First Abdominal Access in Gynecological Laparoscopy: Comparison of Techniques



The choice of a technique to enter the peritoneal cavity during a laparoscopy depends on diverse variables that do not foster any standardized method. It appears impossible to accurately define which is the best method for the first abdominal access in gynecological laparoscopy.


Veress Needle Fascia Transversalis Internal Oblique Muscle Optical Trocar Entry Technique 


  1. 1.
    Molloy D, Kaloo PD, Cooper M, Nguyen TV. Laparoscopic entry: a literature review and analysis of techniques and complications of primary port entry. Aust N Z J Obstet Gynaecol. 2002;42:246–54.PubMedCrossRefGoogle Scholar
  2. 2.
    Kaloo P, Cooper M, Molloy D. A survey of entry techniques and complications of members of the Australian Gynaecological Endoscopy Society. Aust N Z J Obstet Gynaecol. 2002;42:264–6.PubMedCrossRefGoogle Scholar
  3. 3.
    Munro MG. Laparoscopic access: complications, technologies, and techniques. Curr Opin Obstet Gynecol. 2002;14:365–74.PubMedCrossRefGoogle Scholar
  4. 4.
    Nazareno J, Ponich T, Gregor J. Long-term follow-up of trigger point injections for abdominal wall pain. Can J Gastroenterol. 2005;19:561–5.PubMedGoogle Scholar
  5. 5.
    Testut L, Jacob O. Trattato di Anatomia Topografica: Le pareti dell’addome. 1977.Google Scholar
  6. 6.
    Vellinga TT, De Alwis S, Suzuki Y, Einarsson JI. Laparoscopic entry: the modified alwis method and more. Rev Obstet Gynecol. 2009;2(3):193–8.PubMedGoogle Scholar
  7. 7.
    Chapron C, Pierre F, Harchaoui Y, Lacroix S, Beguin S, Querleu D, et al. Gastrointestinal injuries during gynaecological laparoscopy. Hum Reprod. 1999;14:333–7.PubMedCrossRefGoogle Scholar
  8. 8.
    Rongieres C, Gomel V, Garbin O, Fernandez H, Frydman R. C-reactive protein should accelerate the diagnosis of bowel injury after gynecologic surgery. J Am Assoc Gynecol Laparosc. 2002;9:488–92.PubMedCrossRefGoogle Scholar
  9. 9.
    Stany MP, Winter III WE, Dainty L, Lockrow E, Carlson JW. Laparoscopic exposure in obese high-risk patients with mechanical displacement of the abdominal wall. Obstet Gynecol. 2004;103:383–6.PubMedCrossRefGoogle Scholar
  10. 10.
    Neudecker J, Sauerland S, Neugebauer E, Bergamaschi R, Bonier HJ, Cuschieri A, et al. The European Association for Endoscopic Surgery clinical practice guideline on the pneumoperitoneum for laparoscopic surgery. Surg Endosc. 2002;16(7):1121–43.PubMedCrossRefGoogle Scholar
  11. 11.
    Vilos GA. The ABCs of a safer laparoscopic entry. J Minim Invasive Gynecol. 2006;13:249–51.PubMedCrossRefGoogle Scholar
  12. 12.
    Vilos GA, Ternamian A, Dempster J, Laberge PY, The Society of Obstetricians and Gynaecologists of Canada. Laparoscopic entry: a review of techniques, technologies, and complications. J Obstet Gynaecol Can. 2007;29(5):433–65.PubMedGoogle Scholar
  13. 13.
    Teoh B, Sen R, Abbott J. An evaluation of four tests used to ascertain Veres needle placement at closed laparoscopy. J Minim Invasive Gynecol. 2005;12:153–8.PubMedCrossRefGoogle Scholar
  14. 14.
    Riek S, Bachmann KH, Gaiselmann T, Hoernstein F, Marzusch K. A new insufflation needle with a special optical system for use in laparoscopic procedures. Obstet Gynecol. 1994;84:476–8.PubMedGoogle Scholar
  15. 15.
    McGurgan P, O’Donovan P. Optical Veress as an entry technique. Gynaecol Endosc. 1999;8:379–92.CrossRefGoogle Scholar
  16. 16.
    Noorani M, Noorani K. Pneumoperitoneum under vision—a new dimension in laparoscopy. Endo World. 1997;39-E:1–8.Google Scholar
  17. 17.
    Meltzer A, Weiss U, Roth K, Loeffler M, Buess G. Visually controlled trocar insertion by means of the optical scalpel. Endosc Surg Allied Technol. 1993;1:239–42.Google Scholar
  18. 18.
    Lecuru F, Leonard F, Philippe JJ, Rizk E, Robin F, Taurelle R. Laparoscopy in patients with prior surgery: results of the blind approach. JSLS. 2001;5:13–6.PubMedGoogle Scholar
  19. 19.
    Schaller G, Kuenkel M, Manegold BC. The optical “Veress-needle”–initial puncture with a minioptic. Endosc Surg Allied Technol. 1995;3:55–7.PubMedGoogle Scholar
  20. 20.
    Reich H, Ribeiro SC, Rasmussen C, Rosenberg J, Vidali A. High-pressure trocar insertion technique. JSLS. 1999;3:45–8.PubMedGoogle Scholar
  21. 21.
    Shamiyeh A, Glaser K, Kratochwill H, Hormandinger K, Fellner F, Wayand WU, et al. Lifting of the umbilicus for the installation of pneumoperitoneum with the Veress needle increases the distance to the retroperitoneal and intraperitoneal structures. Surg Endosc. 2009;23:313–7.PubMedCrossRefGoogle Scholar
  22. 22.
    Lam KW, Pun TL. Left upper quadrant approach in gynecologic laparoscopic surgery with reusable instruments. J Am Assoc Gynecol Laparosc. 2002;9:199–203.PubMedCrossRefGoogle Scholar
  23. 23.
    Golan A, Sagiv R, Debby A, Glezerman M. The minilaparoscope as a tool for localization and preparation for cannula insertion in patients with multiple previous abdominal incisions or umbilical hernia. J Am Assoc Gynecol Laparosc. 2003;10:14–6.PubMedCrossRefGoogle Scholar
  24. 24.
    Agarwala N, Liu CY. Safe entry technique during laparoscopy: left upper quadrant entry using the ninth intercostal space: a review of 918 procedures. J Minim Invasive Gynecol. 2005;12:55–61.PubMedCrossRefGoogle Scholar
  25. 25.
    Altun H, Banli O, Kavlakoglu B, Kücükkayikci B, Kelesoglu C, Erez N. Comparison between direct trocar and Veress needle insertion in laparoscopic cholecystectomy. J Laparoendosc Adv Surg Tech A. 2007;17:709–12.PubMedCrossRefGoogle Scholar
  26. 26.
    Dingfelder JR. Direct laparoscope trocar insertion without prior pneumoperitoneum. J Reprod Med. 1978;21:45–7.PubMedGoogle Scholar
  27. 27.
    Copeland C, Wing R, Hulka JF. Direct trocar insertion at laparoscopy: an evaluation. Obstet Gynecol. 1983;62:656–9.Google Scholar
  28. 28.
    Byron JW, Fujiyoshi CA, Miyazawa K. Evaluation of the direct trocar insertion technique at laparoscopy. Obstet Gynecol. 1989;74:423–5.PubMedGoogle Scholar
  29. 29.
    Jacobson MT, Osias J, Bizhang R, Tsang M, Lata S, Helmy M, et al. The direct trocar technique: an alternative approach to abdominal entry for laparoscopy. JSLS. 2002;6:169–74.PubMedGoogle Scholar
  30. 30.
    Woolcott R. The safety of laparoscopy performed by direct trocar insertion and carbon dioxide insufflation under vision. Aust N Z J Obstet Gynaecol. 1997;37:216–9.PubMedCrossRefGoogle Scholar
  31. 31.
    Gunenc MZ, Yesildaglar N, Bingol B, Onalan G, Tabak S, Gokmen B. The safety and efficacy of direct trocar insertion with elevation of the rectus sheath instead of the skin for pneumoperitoneum. Surg Laparosc Endosc Percutan Tech. 2005;15:80–1.PubMedCrossRefGoogle Scholar
  32. 32.
    Rahman MM, Mamun AA. Direct trocar insertion: alternative abdominal entry technique for laparoscopic surgery. Mymensingh Med J. 2003;12:45–7.PubMedGoogle Scholar
  33. 33.
    Prieto-Díaz-Chávez E, Medina-Chávez JL, González-Ojeda A, Anaya-Prado R, Trujillo-Hernández B, Vásquez C. Direct trocar insertion without pneumoperitoneum and the veress needle in laparoscopic cholecystectomy: a comparative study. Acta Chir Belg. 2006;106:541–4.PubMedGoogle Scholar
  34. 34.
    Biojo RG, Manzi GB. Safe laparoscopic surgery: tubal ligation without prior pneumoperitoneum. Surg Laparosc Endosc. 1995;5:105–10.PubMedGoogle Scholar
  35. 35.
    Lazarus HM. An alternative technique to create the pneumoperitoneum for laparoscopic surgery. Surg Laparosc Endosc. 1995;5:205–8.PubMedGoogle Scholar
  36. 36.
    McMahon AJ, Baxter JN, O’Dwyer PJ. Preventing complications of laparoscopy. Br J Surg. 1993;80:1593–4.PubMedCrossRefGoogle Scholar
  37. 37.
    Fletcher DR. Abdominal insufflation for laparoscopy: can the risks be reduced? Aust N Z J Surg. 1995;65:462.PubMedCrossRefGoogle Scholar
  38. 38.
    Hanney RM, Alle KM, Cregan PC. Major vascular injury and laparoscopy. Aust N Z J Surg. 1995;65:533–5.PubMedCrossRefGoogle Scholar
  39. 39.
    Byron JW, Markenson G, Miyazawa K. A randomized comparison of Veress needle and direct trocar insertion for laparoscopy. Surg Gynecol Obstet. 1993;177:259–62.PubMedGoogle Scholar
  40. 40.
    Agresta F, DeSimone P, Ciardo LF, Bedin N. Direct trocar insertion versus Veress needle in nonobese patients undergoing laparoscopic procedures: a randomized, prospective, single-center study. Surg Endosc. 2004;18:1778–81.PubMedCrossRefGoogle Scholar
  41. 41.
    Hasson HM. A modified instrument and method for laparoscopy. Am J Obstet Gynecol. 1971;110:886–7.PubMedGoogle Scholar
  42. 42.
    Chapron C, Cravello L, Chopin N, Kreiker G, Blanc B, Dubuisson JB. Complications during set-up procedures for laparoscopy in gynecology: open laparoscopy does not reduce the risk of major complications. Acta Obstet Gynecol Scand. 2003;82:1125–9.PubMedCrossRefGoogle Scholar
  43. 43.
    Decloedt J, Berteloot P, Vergote I. The feasibility of open laparoscopy in gynecologic-oncologic patients. Gynecol Oncol. 1997;66:138–40.PubMedCrossRefGoogle Scholar
  44. 44.
    Cravello L, Banet J, Agostini A, Bretelle F, Roger V, Blanc B. Open laparoscopy: analysis of complications due to first trocar insertion. Gynecol Obstet Fertil. 2002;30:286–90.PubMedCrossRefGoogle Scholar
  45. 45.
    Hasson HM, Rotman C, Rana N, Kumari NA. Open laparoscopy: 29-year experience. Obstet Gynecol. 2000;96:763–6.PubMedCrossRefGoogle Scholar
  46. 46.
    Jansen FW, Kolkman W, Bakkum EA, de Kroon CD, Trimbos-Kemper TC, Trimbos JB. Complications of laparoscopy: an inquiry about closed- versus open-entry technique. Am J Obstet Gynecol. 2004;190:634–8.PubMedCrossRefGoogle Scholar
  47. 47.
    Hasson HM. Open laparoscopy as a method of access in laparoscopic surgery. Gynaecol Endosc. 1999;8:353–62.CrossRefGoogle Scholar
  48. 48.
    Hasson HM, Rotman C, Rana N, Kumari NA. Open laparoscopy: 29-year experience. Obstet Gynecol. 2000;96:63–6.Google Scholar
  49. 49.
    Garry R. Towards evidence based laparoscopic entry techniques: clinical problems and dilemmas. Gynaecol Endosc. 1999;8:315–26.CrossRefGoogle Scholar
  50. 50.
    Ahmad G, Duffy JMN, Phillips K, Watson A. Laparoscopic Entry Techniques. Cochrane Database Syst Rev. 2008;16:CD006583.Google Scholar
  51. 51.
    Garry R. Surgeons may continue to use their chosen entry technique. Gynecol Surg. 2009;6:87–92.CrossRefGoogle Scholar
  52. 52.
    Long JB, Giles DL, Cornella JL, Magtibay PM, Kho RMC, Magrina JF. Open laparoscopic access technique: review of 2010 patients. JSLS. 2008;12:372–5.PubMedGoogle Scholar
  53. 53.
    Molloy D, Kalloo PD, Cooper M, Nguyen TV. Laparoscopic entry: a literature review and analysis of techniques and complications of primary port entry. Aust N Z J Obstet Gynaecol. 2002;42:246–54.PubMedCrossRefGoogle Scholar
  54. 54.
    Liu HF, Chen X, Liu Y. A multi-center study of a modified open trocar first-puncture approach in 17,350 patients for laparoscopic entry. Chin Med J. 2009;122(22):2733–6.PubMedGoogle Scholar
  55. 55.
    McKernan J, Finley C. Experience with optical trocar in performing laparoscopic procedures. Surg Laparosc Endosc. 2002;12:96–9.CrossRefGoogle Scholar
  56. 56.
    Tinelli A, Malvasi A, Hudelist G, Istre O, Keckstein J. Abdominal access in gynaecological laparoscopy: a comparison between direct optical and open access. J Laparoendosc Adv Surg Tech A. 2009;19:529–33.PubMedCrossRefGoogle Scholar
  57. 57.
    Tinelli A, Malvasi A, Guido M, Istre O, Keckstein J, Mettler L. Initial laparoscopic access in postmenopausal women: a preliminary prospective study. Menopause. 2009;16:966–70.PubMedCrossRefGoogle Scholar
  58. 58.
    Tinelli A, Malvasi A, Istre O, Keckstein J, Stark M, Mettler L. Abdominal access in gynaecological laparoscopy: a comparison between direct optical and blind closed access by Veress needle. Eur J Obstet Gynecol Reprod Biol. 2010;148:191–4.PubMedCrossRefGoogle Scholar
  59. 59.
    Tinelli A, Malvasi A, Guido M, Tsin DA, Hudelist G, Stark M, Mettler L. Laparoscopic entry in women with previous abdomino-pelvic surgery. Surg Innov. 2011; [Epub ahead of print].Google Scholar
  60. 60.
    Tai HC, Lai MK, Chueh SC, Chen SC, Hsieh MH, Yu HJ. An alternative access technique under direct vision for preperitoneoscopic pelvic surgery: easier for the beginners. Ann Surg Oncol. 2008;15(9):2589–93.PubMedCrossRefGoogle Scholar
  61. 61.
    Turner DJ. Making the case for the radially expanding access system. Gynaecol Endosc. 1999;8:391–5.CrossRefGoogle Scholar
  62. 62.
    Bhoyrul S, Mori T, Way LW. A safer cannula design for laparoscopic surgery: results of a comparative study. Surg Endosc. 1995;9:227–9.Google Scholar
  63. 63.
    Turner DJ. A new radially expanding access system for laparoscopic procedures versus conventional cannulas. J Am Assoc Gynecol Laparosc. 1996;3:609–15.PubMedCrossRefGoogle Scholar
  64. 64.
    Tarnay CM, Glass KB, Munro MG. Entry force and intra-abdominal pressure associated with six laparoscopic trocar cannula systems: a randomized comparison. Obstet Gynecol. 1999;94:83–8.PubMedCrossRefGoogle Scholar
  65. 65.
    Yim SF, Yuen PM. Randomized double-masked comparison of radially expanding access device and conventional cutting tip trocar in laparoscopy. Obstet Gynecol. 2001;97:435–8.PubMedCrossRefGoogle Scholar
  66. 66.
    Lam TY, Lee SW, So HS, Kwok SP. Radially expanding trocars: a less painful alternative for laparoscopic surgery. J Laparoendosc Adv Surg Tech A. 2000;19(5):269–73.CrossRefGoogle Scholar
  67. 67.
    Bhoyrul S, Payne J, Steffes B, Swanstrom L, Way LW. A randomized prospective study of radially expanding trocars in laparoscopic surgery. J Gastrointest Surg. 2000;4:392–7.PubMedCrossRefGoogle Scholar
  68. 68.
    Feste JR, Bojahr B, Turner DJ. Randomized trial comparing a radially expandable needle system with cutting trocars. JSLS. 2000;4:11–5.PubMedGoogle Scholar
  69. 69.
    Ternamian AM. Laparoscopy without trocars. Surg Endosc. 1997;11:815–88.PubMedCrossRefGoogle Scholar
  70. 70.
    Ternamian AM. A trocarless, reusable, visual-access cannula for safer laparoscopy; an update. J Am Assoc Gynecol Laparosc. 1998;5:197–201.PubMedCrossRefGoogle Scholar
  71. 71.
    Ternamian AM. A second-generation laparoscopic port system: EndoTIP. Gynecol Endosc. 1999;8:397–401.CrossRefGoogle Scholar
  72. 72.
    Ternamian AM, Deitel M. Endoscopic threaded imaging port (EndoTIP) for laparoscopy: experience with different body weights. Obes Surg. 1999;9:44–7.PubMedCrossRefGoogle Scholar
  73. 73.
    Ternamian AM. How to improve laparoscopic access safety: ENDOTIP. Minim Invasive Ther Allied Technol. 2001;10:31–9.CrossRefGoogle Scholar
  74. 74.
    Ternamian AM, Vilos GA, Vilos AG, Abu-Rafea B, Tyrwhitt J, MacLeod NT. Laparoscopic peritoneal entry with the reusable threaded visual cannula. J Minim Invasive Gynecol. 2010;17:461–7.PubMedCrossRefGoogle Scholar
  75. 75.
    Fuller J, Ashar BS, Carey-Corrado J. Trocar-associated injuries and fatalities: an analysis of 1399 reports to the FDA. J Minim Invasive Gynecol. 2005;12:302–7.PubMedCrossRefGoogle Scholar
  76. 76.
    Corson SL, Chandler JG, Way LW. Survey of laparoscopic entry injuries provoking litigation. J Am Assoc Gynecol Laparosc. 2001;8:341–7.PubMedCrossRefGoogle Scholar
  77. 77.
    String A, Berber E, Foroutani A, Macho JR, Pearl JM, Siperstein AE. Use of the optical access trocar for safe and rapid entry in various laparoscopic procedures. Surg Endosc. 2001;15:570–3.PubMedCrossRefGoogle Scholar
  78. 78.
    Tinelli A, Malvasi A, Schneider AJ, Keckstein J, Hudelist G, Barbic M, et al. First abdominal access in gynecological laparoscopy: which method to utilize? Minerva Ginecol. 2006;58:429–40.PubMedGoogle Scholar
  79. 79.
    Sharpe HT, Dodson MK, Draper ML, Watts DA, Doucette RC, Hurd WW. Complications associated with optical-access laparoscopic trocars. Obstet Gynecol. 2002;99:553–5.CrossRefGoogle Scholar
  80. 80.
    Bemelman WA, Dunker MS, Busch OR, Den Boer KT, de Wit LT, Gouma DJ. Efficacy of establishment of pneumoperitoneum with the Veress needle, Hasson trocar, and modified blunt trocar (TrocDoc): a randomized study. J Laparoendosc Adv Surg Tech A. 2000;10:325–30.PubMedCrossRefGoogle Scholar
  81. 81.
    Yerdel MA, Karayalcin K, Koyuncu A, Akin B, Koksoy C, Turkcapar AG, et al. Direct trocar insertion versus Veress needle insertion in laparoscopic cholecystectomy. Am J Surg. 1999;177:247–9.PubMedCrossRefGoogle Scholar
  82. 82.
    Jirecek S, Drager M, Leitich H, Nagele F, Wenzl R. Direct visual or blind insertion of the primary trocar. Surg Endosc. 2002;16:626–9.PubMedCrossRefGoogle Scholar
  83. 83.
    Marcovich R, Del Terzo MA, Wolf Jr JS. Comparison of transperitoneal laparoscopic access techniques: optiview visualizing trocar and Veress needle. J Endourol. 2000;14:175–9.PubMedCrossRefGoogle Scholar
  84. 84.
    Soderstrom RM. Basic operative technique. In: Soderstrom RM, editor. Operative laparoscopy: the masters’ techniques. New York: Lippincott Raven Press; 1998. p. 27–36.Google Scholar
  85. 85.
    Navarra G, Pozza E, Occhionorelli S, Carcoforo P, Donini I. One-wound laparoscopic cholecystectomy. Br J Surg. 1997;84:695.PubMedCrossRefGoogle Scholar
  86. 86.
    Vidal O, Valentini M, Ginestà C, Martì J, Espert JJ, Benarroch G, et al. Laparoendoscopic single-site surgery appendectomy. Surg Endosc. 2010;24(3):686–91.PubMedCrossRefGoogle Scholar
  87. 87.
    Uppal S, Frumovitz M, Escobar P, Ramirez PT. Laparoendoscopic single-site surgery in gynecology: review of literature and available technology. J Minim Invasive Gynecol. 2011;18(1):12–23.PubMedCrossRefGoogle Scholar
  88. 88.
    Nguyen NT, Slone J, Reavis K. Comparison study of conventional laparoscopic gastric banding versus laparoendoscopic single site gastric banding. Surg Obes Relat Dis. 2010;6(5):503–7.PubMedCrossRefGoogle Scholar
  89. 89.
    Canes D, Berger A, Aron M, Brandina R, Goldfarb DA, Shoskes D, et al. Laparo endoscopic single site (LESS) versus standard laparoscopic left donor nephrectomy: matched-pair comparison. Eur Urol. 2010;57(1):95–101.PubMedCrossRefGoogle Scholar
  90. 90.
    Symes A, Rane A. Urological applications of single-site laparoscopic surgery. J Minim Access Surg. 2011;7(1):90–5.PubMedGoogle Scholar
  91. 91.
    Fader AN, Levinson KL, Gunderson CC, Winder AD, Escobar PF. Laparoendoscopic single-site surgery in gynaecology: a new frontier in minimally invasive surgery. J Minim Access Surg. 2011;7(1):71–7.PubMedGoogle Scholar
  92. 92.
    Diana M, Dhumane P, Cahill RA, Mortensen N, Leroy J, Marescaux J. Minimal invasive single-site surgery in colorectal procedures: current state of the art. J Minim Access Surg. 2011;7(1):52–60.PubMedGoogle Scholar
  93. 93.
    Keltz MD, Lang J, Berin I. A 5-mm open-entry technique achieves safe, single-step, cosmetic laparoscopic entry. JSLS. 2007;11:195–7.PubMedGoogle Scholar
  94. 94.
    Piccinni G, Merlicco D, Centonze A, Sciusco A, Petrozza D, Testini M, et al. The semiopen first umbilical trocar access technique in laparoscopic surgery: easy and safe. J Laparoendosc Adv Surg Tech A. 2008;18(6):865–8.PubMedCrossRefGoogle Scholar
  95. 95.
    Dutta S. Early experience with single-incision laparoscopic surgery: eliminating the scar from abdominal operations. J Pedaitr Surg. 2009;44:1741–5.CrossRefGoogle Scholar
  96. 96.
    Stein RJ. Robotic Laparoendoscopic single-site surgery using gelport as the access platform. Eur Urol. 2010;57:132–7.PubMedCrossRefGoogle Scholar
  97. 97.
    Merchant AM. Transumbilical gelport access technique for performing single-incision laparoscopic surgery (SILS). J Gastrointest Surg. 2009;13:159–62.PubMedCrossRefGoogle Scholar
  98. 98.
    Kommu SS, Rane A. Devices for laparoendoscopic single-site surgery in urology. Expert Rev Med Devices. 2009;6:95–103.PubMedCrossRefGoogle Scholar
  99. 99.
    Cox DR, Zeng W, Frisella MM, Brunt LM. Analysis of standard multiport versus single-site access for laparoscopic skills training. Surg Endosc. 2011;25(4):1238–44.PubMedCrossRefGoogle Scholar
  100. 100.
    Varma R, Gupta JK. Laparoscopic entry techniques: clinical guideline, national survey, and medicolegal ramifications. Surg Endosc. 2008;22(12):2686–97.PubMedCrossRefGoogle Scholar

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© Springer-Verlag London Limited 2012

Authors and Affiliations

  1. 1.Department of Obstetrics and GynecologySanta Maria HospitalBariItaly
  2. 2.Department of Obstetrics and Gynecology, Division of Experimental Endoscopic Surgery, Imaging, Technology and Minimally Invasive TherapyVito Fazzi HospitalLecceItaly

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