Scandinavian Journal of Surgery 96: 297–300, 2007
An open Access technique to creAte pneumoperitoneum
in lApAroscopic surgery
A.-c. moberg, u. petersson, A. montgomery
Department of Surgery, University Hospital of Malmö, Malmö, Sweden
Background: An open access technique might reduce severe vascular and visceral injuries.
An open access technique through the umbilical cicatrix tube has been developed as a
routine method with the goal to be easy, safe and used by all surgeons in patients with-
out a previous midline incision.
Aim: to evaluate the open technique in a prospective study in ��� consecutive laparo-
scopic operations regarding time for entrance, surgeons experience and bmi of the pa-
Methods: A midline incision from the linea alba up into the inverted umbilicus was
performed in the cicatrix tube and the peritoneum was penetrated allowing air to flow
into the abdominal cavity followed by a blunt trocar insertion.
Results: time for access was median 93 seconds. entrance time in patients with bmi >
3� (n = �8) was ��� sec and with bmi < 3� it was 9� sec (p = �,7�). the median time for
consultants was 88 sec and for residents �2� sec (p = �,��3). no gas leakage was seen.
prolonged time for access was seen in three patients; two equipment failures and one
Conclusion: the open access technique is applicable in all patients without a former
midline incision. it is fast, easy to learn with very few associated problems.
Key words: Open access; pneumoperitoneum; open laparoscopy; laparoscopy; open technique;
InTrODUCTIOn threatening. Injuries caused by blind port placement
might also be easier overlooked which might have
Laparoscopic surgery might produce technique spe- disastrous effects. Open access techniques reduce the
cific complications. The use of Veress needle followed incidence of vascular injuries to 0–0,03% (8).
by blind trocar placement, major injuries to large ves- Hasson introduced the open technique in 1971 but
sels like the aorta, iliaca artery/vein and the vena it did not become widely accepted perhaps because
cava have been reported in 0,003–0,08% of cases (2, 4, it requires a mini laparotomy, which can be difficult
8). Visceral injuries occur in 0,04–4% (2, 4, 8). Al- in obese patient’s (6). Other techniques for open ac-
though rare, theses complications are potentially life cess using the umbilical cicatrix were then described
by Pawanindra et al (11). This technique is considered
safe and simple and is performed in about 240 sec-
onds. The time required for the Veress needle access
Correspondence: is on average 214–300 seconds (1, 3, 5, 7).
Ann-Cathrin Moberg, M.D.
Department of Surgery At our department the Veress technique was aban-
University Hospital of Malmö doned in the late 1990’s and an open access technique
SE - 205 02 Malmö, Sweden similar to the Pawanindra method, using the umbili-
Email: address: firstname.lastname@example.org cal approach was developed (11). The goal was to
298 A.-C. Moberg, U. Petersson, A. Montgomery
create a safe open technique with a step-wise entrance layers is used as follows;. a towel clip is applied in the
to the abdominal cavity, usable in all patients without centre of the umbilicus, which is then inverted (Figs. 1, 2).
a previous midline laparotomy. The assistant applies downward traction, and a transverse
This study describes the operative technique and skin incision of a length corresponding to the diameter of
the trocar is made in the umbilical fold. The umbilical cica-
evaluates its efficiency and use in obese patients. trix tube is dissected sharply down to the linea alba. A
midline incision of appropriate length is made in the cica-
trix tube extending craniallys with care taken only to incise
MATErIAL AnD METHODS the fascialayer (Fig. 3). In obese patients, two S-shaped re-
tractors can be used to facilitate this approach. The perito-
OPErATIVE TECHnIqUE neum is opened bluntly and the negative pressure allows
air to flow into the abdominal cavity creating a distance
The technique can be applied supra or infra umbilically in between the peritoneum and the intestines by upward trac-
patients with no previous midline laparotomy or incisions tion with the towel clip (Fig. 4). The abdominal cavity is
including the umbilicus. A step-by-step entrance though all then visualised. Finally a blunt, 10 mm, reusable trocar is
placed through the incision into the abdominal cavity fol-
lowed by insertion of the camera (Fig. 5). The same tech-
nique can be applied in children using a 5 mm port. Insuf-
flation is then initiated for the creation of pneumoperito-
neum. If there is a problem with gas leakage, a towel clip
can be applied to the skin adjacent to the trocar.
At the end of the procedure, the towel clamp is again
placed in the centre and the umbilicus is inverted. The
fascia is exposed and closed with absorbable suture by an
X-stitch followed by an intracutaneous suture.
One hundred consecutive patients without previous mid-
line laparotomy were prospectively enrolled in the study.
The operations were mainly laparoscopic cholecystectomies
Time from skin incision to the camera visualising the
peritoneal cavity was recorded in seconds. The surgeon’s
Fig. 1. Midline section viewing the abdominal layers exposing the status, consultant or resident, and complications associated
fascia going up into the umbilicus after inversion. The abdominal with the open technique were registered. Age, sex and body
content follows the abdominal wall upward due to the negative mass index (BMI) was registered. Obesity was defined as
pressure caused due to traction created by the towel clamp. BMI > 30.
Fig. 2. Transverse skin incision after inversion of the umbilicus Fig. 3. Longitudinal fascial incision through part of the linea alba
exposing the pillar down to linea alba. and upwards in the umbilical pillar.
Open access in laparoscopy 299
Fig. 4. The peritoneum is penetrated using a blunt instrument al- Fig. 5. A blunt reusable trocar is inserted into the abdominal cav-
lowing air to flow into the abdominal cavity creating a distance ity during continued upward traction of the umbilicus in the space
between the peritoneum and intestines by upward traction with between the abdominal wall and the intestines.
the towel clamp.
Statistics curve had to be passed simultaneously by many sur-
geons resulting in an increase in major complications.
To detect a possible significant differences in operation time Vascular and visceral injuries became focus also for
between consultants and residents and the difference in
operation time for obese and non-obese patients the Mann-
the press in the early 1990ies. Champault et al de-
Whitney U test was used. scribed an incidence of vascular injuries of 0,04% and
visceral injuries of 0,06% in more than 100 000 pa-
tients using the Veress technique (5).
rESULTS A randomised controlled trial comparing blind ver-
sus open approach requires 10 000 patients in each
Median age was 46 years (range 7–84) and 65% were group to detect a difference in serious complications
females. Eighteen surgeons (9 residents) participated. and such a study does not exist. Guidelines from The
The consultants performed 68% of the operations. European Association for Endoscopic Surgerys con-
Median time for open access was 93 seconds (range clude that available data does not favour the use of
30–600). For consultants the median time was 88 sec either technique (11). However, they agree that major
(range 30–225) and for residents 120 sec (range 49– vascular injuries most often occur with the Veress
600) (p = 0,003). Eighteen patients were obese with a approach.
median BMI of 31 (range 30–43). In these patients A meta-analysis by Merlin et al found vascular in-
(n = 18) the median time for access was 100 sec (range juries in 0,003–1,33% using a blind technique and 0–
52–600) and in patients with BMI < 30 it was 90 sec 0,03% using an open technique, whereas visceral in-
(range 30–480) (p = 0,71). In 74% of the operations, juries were found in 0,04% using the blind technique
open access was achieved within 2 minutes, 15% in and in 0–1,3% using the open technique (10). Vascular
2–3 minutes and in 11% more than 3 minutes were injuries can possibly be avoided with an open tech-
required. nique and the meta-analysis indicates a trend towards
Gas leakage did not occur in any case. In two cases a reduced risk of major complications for the open
the time for open access was prolonged due to techni- access technique (10).
cal failure of the camera equipment and in one obese The open access technique was first described by
patient (BMI 37) the time to open access was 600sec. Hasson in 1971 and was recommended for patients
no injuries to intra-abdominal organs were seen. with previous laparotomies when adhesions were
expected (8). It required a midline incision of up to
3–4 centimetres. A special cone shaped trocar was
DISCUSSIOn used in order to minimise gas leakage. This method
did not gain wide acceptance due to its complexity.
The Veress needle followed by blind trocar placement Hurd et al demonstrated a modification of the Has-
or direct trocar insertion without creating pneumo- son technique without using special instruments, but
peritoneum are the most common approaches to ac- reported problems with gas leakage in 14% and an
cess the abdominal cavity in laparoscopic surgery (4, access time of 300 seconds compared to 230 sec using
5, 12). Laparoscopic surgery developed rapidly in the the Veress technique (9). Their conclusion was to rec-
early 1990ies among general surgeons, paediatric sur- ommend the use of the Veress technique routinely.
geons, gynaecologists and urologist’s. The learning Zaraca et al demonstrated a technique with a trans-
300 A.-C. Moberg, U. Petersson, A. Montgomery
verse fascial incision in the pillar of the umbilicus rEFErEnCES
with a total entry time of 288 seconds (15). Pawanin-
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described in this study (13). We have used this tech- tion vs Veress needle in nonobese patients undergoing lapa-
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opted among all 18 surgeons participating in this Kolbe A: Systematic review of the safety and effectiveness of
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In conclusion, the open access technique used in use of open laparoscopy: 1006 consecutive cases. J Laparoen-
this study is applicable in all patients without a previ- dosc Adv Tech 1999;9:75–80
ous laparotomy. It is fast and easy to learn with very
few associated problems. We strongly recommend
this technique for laparoscopic procedures. received: March 19, 2007
Accepted: October 11, 2007
Financial support from Helge B. Wulff´s foundation,
University of Lund, Lund, Sweden