The Direct Optical Access: A Feasible, Reliable, and Safe Laparoscopic Entry



Access to the peritoneal cavity is the most crucial phase of laparoscopy, and fatal complications of laparoscopic surgery are related to first entry. The primary access- or trocar-related complications generally are underreported, and the true incidence may be higher than studies show. There is no clear consensus as to the optimal method of entry into the peritoneal cavity.


Bowel Injury Veress Needle Open Laparoscopy Trocar Insertion Visceral Slide 


  1. 1.
    Frishman G. Laparoscopic entry roundtable. J Minim Invasive Gynecol. 2009;16(4):400–7.PubMedCrossRefGoogle Scholar
  2. 2.
    Sharp HT, Dodson MK, Draper ML, Watts DA, Doucette RC, Hurd WW. Complications associated with optical-access laparoscopic trocars. Obstet Gynecol. 2002;99:553–5.PubMedCrossRefGoogle Scholar
  3. 3.
    Varma R, Gupta JK. Laparoscopic entry techniques: clinical guideline, national survey, and medicolegal ramifications. Surg Endosc. 2008;22(12):2686–97.PubMedCrossRefGoogle Scholar
  4. 4.
    Ahmad G, Duffy JMN, Phillips K, Watson A. Laparoscopic entry techniques. Cochrane Database Syst Rev. 2008;16:CD006583.Google Scholar
  5. 5.
    Cakir TTD, Esmaeilzadem S, Atkan AO. Safe Veress needle insertion. J Hepatobiliary Pancreat Surg. 2006;13:225–7.PubMedCrossRefGoogle Scholar
  6. 6.
    Shamiyeh A, Glaser K, Kratochwill H, Hörmandinger K, Fellner F, Wayand WU, et al. Lifting of the umbilicus for the installation of pneumoperitoneum with the Veress needle increased the distance to the retroperitoneal and intraperitoneal structures. Surg Endosc. 2009;23:313–7.PubMedCrossRefGoogle Scholar
  7. 7.
    Roy GM, Bazzurini L, Solima E, Luciano AA. Safe technique for laparoscopic entry into the abdominal cavity. J Am Assoc Gynecol Laparosc. 2001;8(4):519–28.PubMedCrossRefGoogle Scholar
  8. 8.
    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
  9. 9.
    RCOG Green-top Guideline. Preventing entry-related gynaecological laparoscopic injuries. 2008;49:1–10.Google Scholar
  10. 10.
    Hurd WH, Bude RO, DeLancey JO, Gauvin JM, Aisen AM. Abdominal wall characterization with magnetic resonance imaging and computed tomography. The effect of obesity on the laparoscopic approach. J Reprod Med. 1991;36:473–6.PubMedGoogle Scholar
  11. 11.
    Garry R. Towards evidence based laparoscopic entry techniques: clinical problems and dilemmas. Gynaecol Endosc. 1999;8:315–26.CrossRefGoogle Scholar
  12. 12.
    Hurd WW, Bude RO, DeLancey JO, Pearl ML. The relationship of the umbilicus to the aortic bifurcation: implications for laparoscopic technique. Obstet Gynecol. 1992;80:48–51.PubMedGoogle Scholar
  13. 13.
    Granata M, Tsimpanakos I, Moeity F, Magos A. Are we underutilizing Palmer’s point entry in gynecologic laparoscopy? Fertil Steril. 2010;94(7):2716–9.PubMedCrossRefGoogle Scholar
  14. 14.
    Richardson R, Sutton CJG. Complications of first entry: a prospective laparoscopic audit. Gynaecol Endosc. 1999;8:327–34.CrossRefGoogle Scholar
  15. 15.
    Vilos GA, Vilos AG. Safe laparoscopic entry guided by Veress needle CO2insufflation pressure. J Minim Invasive Gynecol. 2003;10:415–20.Google Scholar
  16. 16.
    Teoh BSR, Abbott J. An evaluation of four tests used to ascertain Veress needle placement at closed laparoscopy. J Minim Invasive Gynecol. 2005;12:153–8.PubMedCrossRefGoogle Scholar
  17. 17.
    Azevedo JL, Guindalini RS, Sorbello AA, Silva CE, Azevedo OC, Aguiar Gda S, et al. Evaluation of the positioning of the tip of the Veress needle during creation of closed pneumoperitoneum in pigs. Acta Cir Bras. 2006;21:385–91.PubMedGoogle Scholar
  18. 18.
    Kroft J, Aneja A, Tyrwhitt J, Ternamian A. Laparoscopic peritoneal entry preferences among Canadian gynaecologists. J Obstet Gynaecol Can. 2009;31:641–8.PubMedGoogle Scholar
  19. 19.
    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
  20. 20.
    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
  21. 21.
    Merlin TL, Hiller JE, Maddern GJ, Jamieson GG, Brown AR, Kolbe A. Systematic review of the safety and effectiveness of methods used to establish pneumoperitoneum in laparoscopic surgery. Br J Surg. 2003;90:668–79.PubMedCrossRefGoogle Scholar
  22. 22.
    Nezhat C, Cho J, Morozov V, Yeung Jr P. Preoperative periumbilical ultrasound- guided saline infusion (PUGSI) as a tool in predicting obliterating subumbilical adhesions in laparoscopy. Fertil Steril. 2009;91(6):2714–9.PubMedCrossRefGoogle Scholar
  23. 23.
    Bonjer HJ, Hazebrek EJ, Kazemier G, Giuffrida MC, Meijer WS, Lange JF. Open vs closed establishment of pneumoperitoneum in laparoscopic surgery. Br J Surg. 1997;84:599–602.PubMedCrossRefGoogle Scholar
  24. 24.
    Jansen FW, Kolkman W, de Bakkum EA, 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
  25. 25.
    Sasmal PK, Tantia O, Jain M, Khanna S, Sen B. Primary access-related complications in laparoscopic cholecystectomy via the closed technique: experience of a single surgical team over more than 15 years. Surg Endosc. 2009;23(11):2407–15.PubMedCrossRefGoogle Scholar
  26. 26.
    Brill AI, Nezhat F, Nezhat CH, Nezhat C. The incidence of adhesions after prior laparotomy: a laparoscopic appraisal. Obstet Gynecol. 1995;85:269–72.PubMedCrossRefGoogle Scholar
  27. 27.
    Weibel MA, Majno G. Peritoneal adhesions and their relation to abdominal surgery: a postmortem study. Am J Surg. 1973;126:345–53.PubMedCrossRefGoogle Scholar
  28. 28.
    Szomstein S, Lo Menzo E, Simpfendorfer C, Zundel N, Rosenthal RJ. Laparoscopic lysis of adhesions. World J Surg. 2006;30:535–40.PubMedCrossRefGoogle Scholar
  29. 29.
    Kumakiri J, Kikuchi I, Kitade M, Kuroda K, Matsuoka S, Tokita S, et al. Incidence of complications during gynecologic laparoscopic surgery in patients after previous laparotomy. J Minim Invasive Gynecol. 2010;17:480–6.PubMedCrossRefGoogle Scholar
  30. 30.
    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
  31. 31.
    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
  32. 32.
    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
  33. 33.
    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
  34. 34.
    Rabl C, Palazzo F, Aoki H, Campos GM. Initial laparoscopic access using an optical trocar without pneumoperitoneum is safe and effective in the morbidly obese. Surg Innov. 2008;15(2):126–31.PubMedCrossRefGoogle Scholar
  35. 35.
    Swank DJ, Bonjer HJ, Jeekel J. Safe laparoscopic adhesiolysis with optical access trocar and ultrasonic dissection. A prospective study. Surg Endosc. 2002;16:1796–801.PubMedCrossRefGoogle Scholar
  36. 36.
    McKernan JB, Finley CR. Experience with optical trocar in performing laparoscopic procedures. Surg Laparosc Endosc Percutan Tech. 2002;12:96–9.PubMedCrossRefGoogle Scholar
  37. 37.
    Hallfeldt KK, Trupka A, Kalteis T, Stuetzle H. Safe creation of pneumoperitoneum using an optical trocar. Surg Endosc. 1999;13:306–7.PubMedCrossRefGoogle Scholar
  38. 38.
    Jirecek S, Drager M, Leitich H, et al. Direct visual or blind insertion of the primary trocar. Surg Endosc. 2002;16:626–9.PubMedCrossRefGoogle Scholar
  39. 39.
    Angelini L, Lirici MM, Papaspyropoulos V, Sossi FL. Combination of subcutaneous abdominal wall retraction and optical trocar to minimize pneumoperitoneum-related effects and needle and trocar injuries in laparoscopic surgery. Surg Endosc. 1997;11:1006–9.PubMedCrossRefGoogle Scholar
  40. 40.
    String A, Berber E, Foroutani A, et al. Use of the optical access trocar for safe and rapid entry in various laparoscopic procedures. Surg Endosc. 2001;15:570–3.PubMedCrossRefGoogle Scholar
  41. 41.
    Madan AK, Menachery S. Safety and efficacy of initial trocar placement in morbidly obese patients. Arch Surg. 2006;141:300–3.PubMedCrossRefGoogle Scholar
  42. 42.
    Rosenthal RJ, Szomstein S, Kennedy CI, Zundel N. Direct visual insertion of primary trocar and avoidance of fascial closure with laparoscopic Roux-en-Y gastric bypass. Surg Endosc. 2007;21:124–8.PubMedCrossRefGoogle Scholar
  43. 43.
    Berch BR, Torquati A, Lutfi RE, Richards WO. Experience with the optical access trocar for safe and rapid entry in the performance of laparoscopic gastric bypass. Surg Endosc. 2006;20:1238–41.PubMedCrossRefGoogle Scholar
  44. 44.
    Liu CD, McFadden DW. Laparoscopic port sites do not require fascial closure when nonbladed trocars are used. Am Surg. 2000;66:853–4.PubMedGoogle Scholar
  45. 45.
    Shalhav AL, Barret E, Lifshitz DA, et al. Transperitoneal laparoscopic renal surgery using blunt 12-mm trocar without fascial closure. J Endourol. 2002;16:43–6.PubMedCrossRefGoogle Scholar
  46. 46.
    Hamade AM, Issa ME, Haylett KR, Ammori BJ. Fixity of ports to the abdominal wall during laparoscopic surgery: a randomized comparison of cutting versus blunt trocars. Surg Endosc. 2007;21:965–9.PubMedCrossRefGoogle Scholar
  47. 47.
    Sharp HT, Dodson MK, Draper ML, et al. Complications associated with optical-access laparoscopic trocars. Obstet Gynecol. 2002;99:553–5.PubMedCrossRefGoogle Scholar
  48. 48.
    Tsin DA, Tinelli A, Malvasi A, Davila F, Jesus R, Castro-Perez R. Laparoscopy and natural orifice surgery: first entry safety surveillance step. JSLS. 2011;15(2):133-5.PubMedCrossRefGoogle Scholar
  49. 49.
    Deffieux X, Ballester M, Collinet P, Fauconnier A, Pierre F. Risks associated with laparoscopic entry: guidelines for clinical practice from the French College of Gynaecologists and Obstetricians. Eur J Obstet Gynecol Reprod Biol. 2011;158(2):159-66PubMedCrossRefGoogle Scholar

Copyright information

© Springer-Verlag London Limited 2012

Authors and Affiliations

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

Personalised recommendations