Hindawi Publishing Corporation

Diagnostic and Therapeutic Endoscopy

Volume 2012, Article ID 305428, 7 pages
doi:10.1155/2012/305428

Review Article
Comparison of Two Entry Methods for Laparoscopic Port Entry:
Technical Point of View

Adriana Toro, Maurizio Mannino, Giovanni Cappello,

Andrea Di Stefano, and Isidoro Di Carlo
Department of Surgical Sciences, Organ Transplantation, and Advanced Technologies, University of Catania,
Cannizzaro Hospital, Via Messina 829, 95126 Catania, Italy

Correspondence should be addressed to Isidoro Di Carlo, idicarlo@unict.it

Received 27 February 2012; Accepted 5 April 2012

Academic Editor: Andrea Tinelli

Copyright © 2012 Adriana Toro et al. This is an open access article distributed under the Creative Commons Attribution License,
which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Laparoscopic entry is a blind procedure and it often represents a problem for all the related complications. In the last three decades,
rapid advances in laparoscopic surgery have made it an invaluable part of general surgery, but there remains no clear consensus on
an optimal method of entry into the peritoneal cavity. The aim of this paper is to focus on the evolution of two used methods of
entry into the peritoneal cavity in laparoscopic surgery.

1. Introduction
Access into the abdomen is the one challenge of laparoscopy
that is particular to the insertion of surgical instruments
through small incisions. Laparoscopy is currently widely
used in the practice of medicine, for both diagnostic and
therapeutic purposes. The minimally invasive approach has
become the method of choice for treating most benign
abdominal diseases that require surgery. However, it is obvi-
ous that laparoscopic procedures are not risk free. Laparo-
scopic entry is a blind procedure, and it represents a problem
for all the related complications. Complications arising
from laparoscopic surgery are rare and commonly occur
when attempting to gain access to the peritoneal cavity
[1]. Creation of the pneumoperitoneum is the first and
most critical step of a laparoscopic procedure because that
access is associated with injuries to the gastrointestinal
tract and major blood vessels and at least 50% of these
major complications occurs prior to commencement of the
intended surgery. This complication rate has remained the
same during the past 25 years [2].
The number of vascular injuries in laparoscopy is 2 in
10.000 procedures and a serious complication associated
with mortality occurs in 3.3 per 100.000 [3]. Finding a safe
entry technique is a priority not only for the life of the
patients but also for the increasing rate. In the last three
decades, rapid advances in laparoscopic surgery have made
it an invaluable part of general surgery, but there remains no
clear consensus as an on optimal method of entry into the
peritoneal cavity.
There are two methods for creating a pneumoperi-
toneum, the closed technique and the open technique.
Although there is no consensus regarding the best method of
gaining access to the peritoneal cavity to create a pneu-
moperitoneum, the Veress needle insertion is the most fre-
quently used technique.
Aim of this paper is to focus on the evolution of the
most used methods of entry into the peritoneal cavity in
laparoscopic surgery with particular attention to patients
submitted to previous surgery without comorbidities.
2. Most Used Methods of Entry
Classic closed technique (Verres needle) [4] and open classic
technique (Hasson technique) [5] are the common most
procedures used in laparoscopy to entry into the peritoneal
cavity.
2.1. Verres Needle. The Verres needle is the oldest method,
developed by Dr. Verres in 1938 and it is the most used
2 Diagnostic and Therapeutic Endoscopy
technique especially in gynecological procedures. The users
of this technique describe this entry as easy and quick.
Commercially available Verres needles vary from 12 to
15 cm in length, with an external diameter of 2 mm. A bezel-
shaped tip enables the needle to pierce the tissues of the
abdominal wall. Upon entering the peritoneal cavity, the
resistance generated from the abdominal wall is overcome,
which permits the exposure of the interior needle with
its blunt atraumatic mandril [6]. This system affords a
degree of safety and efficacy, making the puncture of the
peritoneal cavity with a Verres needle an easy, fast, and
effective technique. Once the peritoneal cavity is inflated
by this technique, the first trocar can be inserted without
problems, minimizing intraoperative gas leakage and saving
surgical time.
Nevertheless, despite this safety device, incorrect insuf-
flations occur. Injuries to major vessels are the leading
intraoperative cause of death associated with laparoscopic
procedures [7]. The classic location of the Verres needle
puncture is the midline of the abdomen near the umbilical
scar. Due to the short distance between the anterior abdom-
inal wall and the retroperitoneal vascular structures in this
region, less than two centimetres in thin people, puncture
poses risks of injury to these large vessels [8]. The abdominal
aorta, the inferior vena cava, and the common iliac vessels
are especially vulnerable to lesions during puncture with the
Verres needle in proximity of the umbilical scar.
The needle relies on the ability of the blunt outer sheath
to retract while passing through tissue and to spring forward
in order to cover the sharp needle tip when tissue resistance
diminishes. The length of the Verres needle that should be
inserted in the abdominal cavity is not specified in any
scientific report. The use of a click sound associated with
the springing forward of the blunt stylet is recommended to
determine when to stop advancing the needle. Unfortunately
the quality of the sound is not always reliable because it
depends on many factors including ambient noise and the
extent of recoil in the needle spring function. The judgement
is subjective and it is neither quantifiable nor taught in
training. There are two important factors in the insertion of
a Verres needle. First the insertion should be not excessive to
avoid the risk of vascular injury. Second it should be adequate
to avoid extraperitoneal insufflation, because this will lead
to failure of the pneumoperitoneum with an associated
operative difficulty due to inappropriate distension of the
anterior abdominal wall and postoperative pain.
Tests can be performed before insufflation to verify
whether the Verres needle is correctly positioned, thus
avoiding injury.
Traditional texts recommend an insertion angle of 45◦
from horizontal in patients with a body mass index smaller
than 30 kg/m2 to avoid a vascular injury. Some Authors
report not having a problem with a vertical orientation of
the Vessel needle, provided that the umbilicus is significantly
elevated and the needle is only inserted a distance of approx-
imately 2 to 3 cm or until a negative pressure is encountered
[9].
Different methods are reported in literature to improve
the safety, for example the palpation of aorta [10], the
angling of the needle [11], the saline drop test [12], the
spinal needle test [13], imaging (CT and MRI), and the direct
measuring of the distance [14].
One of the major challenge in port entry is the
small bowel lesions. Usually adhesions of small bowel can
be detected by ultrasound. Characteristics of preoperative
abdominal ultrasound in predicting infraumbilical adhe-
sions have been determined in a study. The results were
that prevalence of infraumbilical bowel adhesions was 12%.
A visceral slide threshold <1 cm to predict adhesions had
sensitivity = 86%, specificity = 91%, positive predictive
value = 55%, and negative predictive value = 98%. Measuring
visceral slide improves preoperative prediction of both
presence and absence of bowel adhesions in patients with
previous abdominal operations of infections; this technique
may assist in avoiding iatrogenic bowel injury [15].
This study has been integrated by test with technique
of periumbilical ultrasound-guided saline infusion (PUGSI).
The technique as described below is one of the most used.
The presence or absence of visceral slide is demonstrated
using exaggerated inspiration/expiration after intubation.
Visceral slide in this investigation is defined in accor-
dance with Kodama’s original definition as the longitudinal
distance the intestines or omentum travels as visualized
by ultrasound during an exaggerated inspiration/expiration
cycle [16].
An abnormal test for the visceral slide is considered
a movement of viscera less than 1 cm. A normal test for
the viscera is movement equal to or greater than 1 cm.
Immediately after the visceral slide measurement, the PUGSI
test is conducted. A sterile 19-gauge spinal needle on a
syringe is advanced through the skin and subcutaneous layers
under ultrasound guidance at a 90◦ angle. Once beyond
the peritoneum, 8–10 mL of sterile normal saline is injected
under real-time ultrasound visualization. A normal test for
PUGSI is defined as dispersion of the infused saline without
fluid loculation. The formation of a fluid pocket or localiza-
tion indicated an abnormal test and suggests the presence of
obliterating subumbilical adhesions. An inconclusive test is
defined as one in which the physician is unable to definitively
determine the normality or abnormality of the test. In case
of difficulties to well understand the PUGSI results the
physician uses his clinical judgment to make decisions related
to the best method of entry. The PUGSI test was able to detect
all case of obliterating subumbilical adhesions, demonstrat-
ing sensitivity, and specificity of 100%. Use of both tests
preoperatively appears to be helpful in identifying patients
at risk for visceral injury during laparoscopic surgery [17].
Patients with previous abdominal surgery are more
prone to visceral injury caused by the Verres needle. This
is due to peritoneal adhesions, which typically grow where
the incision of the parietal peritoneum was made [18].
Autopsy studies have found adhesions in 74% to 95% of
patients with previous abdominal surgery. Midline incisions
greatly increase the risk of adhesions in the umbilical region.
Even incisions made away from the umbilicus may lead
to adhesion formation in the periumbilical region. On the
other hand, insertion of the Verres needle into the left
hypochondrium has been reported as safe, with reduced
Diagnostic and Therapeutic Endoscopy
risk of iatrogenic injury [19]. The stomach is immediately
below the anterior abdominal wall at the site where the
left hypochondrium puncture is made. If the stomach is
accidentally perforated, its contents will not necessarily leak.
This is due to the protection provided by the three layers of
gastric muscle, which tend to close the puncture.
A stomach perforation is easy to diagnose upon initial
inspection of the peritoneal cavity and can be repaired by
laparoscopic suture.
Recently another procedure has been developed to
calculate the length of the needle in order to avoid vascular
lesions when it is introduced into the peritoneal cavity. A
monogram has been developed to determine the length of
the Verres needle that could be safely introduced to achieve
the pneumoperitoneum reducing or eliminating the risk
of vascular injuries of the retroperitoneal vessels during
laparoscopic entry. Axial images of the magnetic resonance
imaging (MRI) have been used to measure the vertical
distance between umbilicus and retroperitoneal vessels to
develop this procedure [20].
Two vertical measurements have been calculated. The
first is the vertical distance from the skin at the pit of umbili-
cus to rectus sheath (STP). The second measurement is the
vertical distance from the skin at the pit of umbilicus to the
anterior surface of retroperitoneal vessel on the image (STR).
The abdominal cavity depth has been defined as the ver-
tical distance from rectus sheath at the level of umbilicus to
the anterior surface of retroperitoneal vessels (the difference
between the STP and STR). Two independent observers have
confirmed all measurements [20].
Using the mean regression line for STP (skin to peri-
toneum) a safe insertion distance has been identified and a
monogram has been developed which can be used to predict
objectively the depth of the peritoneal cavity.
Specific measures for the correct insertion and for the
reduction of the risk of injury of obese and thin patients
have to be improved. The Verres needle insertion at 45◦ from
the umbilicus means that needle has to traverse a distance
of 12–16 cm, which increases the risk of extraperitoneal
insufflation. This method using this nomogram gives a
measure of the safe distance in obese patients for vertical
insertion and it improves the success and safety of the
umbilical insufflation. The nomogram is also helpful in thin
patients as this reminds surgeon to be aware of the very short
distance (+2 cm) between umbilical skin and major vessels.
The only controversy of this technique is the need of MRI
for each patients, and its related time and cost.
The safe laparoscopic entry guidance should be dis-
seminated widely but not necessarily negate the risk of
laparoscopic entry-related injury, nor would it protect the
clinician against any ruling of negligence should a compli-
cation occur. Unless practice concurs with recommended
guidance, patients undergoing laparoscopy will be exposed
to increased unnecessary operative risk [21].
2.2. Hasson Technique. Hasson first described open laparo-
scopy in 1971 and it remains the favourite entry method for
many laparoscopic surgeons [5].
3
Some authors believe that trocar injuries to abdominal
viscera occur (a) when the viscera are unusually close to the
point of trocar insertion or (b) where the trocar penetrates
too far into the abdominal cavity as it is inserted. The former
can be anticipated when the patient has undergone a surgery
previously [2].
In this case for avoiding visceral injury can be used the
open Hasson technique or if the closed technique is used
to place the first trocar at a site remote from the previous
incision.The concept in the open technique is to create a
tiny incision, directly incise the layers of the abdominal wall,
directly cut the peritoneum and enter the abdomen. Since gas
can escape around the incision, an olive is placed over the end
of the trocar to occlude the incision, and sutures are placed
on the abdominal fascia and attached to the cannula [2].
The benefits of this method of entry are the prevention
of bowel injury caused of blind puncture with a needle
and subsequent trocar, gas embolism, avoid preperitoneal
insufflation and to have certainty of establishing a pneu-
moperitoneum, a very low incidence of vascular injuries, and
furthermore a correct anatomical repair of the abdominal
wall incision.
Reasons for limiting the use of the open technique
include greater time needed for performance, difficulty with
the technique, obese patients, and difficulty in maintenance
of the pneumoperitoneum.
Open procedures are commonly employed for high-risk
patients, like those with a previous abdominal surgery, in
particular midline incisions or obesity [22]. An additional
factor might be the higher incidence of complications early
on in the surgical learning curve. Safe access depends
critically on adhering to well-recognized principles of trocar
insertion, knowledge of abdominal anatomy, and recognition
of the hazards imposed by previous surgery.
Widespread use of this technique has been limited to
patients with previous lower abdominal surgery, pregnant
women, children, and very thin patients where little space
exists between the abdominal wall and the spine [2].
In experienced hands the open technique for to access the
abdominal cavity is necessary about three to ten minutes.
The open laparoscopic entry is considered particularly
safe in patients with previous abdominal surgery, especially
midline incisions. Vascular injuries are nearly entirely pre-
vented by the open entry technique, with anecdotal cases
of aortic laceration being reported. These injuries have been
attributed to an insufficient elevation of the abdominal wall,
with the skin incision passing directly through skin, fascia,
and into the underlying vessels [21, 23]. A factor accounting
for some of this disparity could be patient selection bias.
In literature are reported fewer injury of bowel and major
vascular injury using this technique than the Verres needle
technique.
A meta-analysis of 760,890 closed laparoscopy and
22,465 open laparoscopy cases reported that the incidence
of vascular injury rate in closed laparoscopy was 0.44%
compared with 0% in open laparoscopy. The incidence
of bowel injury was 0.7% compared to 0.5%, respectively.
The authors concluded that the open (Hasson) technique
eliminates the risk of vascular injury and gas embolism and
4 Diagnostic and Therapeutic Endoscopy
reduces the risk of bowel injury and recommend the open
technique to be adopted for primary laparoscopic entry [24].
Penfield noted a 0.06% incidence of bowel injury, but the
injuries were mostly partial and were recognised immediately
because of the proximity of the bowel to the wound [25].
Patients with previous abdominal surgery and those
known to have peritoneal adhesions present a higher risk
for peritoneal entry complication [26]. In this case the high-
risk patients must be preoperative informed of the possibility
of alternate entry method or the likelihood of conversion
to laparotomy. General surgeons in Canada use the open
primary entry technique, with the Hasson trocar and cannula
applied periumbilically to establish a pneumoperitoneum
for laparoscopic surgery [27]. In a review of 2010 patients
the Authors confirm previous reports of the low risk of
enterotomy, absence of fatal vascular injury, and comparable
rates of umbilical infection/hernia associated with an open
entry technique. The rapid recognition of enterotomy with
this entry technique and the utility of this technique in obese
patients or those with previous abdominal procedures are
additional advantages [28].
Hasson report his experience on 5,284 women who were
subjected to open technique for laparoscopic surgery and
have developed complications related to primary access.
Twenty-one patients had minor wound infections, four had
minor haematomas, one developed an umbilical hernia that
required surgery, and one had an inadvertent injury to
the small bowel that was repaired intraoperatively without
adverse outcome [29].
A new technique emphasizes the identification and the
incision of the point where the midline abdominal fascia
is fused with the base of the umbilicus. The importance of
the application of counter traction directly at the point of
insertion has been described in literature [30]. This method
allows the penetration under the direct vision with minimal
controlled axial force and without the requirement of fascial
sutures or other cumbersome aspects of the traditional open
technique.
Knowledge application of the anatomy of the umbilicus is
critical to this method of access. The use of a lateral incision
to the umbilicus allows ideal delineation of the umbilical
junction with the midline fascia, and a left-sided incision is
preferentially employed as this minimizes interference from
the falciform ligament. The success of this method depends
on identifying the single point where the umbilical fascia and
the peritoneum are fused. The Incision with suture scissors
of this point provides a rapid, safe, and easy access to the
peritoneal cavity. This technique has been used for more
than 1000 consecutive laparoscopic procedures over a 4-year
period and there was only one intraabdominal injury to
the small bowel in a patient with multiple previous midline
laparotomies and a prosthetic mesh closure [30].
Another technique consists in a transverse supra- or
subumbilical incision showing the umbilical cicatrix pillar
and the junction of the pillar with the linea alba. After
the incision (1 cm) at the junction of the umbilical cicatrix
pillar with the linea alba is possible to have the peritoneal
cavity opened [31]. This technique is safe, effective, easy to
learn, and quick to perform. The method clearly displays the
point on the abdominal wall where the peritoneum is tightly
fused and allows direct entry to the peritoneal cavity in the
majority of the cases, while the abdominal wall is kept tented
and away from the underlying viscera at all times [31].
Probably the safest initial entry site in high-risk patients
is the left upper quadrant, better known as Palmer’s point.
This site (3 cm below the left costal margin in the mid-
clavicular line) is rarely affected by adhesions, and with
splenomegaly and stomach distension being excluded it has
been shown to be safe [32, 33]. Molloy et al. in a meta-
analysis of 51 studies on techniques and complications of
primary port entry, the authors found that risks associated
with open entry are similar to those with direct entry. Left
upper quadrant entry is available but is more complicated in
obese patients and carries its own risks as well [34].
3. Discussion
Over the last two decades, rapid advances have made
laparoscopic surgery a well-established procedure. However,
because laparoscopy is relatively new, it still arouses contro-
versy, particularly with regard to the best method for the
creation of the pneumoperitoneum.
To establish the pneumoperitoneum, access to the peri-
toneal cavity can be gained through minilaparotomy and
insertion of a laparoscopic trocar or Hasson trocar. Alter-
natively, an optical trocar can be blindly inserted into the
peritoneal cavity, or a Verres needle may be inserted through
the abdominal midline. The latter is the most frequently used
technique.
In literature are reported various cases of injury to the
great vessels caused by the Verres needle. A report illustrates
the difficulty in correctly diagnosing this complication,
which is mainly due to the retroperitoneal position of the
vessels.
Major vascular injuries caused by the insertion of the
Verres needle into the abdominal midline occur even in the
hands of experienced surgeons. Schäfer et al. analyzed 26
major vascular injuries and reported that only four of them
(15%) had been caused by inexperienced surgeons (surgeons
who had performed fewer than 50 laparoscopic procedures).
The other 22 injuries (85%) had been caused either by
experienced surgeons (those who had performed between
51 and 100 procedures) or very experienced surgeons (over
100 procedures performed) [35]. Thus, it is essential that the
position of the needle tip after insertion be determined as
accurately as possible.
In addition, analysis of intraperitoneal pressure and
volume of gas insufflated at different time points during
insufflation is essential to prevent gas insufflation into sites
other than the peritoneal cavity. It has been established that
intraperitoneal pressure levels and the total volume of gas
insufflated into the peritoneal cavity at given time points can
be predicted, provided that the tip of the Verres needle is in
fact in the peritoneal cavity during insufflation [36].
No vascular injury was reported in a study investigating
3,041 patients submitted to blind insertion of the first trocar
Diagnostic and Therapeutic Endoscopy
through a midline incision at the umbilicus under intraperi-
toneal pressure of 25–30 mmHg [37]. This corroborates the
hypothesis that elevated intraperitoneal pressure protects the
intraabdominal structures from injury caused by the first
trocar. No injury caused by blind insertion of the first trocar
was reported in a study involving 1,150 patients submitted
to laparoscopy under intraperitoneal pressure of 25 mmHg
[38]. No clinical complications have been shown to arise
from transitory elevation of intraperitoneal pressure [37, 38].
However, it is known that extremely high levels of
intraperitoneal pressure for longer periods of time can cause
physiological and structural changes, directly related to the
tension levels caused by the high pressure. Studies have
demonstrated that patients submitted to high intraperitoneal
pressure for longer periods of time can present decreased car-
diac output, decreased venous return, increased mean arte-
rial pressure, increased systemic vascular resistance, altered
renal perfusion and glomerular filtration rate, and ischemia-
reperfusion injury of intraabdominal organs [39]. Therefore,
most authors have proposed that intraperitoneal pressure
remains at 12 mmHg and never above 15 mmHg during
laparoscopic procedures.
The Verres needle is typically inserted through the
abdominal midline, at the umbilicus. Albeit effective, inser-
tion of the Verres needle through the midline poses danger.
All injuries to the great vessels caused by the Verres needle
reported in the literature resulted from midline punctures in
the umbilical region [40]. Azevedo et al. claim that insertion
of the Verres needle into the left hypochondrium has been
reported as safe and effective and potential injuries are less
severe [38]. Nevertheless, it is essential that the position of
the needle after insertion be determined as accurately as
possible. Needle-positioning tests prior to insufflation have
been evaluated and considered adequate to guide surgeons
with regard to the correct positioning of the Veress needle
for creation of the pneumoperitoneum [41].
The objective of the study of Azevedo was to evaluate
five tests that are used to confirm the correct position of the
Verres needle inside the peritoneal cavity. The tests were (1)
aspiration test: aspiration using a 5 mL syringe with a Verres
needle. This test was considered positive when no material
was aspirated and negative when material was aspirated; (2)
injection test: injection of 5 mL of saline solution through
the Verres needle. This test was considered positive when
moderate resistance to liquid flow was observed and negative
when increased resistance to liquid flow was observed; (3)
recovery test: after injection of 5 mL of saline solution, aspi-
ration was performed, this test was considered positive when
the liquid injected was not recovered and negative when the
liquid was not recovered; (4) saline drop test: saline solution
was poured into the needle. Liquid flow was observed. This
test was considered positive when the liquid disappeared
immediately and negative when the liquid remained inside
the needle; (5) initial intraperitoneal pressure test. This
test was considered positive (needle correctly positioned
inside the peritoneal cavity with unobstructed side hole)
when initial intraperitoneal pressure was 8 mmHg or lower
during the first ten seconds of insufflation. When initial
intraperitoneal pressure was over 8 mmHg and remained this
5
way for ten seconds, test was considered negative (needle
incorrectly positioned inside the peritoneal cavity or ob-
struction of its side hole).
The five tests evaluated in this study are adequate to guide
surgeons with regard to the correct positioning of the Verres
needle for creation of pneumoperitoneum. These tests may
avoid iatrogenic injury and insufflation of gas into the wrong
site [41].
Although these tests and techniques may be helpful in
accessing the peritoneal cavity, the fact that visceral and
vascular injuries occur shows that they are not foolproof.
A study reported that complication rates during intro-
duction of Verres needle are one attempt 0.8–16.3%, two
attempts 16.31–37.5%, three attempts 44.4–64%, and more
than three attempts 84.6–100%. The complications associ-
ated were extraperitoneal insufflation, omental and bowel
injuries, and failed laparoscopy [42].
Merlin et al. reported on a systematic review that the
most common of the major complications associated with
access were bowel injuries [43]. The risk of bowel injury
in nonrandomized studies was higher with the open tech-
nique than with closed technique, although bias introduced
through patient selection may have been a factor. The
evidence on the comparative safety and effectiveness of the
different access methods was not definitive, but trends in the
data merit further exploration.
Chapron et al. reported on a nonrandomized comparison
of open versus closed laparoscopic entry practised by uni-
versity affiliated hospital teams. The bowel and major vessel
injury rates were 0.04% and 0.01% in the closed technique
and 0.19% and 0% in the open technique, respectively. They
concluded that open laparoscopy does not reduce the risk of
major complications during laparoscopic access [44].
Catarci et al. analysed a multicenter questionnaire survey
of general surgeons (57% responding) reported a relatively
high incidence of major injuries; the highest with optical
trocars (0.27%), the second highest with the closed technique
(0.18%, used 82% of the time), and the lowest with the
open technique (0.09%). Until 1997, no case of major
retroperitoneal vessel injury had been reported with the use
of a blunt Hasson’s cannula, which therefore was considered
to be absolutely safe, while the rate of vascular injury was
from 0.02% to 0.24% for closed technique. The rate of
visceral injury with closed technique varied from 0.03% to
0.15% with prevalence of injury to the gastrointestinal tract
(80%) greater than that for urinary tract (20%). With the
open technique, the same figure varied from 0% to 0.12%.
High rates of morality related to major injury (10–50%)
actually were reported in gynaecologic series, associated
mainly with delayed diagnosis and treatment [45].
Jansen et al. in clinical trials that compared closed
and open entry techniques, the complication rates were
0.07% and 0.17% for the closed and open techniques,
respectively. The number of entry-related complications with
the open technique was significantly higher than with the
closed technique. Hasson et al. [5] conclude “There is no
evidence to support abandoning the closed entry technique
in laparoscopy; however, the selection of patients for an open
or alternative procedure is still recommended” [46].
6 Diagnostic and Therapeutic Endoscopy
Meta-analysis failed to reveal any safety advantage of an
open technique when compared with a closed method of
entry, in terms of both visceral and major vascular injury.
It must be noted that the included randomised controlled
trials had insufficient power to effectively demonstrate an
advantage [47].
The rate of carbon dioxide embolism was 0.001% in
a review of 489 335 closed laparoscopies [48]. Several case
reports have detailed fatal or near-fatal coronary, cerebral,
or other gas embolism. Such a complication has not been
reported at open laparoscopy.
Tinelli et al. present a modified direct optical entry
(DOE) in patients previously undergone abdominal pelvic
surgery, compared with the classical open laparoscopy. The
authors suggest that DOE is as safe as open laparoscopy
and can be used in patients with previous abdomino-pelvic
surgery [49].
The use of Hasson technique has not cost due to the
complete surgical procedure do not need any disposable
device. On the opposite Verres needle has the cost of the
Verres disposable device permitting only one use. The cost of
complications varies depending on the type of complication.
The major complications are vascular injury and bowel
injury. The complete amount of the complication depends
from the operating room cost, the hospitalization duration
cost, and from the supplementary devices utilized for the
complication. The cost of operating room per hour is about
300C, while the cost of hospitalization is estimated at about
600C a day. In case of vascular injury the possible use of
prosthesis must be added, while in the case of intestinal
injury the possible use of the stapler should be added.
In our personal experience based on 750 laparoscopic
surgical procedure, 50 patients were previously undergone to
abdominal surgery. Between these patients only one reported
a minor intestinal injury during Verres procedure repaired
during the laparoscopic procedure injury.
In conclusion between two techniques was analysed the
Hasson technique that could be preferred in case of operated
patients without comorbidities.
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