Laparoscopic gynecologic surgery has been widely used with a range of benefits. However, there are complications that are related to the abdominal entry process. Serious complications are gastrointestinal tract and major blood vessel injuries. This review introduces the recent available literature to prevent and eliminate the laparoscopic entry complications. The open entry technique is associated with a significant reduction of failed entry, compared to the closed entry technique; however there is no difference in the incidence of visceral or vascular injury. Laparoscopic entry by the left upper abdomen (i.e., Palmer’s point) or the middle upper abdomen (i.e., the Lee-Huang point) could be considered in patients with suspected periumbilical adhesions or a history of umbilical hernia, or after three failed attempts of insufflation at the umbilicus. The Lee-Huang point has its own benefit for the operative laparoscopy in large pelvic pathologies and gynecology malignancy cases. The angle of Veress needle insertion varies from 45 in nonobese women to 90 in extraordinarily obese women. The high intra-peritoneal pressure entries, which range from 20 mmHg to 25 mmHg, minimize the risk of vascular injury. Therefore, this will not adversely affect the cardiopulmonary function in healthy women. The Veress intraperitoneal pressure (<10 mmHg) is a reliable indicator of correct intraperitoneal placement of the Veress needle.

The elevation of anterior abdominal wall for placement of a Veress needle increases the risks of failed entry and shows no advantage in regard to vascular or visceral complications. Surgeons should continue to increase their knowledge of anatomy, their training, and their experience to decrease laparoscopic complications.

Trocar Literature

Introduction

Laparoscopy has gradually become popular in gynecology practices because of its many benefits. A meta-analysis of 27 randomized controlled trials (RCTs) that compared laparoscopy and laparotomy for benign gynecological procedures, concluded that there is a 40% lower risk of minor complications after laparoscopic gynecology surgery than after laparotomy; however, the risks of major complications are similar.

1. Compared to laparotomy, laparoscopic surgery for benign ovarian tumors is associated with reduced surgical complications such as pain and hospitalization, according to the 2005 Cochrane review.

2. There was no difference between the procedures in regard to postoperative infections and tumor recurrence.However, the abdominal entry is a challenging procedure in laparoscopy because of serious complications such as gastrointestinal tract and major blood vessel injuries that account for 50% prior to the commencement of the intended surgery.

3. Most injuries are caused by the insertion of the primary trocar.

4. Increased morbidity and mortality occurs if neither the surgeon nor the patient acknowledge the injuries and treat them earlier.

5. The overall incidence of major injuries at the time of entry is 1.1/1000. Bowel injuries have occurred in 0.7/1000 laparoscopies and major vascular injuries in 0.4/1000 laparoscopies.

6. The incidence of bowel and major vessel injuries are low, but both of these types of injuries are potentially life-threatening, especially during the initial access. This article will review the principles of safe abdominal entry in laparoscopic surgery to minimize laparoscopic entry complications, based on the best available evidence.