JOURNAL OF LAPAROENDOSCOPIC SURGERY

Volume 2, Number 4, 1992

Mary Ann Liebert, Inc., Publishers

Brief Technical Report

A Simple, Safe Technique for Placement of the Veress
Needle and Trocar in Laparoscopy

THOMAS W. HILGERS, M.D., Dip. ABOG, ABLS, SRS

ABSTRACT

A simple technique of placing two Kocher clamps on the anterior rectus fascia for the elevation
of the anterior abdominal wall during the insertion of the veress needle and the laparoscopic
trocar is described in 243 consecutive patients. There were no failed insufflations during this
study and no cases of preperitoneal emphysema. The technique is simple to use and adds safety
to a basically blind procedure.

INTRODUCTION

techniques have been described to decrease the risks associated with closed laparoscopy.1
Various techniques
These are designed to reduce the risks and complications which might result in failed
attempts, inappropriate gas insufflation (pre-peritoneal emphysema), gas embolism, bladder or pelvic kidney
puncture, major vessel injury, and postoperative herniations.
This paper describes a simple adjunct to the elevation of the anterior abdominal wall that can be easily added
to one's technique and, in turn, improve the overall safety of the insertion phase of the laparoscopic procedure.

MATERIALS AND METHODS

A group of patients (n =
243) who were undergoing diagnostic laparoscopy for reasons mostly associated
with infertility or other reproductive disorders, were consecutively treated with the insertion technique
described below.
After having made an incision either horizontal or vertical in the immediate infraumbilical area, a medium
Kocher clamp was used to bluntly dissect free the subcutaneous tissue and make access to the anterior rectus
fascia. Verification of position on the anterior rectus fascia was obtained by manual palpation through the

Department of Obstetrics andGynecology, Creighton University School of Medicine, and Pope Paul VI Institute for the
Study of Human Reproduction, Omaha, NE.

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 HILGERS

FIG. 1. The Kocher clamps with a secure hold on the anterior rectus fascia without elevation of the anterior abdominal
wall.

incision with the index finger. The Kocher clamp was then placed on the anterior rectus fascia and the anterior
abdominal wall elevated. A second Kocher clamp was more securely placed just caudal to the first clamp
while the first clamp elevated the anterior abdominal wall. Once the second clamp was placed in this fashion,
the first clamp was repositioned to obtain a secure hold on the anterior rectus fascia. With both Kocher clamps
securely in place in this fashion (Fig. 1), the anterior abdominal wall was placed on strong traction and the
veress needle inserted at a 45 degree angle using the saline technique.
Records were kept of any problems or complications that might be observed with this technique, as well as
the number of attempts at insertion of the veress needle for entry into the intraabdominal cavity.

RESULTS

The data on this technique for 243 consecutive patients are presented in Table 1.
In no case was there a failed attempt, preperitoneal emphysema, or any of the usual entry problems. There
was one patient whose anterior rectus fascia was very thin and the Kocher clamps pierced into the
intraabdominal cavity during exploration for the anterior rectus fascia. However, this was discovered at the
time of entry into the abdominal cavity and, thus, closure of the Kocher clamps was avoided with no injury of
the bowel or other intraabdominal contents. That case proceeded without difficulty by replacing the Kocher
clamps on the anterior rectus sheath and then proceeding as usual.

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 PLACEMENT OF VERESS NEEDLE AND TROCAR

Table 1. Insertion of Veress Needle in Study Population

Consecutive Laparoscopies (N 243) =

A' %

False Entries 0 0.0

Insertions Successful 243 100.0
1 attempt 195 80.2
2-4 attempts 47 19.3
5 attempts 1 0.4
Multiple Attempts by Weight
150 lbs. or less (N =
146) 27 18.5
151 lbs. or more (N =
97) 24 24.7

DISCUSSION

When performing closed laparoscopy it is desirable to elevate the parietal peritoneum so that the veress
needle is inserted directly into the intraabdominal cavity without injuring any of its contents. Several
techniques have been used to accomplish this task. The most commonly used is the technique of grasping the
skin and subcutaneous tissue with one hand in the suprapubic position, thus elevating the anterior abdominal
wall. A second technique, also commonly used, is to place either towel clips or Alice clamps on the
periumbilical skin and then elevating the abdominal wall in this fashion.
It has been the author's experience and the experience of others2 that elevating the abdominal wall in this
fashion does not always appear to provide a consonant elevation of the parietal peritoneum. With these
techniques, the skin and subcutaneous tissues are mostly elevated with only minimal elevation of the parietal
peritoneum, while the distance from the skin to the peritoneum may actually be increasing the risk of
preperitoneal insertion.
By placing the Kocher clamps on the anterior rectus sheath, one can obtain a secure hold on the anterior
rectus fascia and obtain an excellent elevation of the anterior abdominal wall and, with it, the parietal
peritoneum (Fig. 2). This provides several additional centimeters of room in the immediate vicinity of the

FIG. 2. The Kocher clamps with a secure hold on the anterior rectus fascia obtaining an excellent elevation of the
anterior abdominal wall and, with it, the parietal peritoneum.

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 HILGERS

veress needle insertion and clearly increases the margin of safety when inserting both the veress needle and
subsequently the laparoscopic trocar.
In this consecutive group of patients there were no failures of insertion of the veress needle and introduction
of the carbon dioxide gas or, for that matter, the introduction of the trocar. Perhaps the most common problem
observed, and one which is not quantifiable, is the placement of the Kocher clamps on the pre-fascial
subcutaneous tissue instead of on the fascia. Thus, the operator must be careful in the placement of the Kocher
clamps to make certain that they are tightly and securely on the fascia. If the Kocher clamps are placed more
on the pre-fascial subcutaneous tissue they will not hold as strongly; and when inserting either the veress
needle or the trocar, there may be a tendency to slip. This tendency exists with other techniques as well, but
with proper placement of the Kocher clamps this can be eliminated.
Therefore, from a technique point of view, it is important for one to pay attention to the security of the
Kochers as they are being held during the insertion of either the veress needle or the trocar. If there is any
tendency for the Kocher clamp to be on the pre-fascial subcutaneous tissue, that will exhibit itself with some
slight slipping of the Kochers at a time when you can stop the procedure, reidentify the fascia, and replace the
Kocher clamps.
This technique was originally developed for patients who were difficult to laparoscope, especially the obese
patient. However, after gaining experience with the technique, it was felt that it significantly improved the
safety of the procedures and, since laparoscopy is basically a blind procedure, the addition of a technique such
as this was welcomed and now used universally on all patients.
This technique is easy to use and easy to add to one's practice. Some attention to detail is necessary, but the
security of a firm hold on the anterior abdominal wall improves the confidence with which the procedure is
performed.

REFERENCES

1. Hasson HM: Open techniques for equipment insertion. In: Manual ofEndoscopy, Martin DC, Holtz GL, Levinson CJ,
Soderstrom RM (Eds). Santa Fe, CA: The American Association of Gynecologic Laparoscopists; 1990:23.
2. KleppingerRK: Closed Techniques for Equipment insertion. In: Manual of Endoscopy, Martin DC, Holtz GL,
Levinson CJ, Soderstrom RM (Eds). Santa Fe, CA: The American Association of Gynecologic Laparoscopists;
1990:15.

Address
reprint requests to:
Thomas W. Hilgers, M.D., Dip. ABOG, ABLS, SRS
Senior Medical Consultant
Obstetrics, Gynecology and Reproductive Medicine
Pope Paul VI Institute
For the Study of Human Reproduction
6901 Mercy Road
Omaha, NE 68106

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