk of visceral and vascular injury.

Complications and Risk Factors

Despite advancements, laparoscopic entry carries inherent risks:

Major Complications: These include bowel perforation, major vessel injury, urinary bladder injury, and gas embolism. The overall mortality rate associated with laparoscopic entry is estimated at 1 per 100,000 procedures.
Minor Complications: These encompass port site hernia, surgical wound infection, abdominal wall haemorrhage, subcutaneous emphysema, and extraperitoneal insufflation. Port-site incisional hernia (PIH) is an uncommon but serious complication (0.5-5% incidence) that can lead to intestinal obstruction.
Delayed Diagnosis: A significant concern is that 30% to 50% of bowel injuries and 13% to 50% of vascular injuries may be undiagnosed at the time of surgery, leading to severe consequences and a mortality rate of 2.5-5% for bowel injuries.
Patient-Specific Factors:
- Previous Surgeries: A history of previous abdominal surgeries increases the likelihood of adhesions, which can complicate entry.
- BMI: Both obesity and extreme thinness can affect the ease and safety of entry. While obesity is a risk factor for PIH due to increased intra-abdominal pressure, this is a debated point.
- Age: Patients aged 60 or older may have an increased risk of developing PIH.
Trocar Size and Placement: The incidence of PIH is higher with trocars larger than 10 mm. However, recent reports highlight PIH occurring at 8 mm trocar sites, especially in robot-assisted laparoscopic surgery (RALS) where robotic arms often require more lateral port placement, which can weaken the abdominal fascia. Therefore, it is now recommended to routinely close the fascia of 8 mm trocar sites after RALS, preferably laparoscopically under direct vision, to prevent PIH.
Optimal Port Positioning: The “baseball diamond concept” emphasizes creating an optimal working space with a 60-degree angle between instrument tips, a tangential approach to the operative site, and appropriate working distance. For procedures like laparoscopic transabdominal preperitoneal (TAPP) hernia repair, specific challenges with left-side dissection using conventional three-port techniques have led to the development of four-port configurations (e.g., “Believers Port Positions”) to improve instrument reach and ease of dissection.

While no single laparoscopic entry technique has been definitively proven to be superior in completely eliminating major complications, recent meta-analyses suggest that the direct trocar method may be the preferred choice due to its association with a lower risk of minor complications (such as omental injury, failed entry, extraperitoneal insufflation, visceral injury, and trocar site infection) and faster entry times. The choice of technique, however, remains dependent on the surgeon’s experience and specific patient characteristics. Continued vigilance and careful technique remain paramount to minimise entry-related complications in laparoscopic surgery.

Direct Trocar Insertion (DTI)

Direct Trocar Insertion (DTI) is a laparoscopic entry technique that involves inserting a trocar directly into the abdominal cavity without prior establishment of pneumoperitoneum. This method contrasts with traditional approaches, such as the Veress needle technique, which typically requires insufflation of the abdomen with carbon dioxide (CO2) to create a buffer space before trocar entry.

Here’s a detailed discussion of DTI within the larger context of laparoscopic entry techniques:

Advantages and Rationale for DTI

Avoidance of Veress Needle Complications: DTI was initially proposed to avoid complications associated with the Veress needle insufflation, such as subcutaneous or subfascial insufflation, gas embolism, bowel or visceral insufflation, and the failure of pneumoperitoneum. It reduces the number of “blind steps” during laparoscopic entry from three (Veress needle, insufflation, trocar) to just one (trocar).
Speed and Efficiency: DTI is considered a faster method of abdominal entry compared to other techniques.
Safety and Reliability: Studies suggest DTI is a safer and more reliable alternative to traditional techniques for establishing pneumoperitoneum. It has been increasingly used to minimise entry-related injuries.
Reduced Complications:
- The Tasneem et al. (2022) study found DTI to be 100% successful in all 1913 patients without any major or minor intra-abdominal or visceral injuries or gas leakage. This study reported low rates of abdominal wall haemorrhage (1.4%) and wound infection (1.9%).
- A meta-analysis by Raimondo et al. (2023) concluded that DTI is associated with a significantly lower risk of omental injury, failed entry, and extraperitoneal insufflation compared to the Veress needle method.
- This same meta-analysis also indicated a significantly lower risk of visceral injury and infection at the trocar site for DTI compared to the open (Hasson) method.
- Other research has reported minimal or easily manageable complications with DTI, with one study even preferring it due to minimal and minor complications and less operating time. Choudhury et al. (2017) observed no vascular or visceral complications in 175 laparoscopic surgeries using DTI. Ahmed et al. (2019) noted no or minor complications and fewer incidences of failed entry, extraperitoneal insufflation, and omental injury compared to Veress needle entry. Ulusoy et al. (2018) found DTI to be safe and efficient, with only minor complications like skin hematoma, ecchymosis, and abdominal wall haemorrhage in a study of 1200 patients.
Applicability to Various Patient Types: DTI has been successfully employed for young, old, obese, non-obese, non-virginal, or virginal abdominal surgeries, with one study even reporting it safer in obese patients.

Historical Context

The technique for direct trocar insertion was first demonstrated by Dingfelder in 1978, who termed it both safe and effective.

Considerations for DTI

Blind Technique with Reduced Blind Steps: While DTI is fundamentally a blind technique, it significantly reduces the number of blind steps compared to conventional methods.
Abdominal Wall Elevation: Elevation of the abdominal wall is considered an important factor in achieving safety with DTI.
Trocar Type: Sharp trocars are recommended for DTI. There is a concern that reusable trocars may not be consistently sharpened.
Potential Complications: Although the Tasneem et al. study reported no major injuries, other sources mention potential complications. For instance, Hill and Maher reported omental perforations in 4.8% of cases where the omentum was elevated with the anterior wall during DTI. While Molloy et al. (2002) reported 0% vascular injury for DTI in their review, case reports of major vessel injuries with DTI have been documented.

Comparison with Other Laparoscopic Entry Techniques

Veress Needle Technique (Closed Entry):
- Traditionally, a successfully established pneumoperitoneum using a Veress needle is the initial step in laparoscopy to create buffer space.
- Despite its common use, especially preferred by most gynaecologists, it is associated with a substantial number of complications such as gas embolism, sub-cutaneous or sub-fascial insufflation, bowel or visceral insufflation, and failure of pneumoperitoneum.
- The Raimondo et al. (2023) meta-analysis found that compared to DTI, the Veress needle method had a significantly higher risk of omental injury, failed entry, and extraperitoneal insufflation. It also had a higher total entry time.
- Compared to the open method, the Veress needle method showed a significantly higher risk for omental injury, failed entry, extraperitoneal insufflation, and incisional hernia.
Hasson Open Technique (Open Entry):
- This technique involves a mini-laparotomy and entering the peritoneal cavity under direct vision. General surgeons often favour it, especially in patients with a history of previous abdominal surgery.
- The suggested benefits include preventing gas embolism and preperitoneal insufflation, and potentially reducing visceral and major vascular injury.
- However, evidence does not definitively prove its superiority or inferiority over other entry techniques. Some studies suggest it may have a higher incidence of bowel injury compared to closed techniques.
- The Raimondo et al. (2023) meta-analysis found that DTI showed a significantly lower risk of visceral injury and trocar site infection compared to the open method. The open method was also found to be the slowest entry method.
Shielded Trocars: These disposable trocars are designed with a shield to protect the sharp tip, but they do not fully eliminate injuries as the sharp tip is briefly exposed upon entry. Some reports indicate they are responsible for a significant proportion of serious injuries and vascular injuries.
Radially Expanding Access Systems: These systems use a blunt obturator and a dilating sleeve. While they have blunt tips and may offer some protection, they require significantly greater force for entry compared to disposable trocars and are not recommended as superior to traditional trocars.
Visual Entry Systems (Optical Trocars): These systems allow for optical entry by having a laparoscope loaded into a hollow trocar to visualise tissue layers during insertion. While they offer clear optical entry and may minimise wound size, they are not superior in avoiding visceral and vascular injury. Some designs may still require considerable axial force, making layer recognition difficult and risking overshoot.

The Tasneem et al. (2022) study concludes that DTI is a faster, safer, and more reliable alternative to the traditional technique for establishment of pneumoperitoneum and should be used routinely. The SOGC Clinical Practice Guideline (2007) states that direct insertion of the trocar without prior pneumoperitoneum may be considered a safe alternative to the Veress needle technique and is associated with fewer insufflation-related complications and is faster.

The most recent meta-analysis by Raimondo et al. (2023) further strengthens this position, suggesting that the direct trocar method may be preferred over the Veress needle and open methods as a laparoscopic entry technique due to its association with a lower risk of omental injury, failed entry, and extraperitoneal insufflation (compared to Veress needle), and a lower risk of visceral injury and infection at the trocar site (compared to the open method). It was also identified as the fastest entry method. While no difference in major complications was found in this meta-analysis, the authors note that the limitations of included studies (such as poor quality or inappropriate statistical power) might affect these conclusions, as major complications are rare events. Despite this, they argue that even a minimal reduction in minor complications is a significant improvement. They suggest that the choice of entry technique currently often depends on the surgeon’s experience and available resources, but their findings support a preference for DTI.

Veress Needle Method

The Veress Needle Method, also known as Closed Entry, is a traditional laparoscopic entry technique that involves the prior establishment of pneumoperitoneum by insufflating the abdomen with carbon dioxide (CO2) gas, before the insertion of the primary trocar. This method is typically the initial step in laparoscopy, creating a buffer space between the insertion site and the abdominal or pelvic viscera.

Here’s a detailed discussion of the Veress Needle Method in the larger context of laparoscopic entry techniques:

Historical Context and Prevalence

The use of the Veress needle to induce pneumoperitoneum for laparoscopy was popularised by Raoul Palmer of France in 1947. Despite the development of numerous techniques to reduce risks associated with pneumoperitoneum induction, no single technique has been proven to eliminate complications. Nevertheless, most gynaecologists worldwide prefer and routinely use the Veress needle-pneumoperitoneum-primary trocar technique for abdominal access. A Canadian survey indicated that 96.3% of obstetricians and gynaecologists always induce pneumoperitoneum prior to primary trocar insertion.

Technique and Safety Considerations

The Veress needle is typically inserted in the umbilical area, in the midsagittal plane, as it offers the thinnest abdominal wall and a relatively avascular area. Alternative insertion sites may be considered in cases of suspected periumbilical adhesions, umbilical hernia, or after three failed umbilical insufflation attempts. These include the left upper quadrant (LUQ, Palmer’s point), transuterine, trans cul-de-sac, or ninth/tenth intercostal space.

Regarding safety during insertion:

Various Veress needle safety tests or checks, such as the double click sound, aspiration test, hanging drop of saline test, “hiss” sound test, and syringe test, provide very little useful information and are therefore not necessary to perform.
It is crucial to avoid waggling the Veress needle from side to side, as this manoeuvre can enlarge a 1.6 mm puncture injury to an injury of up to 1 cm in viscera or blood vessels.
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.
The angle of the Veress needle insertion should vary with the patient’s BMI, from 45° in non-obese women to 90° in obese women.
Adequate pneumoperitoneum should be determined by a pressure of 20 to 30 mm Hg, rather than a predetermined CO2 volume. High intraperitoneal (HIP-pressure) laparoscopic entry (25-30 mm Hg) has been advocated and is reported not to adversely affect cardiopulmonary function in healthy women. A higher pressure creates a deeper CO2 bubble, reducing the risk of the trocar tip touching abdominal contents upon insertion.
A Veress intraperitoneal (VIP) pressure of ≤ 10 mm Hg is a reliable indicator of correct intraperitoneal placement.
After approximately 1 L of gas has been insufflated, the Veress needle can be advanced a further 5 mm to ensure it does not exit with increasing intra-abdominal pressure.
Measuring the depth from the skin to the rectus sheath and then estimating the distance to the abdominal aorta can aid in safe Veress needle insertion.

Complications and Risks

Despite its widespread use, the Veress needle method is associated with a substantial number of complications, with almost half of all observed laparoscopic complications occurring during pneumoperitoneum creation. These complications include:

Subcutaneous or subfascial insufflation.
Gas embolism, which can be fatal or near-fatal (reported incidence of 0.001%).
Bowel or visceral insufflation.
Failure of pneumoperitoneum, frequently leading to abandonment of the procedure.
Gastrointestinal tract perforation and major or minor vessel injury. Vascular injury, though rare, has a reported mortality of 15%.
Omental injury.
Wound infection and abdominal wall haematoma.

The difficulty of inserting the Veress needle can significantly increase complication rates. Studies show that complication rates rise with the number of insertion attempts: 0.8%–16.3% for one attempt, increasing to 84.6%–100% for more than three attempts.

Comparison with Other Laparoscopic Entry Techniques

The sources provide extensive comparisons of the Veress needle method with other common entry techniques:

Direct Trocar Insertion (DTI):
- DTI is associated with a significantly lower risk of omental injury, failed entry, and extraperitoneal insufflation compared to the Veress needle method.
- The Veress needle method showed a higher total time for entry than the direct trocar method (mean difference of 262.88 seconds).
- DTI reduces the number of “blind steps” from three (Veress needle, insufflation, trocar) to just one (trocar).
- DTI has been found to be a faster, safer, and more reliable alternative to the traditional Veress needle technique for establishing pneumoperitoneum.
- Studies comparing DTI and Veress needle entry have reported fewer minor complications with DTI.
Hasson Open Technique:
- Compared to the open method, the Veress needle method is associated with a significantly higher risk for omental injury, failed entry, extraperitoneal insufflation, and incisional hernia.
- The open technique, favoured by general surgeons, involves incision and direct vision. General surgeons have historically been cautious of the “blind puncture” associated with the Veress needle.
- Hasson’s review reported that the open technique had lower rates of umbilical infection, bowel injury, and vascular injury compared to closed laparoscopy (which includes the Veress needle). Bonjer et al. also found lower rates of visceral and vascular injury with the open technique. However, other studies contradict this, showing higher complication rates with the open method.
- The European Association for Endoscopic Surgery noted that while randomised controlled trials (RCTs) found the open approach faster and associated with a lower incidence of minor complications, large outcome studies found fewer complications in the closed group (Veress plus trocar).
- The optimal form of laparoscopic entry in low-risk patients remains unclear, with no clear evidence that the open entry technique is superior or inferior to others.
Shielded Trocars, Radially Expanding Access Systems, and Visual Entry Systems:
- Shielded trocars were designed to prevent injury but still have a brief moment where the sharp tip is exposed. They are reportedly responsible for a significant proportion of serious injuries and vascular injuries. There is no evidence that they result in fewer visceral and vascular injuries.
- Radially expanding trocars have blunt tips but require significantly greater force for entry compared to disposable trocars and are not recommended as superior.
- Visual entry cannula systems (optical trocars) allow for clear optical entry and may minimise wound size and reduce insertion force. However, they are not superior in avoiding visceral and vascular injury.

Overall Conclusion Regarding Veress Needle Method

Despite a two-decade-long debate, no consensus has been achieved about the safest laparoscopic entry technique. International guidelines often state that the choice depends on surgeon experience and available resources.

However, recent meta-analyses offer clearer preferences:

The Tasneem et al. (2022) study concludes that Direct Trocar Insertion (DTI) is a faster, safer, and more reliable alternative to the traditional Veress needle technique for establishing pneumoperitoneum and recommends its routine use.
The Raimondo et al. (2023) meta-analysis suggests that the direct trocar method may be preferred over the Veress needle and open methods as a laparoscopic entry technique. This preference is based on the Veress needle method being associated with a significantly higher risk of omental injury, failed entry, and extraperitoneal insufflation compared to DTI, and a higher total entry time. The authors argue that even a minimal reduction in minor complications is a significant improvement, especially since Veress needle injuries (like omental perforations) can remain undetected for prolonged periods.

In summary, while the Veress needle technique remains widely used, evidence from the sources indicates that it carries notable risks and complications, particularly in comparison to Direct Trocar Insertion, which is increasingly viewed as a safer, faster, and more reliable alternative.

Hasson Open Technique

The Hasson Open Technique, also referred to as the open entry technique, is a method for laparoscopic access that involves creating a mini-laparotomy to enter the peritoneal cavity under direct vision, before the introduction of the primary trocar and establishment of pneumoperitoneum.

Historical Context and Popularity

The Hasson Open Technique was first described by Hasson in 1971. Historically, general surgeons have been cautious about the “blind puncture” associated with the Veress needle technique, as their training emphasises complete visualisation of anatomy and surgical actions. Consequently, the open or Hasson technique has become more popular and is considered safer by some in this specialty. However, it is noted that the majority of gynaecologists prefer the Veress entry.

Technique Details

The Hasson technique is essentially a mini-laparotomy. The general steps include:

Making a small incision (approximately 10 to 12 mm in length), either vertical or transverse, typically just below or above the umbilicus. The choice of site can depend on surgeon preference or the presence of previous regional incisions.
Bluntly dissecting the subcutaneous fat and tissues.
Visualising and grasping the white linea alba with hemostats and making a 10-mm vertical incision through it.
Further dissection with a hemostat to reveal the thickened white peritoneum, which is then grasped laterally and opened cautiously with a scalpel.
Verifying free entry into the intraperitoneal space by inserting the surgeon’s fifth finger to size the hole and palpate the region, sweeping away any filmy omental adhesions.
Introducing the Hasson port with its blunt, rounded-tip obturator into the abdomen.
Screwing the spiral collar into the fascia to create a snug gas seal, and securing lateral stay sutures to the collar’s notches. These sutures incorporate the peritoneum and linea alba and are used to secure the port.
Removing the obturator, attaching the CO2 line, and opening the stopcock to commence insufflation (typically setting maximum pressure to 15 mm Hg).
Finally, at the end of the procedure, closing the fascial defect and re-approximating the skin.

Perceived Advantages and Benefits

The suggested benefits of the Hasson open technique include:

Prevention of gas embolism.
Prevention of preperitoneal insufflation.
Possibly preventing visceral and major vascular injury.

Some studies or reviews have reported specific advantages:

Hasson’s own review suggested lower rates of umbilical infection (0.4% vs 1%), bowel injury (0.1% vs 0.2%), and vascular injury (0% vs 0.2%) compared to closed laparoscopy (Veress needle).
Bonjer et al. reported lower rates of visceral (0.05% vs 0.08%) and vascular injury (0% vs 0.07%) after open laparoscopy compared to closed.
Garry concluded that open laparoscopy is an acceptable alternative method that has been shown to almost completely avoid the risk of injury in normally situated intra-abdominal structures.
The European Association for Endoscopic Surgery (EAES) states that the open technique is faster compared to the Veress needle for first trocar insertion.
One meta-analysis found that vascular injuries are prevented almost entirely by the open technique.
Merlin et al.’s systematic review noted a clear trend towards a reduced risk of major complications in unselected patients undergoing open access procedures in retrospective studies. It also showed a trend towards a reduced risk of access-site herniation (RRp 0.21, 95% CI 0.04–1.03) and a 57% reduced risk of minor complications in non-obese patients (RRp 0.43, 95% CI 0.02–0.92), as well as a trend for fewer conversions to laparotomy (RRp 0.21, 95% CI 0.04–1.17).

Disadvantages and Complications

Despite its perceived benefits, the Hasson Open Technique is also associated with risks and disadvantages:

It is associated with a significantly higher risk for omental injury, failed entry, extraperitoneal insufflation, and incisional hernia compared to the Direct Trocar Insertion (DTI) method.
One study reported a higher number of entry-related complications with the open technique (0.17%) compared to the closed technique (0.07%).
The Raimondo et al. meta-analysis found that compared to the Veress needle method, the open method was associated with a higher risk for omental injury (OR 1/4.34, P = 0.009) and incisional hernia (OR 1/4.77, P = 0.040).
Bowel injuries are reported more frequently with open laparoscopy (0.11%) compared to Veress needle entry (0.04%) or direct entry (0.05%). This might be influenced by patient selection bias, as open procedures may be chosen for patients with previous abdominal surgery.
Several case reports of vascular injuries with the open technique have been published. Chandler et al. reported 18 Hasson-type entries associated with primary entry injuries, including small bowel injuries (4 cases, 2 with delayed recognition and death) and retroperitoneal vessel injuries (4 cases, 1 resulting in death). Other injuries included colon injuries, abdominal wall vessel laceration, liver, urinary bladder, or mesenteric vessel injury.
The open technique can be slower than direct trocar insertion.
It may be associated with a higher risk of trocar site infection compared to DTI. This could be due to longer procedure length and more handling of surgical tools, increasing contamination risk.

Comparison with Other Laparoscopic Entry Techniques

Versus Veress Needle Method (Closed Entry)

Complications: The Raimondo et al. meta-analysis found that the Veress needle method was associated with a significantly higher risk of omental injury, failed entry, and extraperitoneal insufflation compared to DTI, and a higher risk for omental injury, extraperitoneal insufflation, and incisional hernia compared to the open method. This implies that while the Veress needle has certain issues, the open method also carries its own set of distinct risks.
Entry Time: The EAES notes that the open approach is faster than the Veress needle. However, the Tasneem et al. study indicates that DTI is faster than the traditional Veress needle technique.
Surgeon Preference: The majority of gynaecologists prefer the Veress entry.
Evidence Conflict: RCTs comparing closed (Veress plus trocar) versus open approach have inadequate sample sizes to find a difference in serious complications. Large outcome studies have shown fewer complications in the closed group, while RCTs found the open approach faster and associated with lower minor complications.

Versus Direct Trocar Insertion (DTI)

The Raimondo et al. meta-analysis found that compared to the open method, the Direct Trocar Insertion (DTI) method had a significantly lower risk of visceral injury (OR 0.17, P = 0.002) and trocar site infection (OR 0.27, P = 0.001).
The DTI method was also found to be faster than the open method, with a mean difference of -135.44 seconds.
The DTI technique may benefit from optical trocars for quicker visual identification of bowel during insertion, which is an advantage over the open method that mandatorily uses sharp tools and direct vision.

Despite a long-standing debate, no consensus has been achieved about the safest laparoscopic entry technique. International guidelines often state that the choice depends on surgeon experience and available resources, rather than recommending one method over others.

While the Hasson open technique aims to provide direct visualisation and theoretically reduce blind injuries, the sources present a mixed picture:

It is considered a valid alternative to the Veress needle.
It may have advantages in specific patient subgroups.
However, it does not clearly show superiority over other techniques in preventing major complications.
The optimal form of laparoscopic entry in low-risk patients remains unclear.

More recent meta-analyses, such as Raimondo et al. (2023), suggest that the direct trocar method may be preferred over both the Veress needle and open methods, based on its association with a lower risk of specific complications and faster entry times. The open method’s requirement for sharp surgical tools and its potential for higher infection rates compared to DTI are also noted.

Other Entry Technologies

The provided sources discuss several laparoscopic entry techniques beyond the widely known Hasson (open), Veress needle (closed), and Direct Trocar Insertion (DTI) methods. These “Other Entry Technologies” primarily include shielded trocars, radially expanding access systems, and visual entry systems (optical trocars/cannulas). The choice among these, and other methods, often depends on the surgeon’s experience, training, bias, and available resources, as no single technique has achieved definitive consensus as the safest.

Here’s what the sources say about these other entry technologies in the larger context of laparoscopic entry:

1. Shielded Trocars

Description and Intended Purpose:

Shielded disposable “safety” trocars were introduced in 1984.
They are designed with a shield that partially retracts to expose the sharp tip as it encounters resistance through the abdominal wall.
Upon entering the abdominal cavity, the shield springs forward to cover the sharp tip, with the intention of preventing the sharp tip from injuring intra-abdominal contents.

Mechanism and Associated Factors:

Even when functioning properly, there is a brief moment when the sharp trocar tip is exposed and unprotected upon entering the abdominal cavity.
With pre-existing pneumoperitoneum, these trocars have been shown to require half the force needed for a reusable trocar.
However, the force required to enter the abdomen with various disposable trocars in a pig model was 4 to 6 kg. Increased entry force can frequently result in loss of operator control and overthrusting of the trocar, a potential cause of serious vascular and visceral injuries.

Evidence of Safety and Complications:

A randomized study comparing direct laparoscopic entries found no complications with disposable trocars (n=50), compared to three minor complications (6%) with conventional trocars.
However, other studies reported concerning findings:
- A randomized experimental study in rabbits concluded that initial insufflation was safer than direct trocar insertion, and the use of disposable trocars did not improve the safety of the procedure.
- Champault et al. reported that shielded trocars were involved in 10 out of 36 (28%) serious injuries and 2 out of 7 (29%) deaths across 103,852 operations.
- Saville and Woods reported that all four major retroperitoneal vessel injuries in 3,591 laparoscopies involved shielded trocars.
- Marret et al. found that half of the large blood vessel injuries between 1994 and 1997 were caused by disposable safety trocars.
- An analysis of 629 trocar injuries reported to the FDA database (1993-1996) found that 87% of deaths from vascular injuries and 91% of bowel injuries involved disposable trocars with safety shields. The authors concluded that “safety shields and direct-view trocars cannot prevent serious injuries”. There were few reports alleging or finding safety-shield malfunction.
Despite these findings, the Emergency Care Research Institute (ECRI) in 1998 and 2000 suggested that while shielded trocars don’t totally protect against injuries, they are preferable to unshielded trocars.

Recommendations:

Shielded trocars may be used in an effort to decrease entry injuries.
However, there is no evidence that they result in fewer visceral and vascular injuries during laparoscopic access. The FDA, in 1996, requested manufacturers to eliminate safety claims from their labelling due to a lack of supporting clinical data.

2. Radially Expanding Access Systems

Description and Mechanism:

The radially expanding access system (e.g., Step) was introduced in 1994.
It comprises a 1.9 mm Veress needle surrounded by an expanding polymeric sleeve.
After initial insufflation and removal of the Veress needle, the sleeve acts as a tract that can be dilated up to 12 mm by inserting a blunt obturator with a twisting motion.

Force and Benefits/Complications:

The force required to push this trocar through the abdomen is 14.2 kg, which is significantly greater compared to the 4 to 6 kg needed for disposable trocars.
Studies have reported no injury to major vessels and no deaths with this system.
However, abdominal wall bleeding and Veress injury to the mesentery have been encountered.
Randomized controlled trials (RCTs) have demonstrated less post-operative pain and more patient satisfaction with the radially expanding device compared to conventional trocar entry techniques.
Advantages include the elimination of sharp trocars, application of radial force, stabilization of the cannula’s position (preventing sliding), avoidance of injury to abdominal wall vessels, and elimination of the need for suturing fascial defects.

Recommendations:

Radially expanding trocars are not recommended as being superior to traditional trocars.
While they have blunt tips that may provide some protection from injuries, the force required for entry is significantly greater than with disposable trocars.

3. Visual Entry Systems (Optical Trocars/Cannulas)

Description and Mechanism:

Disposable optical/access trocars (e.g., Endopath Optiview, The Visiport optical trocar) were introduced in 1994 and are popular among urologists.
These systems feature a hollow trocar into which a zero-degree laparoscope is loaded, allowing the distal crystal tip to transmit real-time monitor images while transecting abdominal wall tissue layers.
They require significant axial thrust from the surgeon’s dominant upper body muscles to transect myofascial layers.
The EndoTIP (endoscopic threaded imaging port) is a reusable visual cannula system that enables real-time interactive port creation. It stands out by reducing push-force, allowing visually controlled entry, eliminating overshoot, and lacking a sharp trocar. Tissue layers are parted by its outer thread rather than transected, preserving port competence and resulting in smaller fascial entry wounds.

Perceived Advantages:

The visual entry cannula system may represent an advantage over traditional trocars due to its clear optical entry.
They have the advantage of minimizing the size of the entry wound and reducing the force necessary for insertion.
The EndoTIP system in particular eliminates a sharp trocar and provides real-time, layered-entry visual interpretation.

Reported Complications:

Despite the visual control, visual entry trocars are not superior to other trocars in avoiding visceral and vascular injury.
A prospective study of 184 cases using an optical Veress system reported two bowel perforations, making its relative predictive risks uncertain due to the absence of randomized studies.
A multicentre survey of general surgeons indicated the highest incidence of major injuries (0.27%) with optical trocars.
Bhoyrul et al. found that 9% of deaths from vascular injuries and 7% of bowel injuries involved disposable optical trocars.
Marret et al. reported that half of the large blood vessel injuries involved this type of “safety” trocar.
The push-through design of some optical trocars necessitates considerable axial force, with no mechanism to offset overshoot, and the generated force can dent tissue layers, making layer recognition more difficult.

The landscape of laparoscopic entry techniques is diverse, with ongoing efforts to improve safety and reduce complications. While the Hasson open technique, Veress needle, and direct trocar insertion remain primary contenders, technologies like shielded trocars, radially expanding systems, and visual entry systems offer various approaches.

The sources indicate that:

No single entry technique has been definitively proven to eliminate complications or to be inherently superior or inferior to others.
The choice of entry method often depends on the surgeon’s experience and preferences, as well as patient-specific factors (e.g., history of previous abdominal surgery, BMI).
While some “other” technologies theoretically aim to enhance safety (e.g., direct visualisation with optical trocars, blunt entry with radially expanding systems), the evidence regarding their superiority in preventing major complications like visceral or vascular injury is conflicting or insufficient. Indeed, some data suggest they may still be associated with significant risks.
More recent meta-analyses emphasize that the choice of entry technique should consider the risk profile of specific complications rather than focusing solely on major injuries. For instance, while the direct trocar method appears to have advantages over both Veress and open methods in terms of certain complications and speed, the “other” technologies present their own unique risk-benefit profiles.

Ultimately, continuous vigilance, thorough anatomical knowledge, and careful technique remain paramount regardless of the chosen entry technology to minimize the “Achilles’ heel” of laparoscopic surgery: entry-related complications. Further research is needed, especially in higher-risk patient populations and to account for surgeon experience, to tailor recommendations more precisely.

Laparoscopic Port Positioning Principles

Fundamental Principles of Laparoscopic Port Positioning

The relative position of instrument ports is paramount in laparoscopic surgery, as it is intended to mimic, as closely as possible, the natural relationship of the hands and eyes during conventional open surgery. The aim is to minimise surgical stress, which often results from incorrect port placement.

Primary Optical Port Site Considerations

The choice of the primary optical port site is critical, as it is the initial point of entry into the abdominal cavity and is associated with a significant portion of major complications.

Umbilical Site: The umbilicus is commonly selected for primary trocar insertion because it offers the shortest distance between the skin and the anterior peritoneum and is cosmetically appealing. However, the umbilicus is a naturally weak area due to the absence of all fascial layers and its central location at the abdomen’s greatest diameter. The primary port can be placed at the superior crease, inferior crease, or trans-umbilically. While umbilical sites can be prone to infection, studies suggest this is more related to the retrieval of infected organs (e.g., gallbladder) through the umbilicus, rather than the site itself. The postoperative ventral hernia rate at the umbilicus is similar to other sites if a port larger than 10 mm is not repaired.
Supra-umbilical Port: This position is highly advantageous for upper abdominal surgery (e.g., fundoplication, Heller’s myotomy, hiatus hernia, most bariatric surgeries). It is also optimum for many gynaecological surgeries, especially in complex cases with large masses like fibroid uteri, large ovarian cysts, or in pregnant patients, as it increases the distance from enlarged pelvic pathology, thereby improving exposure and surgical efficiency and avoiding injury to the gravid uterus. In obese patients, where the umbilicus is displaced downwards, the xiphisternum should be used to plan the supra-umbilical port. It is also frequently used in robotic surgery to help eliminate robotic arm collisions.
Infra-umbilical Port: Less commonly used, placed 3-5 cm below the umbilicus. It is indicated for single puncture sterilisation or for upper abdominal surgery in very short patients.
Left Upper Quadrant (LUQ) / Palmer’s Point: This alternative site, located 3 cm below the left subcostal border in the midclavicular line, should be considered in patients with suspected or known periumbilical adhesions or a history/presence of umbilical hernia, or after three failed insufflation attempts at the umbilicus. It may also be considered for obese or very thin patients where the great vessels might lie close to the umbilicus. Patients with previous splenic or gastric surgery, significant hepatosplenomegaly, portal hypertension, or gastropancreatic masses should be excluded.
Other Sites: Other less common sites for establishing pneumoperitoneum via Veress needle include transuterine (especially in obese women) and trans cul-de-sac (posterior vaginal fornix). Insertion through the ninth or tenth intercostal space at the anterior axillary line, along the superior surface of the lower rib, is also mentioned to avoid neurovascular bundle injury.

Secondary Port Positions and the “Baseball Diamond Concept”

The placement of secondary ports is guided by principles that enhance instrument manipulation and visual field.

Fulcrum Effect: Laparoscopic instruments create a fixed point (fulcrum) at the abdominal wall, causing movements to be reversed (e.g., hand moves left, instrument moves right). The force feedback depends on the instrument length inside the abdomen.
“Baseball Diamond Concept”: This concept guides optimal port placement for effective surgical performance. It suggests that the telescope should be in the middle of the working instruments, and the manipulation angle between the two instrument tips should ideally be 60 degrees. This provides a tangential approach to the target site and an appropriate working distance.
Distance between Ports: Ports should generally be kept at least 5 cm apart to prevent crowding and facilitate instrument movement.
Instrument Length: For optimal task performance, half to two-thirds of the instrument should be inside the abdomen.
Target-Specific Placement: Port sites are determined by the surgical target, such as the suprapubic region for laparoscopic-assisted vaginal hysterectomy (LAVH), the right iliac fossa for appendectomy, or the right upper quadrant for laparoscopic cholecystectomy. For standard operations, surface markings may suffice, but for advanced or varied situations, mastering individual port placement using the internal view is recommended.
Addressing Incorrect Port Positions: “Swording” occurs when the telescope or assistant’s instrument obstructs the operator’s instruments. This can be addressed by repositioning retracting instruments, rotating the telescope, withdrawing the telescope, transposing instruments, adding new ports, or changing instruments to different ports.

Port Positioning in Specific Laparoscopic Procedures

The choice and number of ports vary depending on the procedure and surgeon’s preference.

Laparoscopic Cholecystectomy:
- The four-port technique is the standard approach.
- A three-port technique has been described where the lateral-most port for fundal retraction is absent, and the gallbladder infundibulum is held via the right upper quadrant port. A meta-analysis suggests that the three-port technique is associated with a lower length of hospital stay and reduced postoperative analgesia requirement compared to the four-port approach, likely due to fewer incisions. There was no statistically significant difference in procedure length or success rate, nor in adverse events such as gallbladder perforation, biliary content spillage, liver bed bleeding, or wound infection. While it can be an option for appropriately trained surgeons, it should not compromise safe dissection.
Laparoscopic Appendectomy:
- A technique for three-port laparoscopic appendectomy involves one umbilical incision (5-10 mm for optical device) and two suprapubic incisions (one 5 mm, one 10 mm with reducer). This technique offers low cost and aesthetic advantages, as the umbilical incision is often hidden, and suprapubic incisions can be concealed by underclothes. It allows for proper triangulation and a privileged view of the appendix, enhancing security and potentially reducing operative time.
- Single umbilical access is feasible for appendectomy and offers better aesthetic appeal than multiple visible incisions. However, it may require a wider incision that can deform the umbilicus and can be associated with higher pain intensity. The sources note that single-port techniques might present technical difficulty due to lack of triangulation, promoting higher risk in challenging cases.
Laparoscopic Hernia Repair (Transabdominal Preperitoneal – TAPP):
- The conventional three-port technique for bilateral TAPP typically uses a central 10-12 mm umbilical port for the laparoscope and two 5 mm lateral ports 5-7 cm away for working instruments. Right-handed surgeons often find dissection of the left side challenging due to the limitations of the right-hand dissecting instrument’s reach, especially on the medial side near the medial umbilical ligament. This is particularly relevant in populations like those in India, where the distance between the pubic symphysis and the umbilicus may be shorter.
- To address this, a “Believers Port Positions” technique (four-port configuration) has been devised. This involves adding an additional 5 mm port on the left side of the camera port, positioned in the anterior axillary line at the level of the umbilicus, while keeping the conventional left port midway between the anterior axillary line and the central camera port. This modification allows two 5 mm instruments to be used for left-sided dissection, making it much easier, faster, and with fewer complications. The additional port is considered a small disadvantage, but it offers improved reach to anatomical landmarks, can provide an additional “hand” for mesh manipulation, and is cosmetically more acceptable than placing ports more superiorly.
Robotic-Assisted Laparoscopic Surgery (RALS):
- While RALS offers advantages like 3D vision and precise movements, it has unique complications. Port-site incisional hernia (PIH) is an uncommon complication, with most reports linked to ports larger than 10 mm. However, 8-mm PIH can occur, particularly when robotic trocars are positioned more laterally (where abdominal fascia weakens) and in thin patients. This is partly due to the conical movement of robotic ports, which can widen the abdominal wall defect. The sources suggest that all fascia at 8-mm trocar sites should be closed laparoscopically under direct vision after RALS to prevent PIH, often using techniques like the laparoscopic extraperitoneal suture approach.

Interplay with Laparoscopic Entry Techniques

The choice of entry technique (Hasson, Veress, Direct Trocar Insertion, etc.) can directly influence or be influenced by port positioning decisions:

Direct Trocar Insertion (DTI): DTI, performed without prior pneumoperitoneum, involves direct insertion of the trocar through a skin incision. A study found DTI at the umbilicus to be 100% successful in a large cohort, without major intra-abdominal or visceral injuries. This suggests DTI is a viable method for initial port placement at common sites. The latest meta-analysis indicates DTI may be preferred over Veress needle and open methods, being associated with a lower risk of omental injury, failed entry, extraperitoneal insufflation, and visceral injury and infection at the trocar site. It is also reported as the fastest method.
Hasson Open Technique: This involves a mini-laparotomy incision and dissection under direct vision to enter the peritoneal cavity. While it allows direct visual control of port placement, evidence on its superiority in complication prevention compared to other techniques is conflicting.
Visual Entry Systems (Optical Trocars): These systems allow real-time visualisation of tissue layers during insertion. While they offer the advantage of minimising wound size and reducing insertion force, they are not superior in avoiding visceral and vascular injury. Despite visual control, some studies still report complications like bowel perforations with optical Veress systems, and a multicentre survey reported the highest incidence of major injuries with optical trocars. Their push-through design may still necessitate considerable axial force, and tissue compression can hinder layer recognition.
Radially Expanding Access Systems: These systems involve a small initial entry, followed by progressive dilation, aiming to eliminate sharp trocars and apply radial force. While some studies reported no major vessel injuries or deaths, the force required for entry is significantly greater than disposable trocars. They are not recommended as superior to traditional trocars.

Optimal laparoscopic port positioning is a multifaceted decision influenced by the specific surgical procedure, patient anatomy, and the chosen entry technique, all aiming to maximise surgical efficiency and minimise complications, though no single technique or position is entirely without risk.

Port-Site Incisional Hernia (PIH)

Port-Site Incisional Hernia (PIH) is a complication that can occur after laparoscopic procedures, including Robot-Assisted Laparoscopic Surgery (RALS), and can lead to serious adverse effects like intestinal obstruction.

Here’s what the sources say about PIH in the larger context of laparoscopic entry techniques:

Understanding Port-Site Incisional Hernia (PIH)

PIH is an uncommon complication following a laparoscopic procedure.
Its reported incidence ranges from 0.5% to 5%, with other reports estimating it at 21 per 100,000 laparoscopic surgeries. A study reviewing 4532 laparoscopies reported an incidence of only 0.2 per 1000 for umbilical adhesions.

Risk Factors for PIH

Inadequate Fascial Closure: Most PIH cases are attributed to inadequate fascial closure of the port site. Complete and secure sutures, including the peritoneum, are necessary for closing the trocar site.
Trocar Size: The incidence of PIH depends on the trocar size. Most reported PIH cases have been associated with trocars larger than 10 mm in diameter, while only 2.7% occurred with trocars less than 8 mm in diameter.
Increased Intra-abdominal Pressure: Obese patients are reported to be at a higher risk of developing PIH due to a tendency toward increased intra-abdominal pressure. However, some reports indicate that the risk of PIH does not change with a higher BMI.
Patient-Specific Factors:
- Age (60 years or older).
- Obesity (BMI of 28 kg/m2 or more).
- Diabetes.
- Presence of wound infection.
- Previous abdominal surgery or extremely high/low BMI can make laparoscopic entry more difficult and may show a higher rate of complications, though further studies are needed to assess specific entry techniques for these patient categories.
Operation-Specific Factors:
- Trocar type.
- Port diameter.
- Insertion position.
- Presence or absence of fascial closure.
- Thread type used for closure.
Robot-Assisted Laparoscopic Surgery (RALS) Specific Factors:
- In RALS, the port moves conically around the remote center, which can widen the diameter where the port passes through the peritoneum, making the abdominal wall defect larger than the port diameter.
- Robotic arms are often positioned more laterally than conventional laparoscopic ports, adhering to a “10-cm rule” to prevent arm collisions, especially in thin patients. This lateral placement can occur where the abdominal fascia weakens. For instance, two cases of 8-mm PIH in RALS involved thin patients and occurred in the lateral abdomen where the fascia weakens.

Prevention and Management of PIH

Fascial Closure:
- Closing port sites larger than 10 mm is a common practice due to the higher risk of PIH at these sites.
- For 8-mm trocar sites, while there has been debate, closing the fascia is now recommended, especially after cases of PIH occurring at these smaller sites in RALS.
- The laparoscopic extraperitoneal suture approach using a port closure needle (e.g., Endo Close™) is a method to securely close the fascia at 8-mm trocar sites under direct vision. This technique involves inserting a suture through the abdominal wall, retrieving it with forceps, and then ligating and closing the muscle layer and peritoneum outside the body.

Laparoscopic Entry Techniques and PIH Laparoscopic entry is the initial step in laparoscopic surgery, and it is associated with a significant portion of complications, with almost half of observed complications occurring during pneumoperitoneum creation. These complications can include wound infection, subcutaneous emphysema, extraperitoneal insufflation, and trocar site hernia (PIH).

Veress Needle Technique:
- This is the most established technique and involves initial insufflation of CO2 to create pneumoperitoneum before trocar insertion.
- A meta-analysis indicates that the Veress needle method is associated with a significantly higher risk of incisional hernia compared to the open method.
- It is also associated with higher risks of omental injury, failed entry, and extraperitoneal insufflation compared to the direct trocar method.
- The Veress needle method also tends to have a longer total time for entry compared to the direct trocar method.
Open (Hasson) Technique:
- This technique involves a mini-laparotomy incision at the umbilicus, dissecting down to the fascia, incising it, and entering the peritoneal cavity under direct vision.
- Compared to the Veress needle method, the open technique is associated with a lower risk of incisional hernia.
- However, compared to the direct trocar method, the open technique shows a higher risk of visceral injury and trocar site infection.
- The open method is generally considered the slowest entry method. It is favored by general surgeons and is often indicated in patients with previous abdominal surgery.
Direct Trocar Insertion (DTI):
- This technique involves inserting a sharp trocar directly into the abdomen without prior pneumoperitoneum. The abdominal wall is typically elevated by hand or with towel clips.
- A study suggests that DTI is a faster, safer, and more reliable alternative to the traditional technique for pneumoperitoneum establishment and should be used routinely.
- A meta-analysis indicates that the direct trocar method may be preferred as it is associated with a lower risk of omental injury, failed entry, and extraperitoneal insufflation compared to the Veress needle method.
- Furthermore, compared to the open method, the direct trocar method is associated with a lower risk of visceral injury and infection at the trocar site.
- DTI is considered the fastest abdominal entry method. It also reduces the number of blind steps from three (Veress needle, insufflation, trocar) to one (trocar).
- The DTI study by Tasneem et al. reported DTI was successful in 100% of 1913 patients with no intra-abdominal or visceral injuries (major or minor), and no gas leakage. Complications observed were abdominal wall hemorrhage (1.4%) and wound infection (1.9%).

While PIH can occur with any laparoscopic entry technique, specific factors like inadequate fascial closure, trocar size, and patient characteristics increase the risk. Among the entry techniques, recent meta-analyses suggest that the direct trocar method may be preferred due to its association with a lower risk of several complications, including certain types of injuries and infections, and its speed. The Veress needle method, despite its popularity, showed a higher risk of incisional hernia compared to the open method. The open technique, while potentially safer for vascular injuries, might carry a higher risk of bowel injury in some contexts and is slower. The importance of meticulously closing port sites, especially 8mm and 10mm or larger, is highlighted as a key preventive measure against PIH.