Principles of safe laparoscopic entry

Laparoscopy is now the preferred approach for performing diagnostic procedures and therapeutic interventions in gynaecology. Minimally invasive surgery is less disabling, reduced hospital stay and more cost effective to health care systems, when compared with conventional open operations [1–6]. Although the risk of major complications does not significantly differ between benign gynaecological laparoscopic and conventional open procedures, laparotomy has been associated with a 40% higher risk of minor complications [6]. Most often the risk of complications during laparoscopy occurs during initial entry into the abdominal cavity. The rates of life-threatening complications at the time of abdominal entry are low – 0.4 gastrointestinal iatrogenic injuries and 0.2 major blood vessel injuries per 1000 laparoscopies [7]. However these represent approximately 50% of all serious laparoscopic complications [8] and laparoscopic medico-legal litigations (http://www. piaa.us/LaparoscopicInjuryStudy/pdf/PIAA_2000). Minor complications include extra-peritoneal insufflation, which also occurs prior to the initiation of the intended surgical procedure, and postoperative wound infection. On reviewing the published literature (gynaecology, urology, general surgery), it appears that most practitioners use one of three blind primary entry methods to access the peritoneal cavity during laparoscopic surgery: (1) the closed (classic or Veress needle) technique, (2) the open (Hasson) technique, and (3) the direct trocar insertion described by Dingfelder in 1978 [9,10]. Variations of these three techniques such as visual entry systems and radially expanding trocars are less frequently utilized. Evidence based risk management methods can be applied to deconstruct the primary abdominal entry into its three distinctly separate, interdependent and salient components; entry methods, entry instruments and entry sites [11]. Based on currently available data, no one abdominal entry method appears to be generally considered superior over another and recommended as the technique of choice [2,12–14]. However, in the large majority of trials, there is a type II error to detect complications. Since the complication rates are low, most trials are inadequately powered to detect statistically significant differences between the comparison techniques. For example, to show a difference in bowel injury rate of say 50%, i.e.