Pneumoperitoneum can be established using a Veress needle or by an open approach. The open technique is generally preferred, as it minimizes the risks of inherent lesions to the small bowel. However, in obese patients, the Veress needle is used, as the thick subcutis does not allow visualization of the fascia through a 1-2cm incision.
Gaining Access with a Veress Needle
Incision of the skin (generally infraumbilical in the midline) and blunt dissection of the subcutaneous tissue
The fascia is grasped with a hook retractor or a Kocher clamp and is pulled anteriorly (A-1)
Before inserting the Veress needle, its correct functioning must be checked Insertion of the needle at a 90° angle to the abdominal wall. As the needle's spring-loaded safety mechanism crosses the abdominal fascia and then the peritoneum, two clicks are heard and are usually felt
Verification of the needle's intraperitoneal location by injecting 3 ml of saline with no resistance (A-2) followed by the "hanging drop" test (A-3) (i.e., a drop of saline is placed on the top of the needle, which is sucked into the needle when the abdominal fascia is lifted up)
Pneumoperitoneum. When a pressure of 13-15mmHg is reached, the Veress needle is withdrawn, and a sharp-tipped camera trocar is blindly inserted through the same incision
Gaining Access with the Open Technique
■ Incision of the skin (generally infraumbilical in the midline) and blunt dissection of the subcutaneous tissue
■ Incision of the fascia (1-2cm) and opening of the peritoneum with scissors (two sutures can be placed to lift up the abdominal wall and to later secure the port) (A-1)
■ Entry into the abdominal cavity is easily confirmed by inserting a finger
■ A blunt-tipped camera trocar is inserted and fixed with the two sutures if needed (A-2)
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