https://en.wikipedia.org/wiki/Veress_needle

In standard laparoscopic surgeries, the closure method of the Veress needle for establishing the pneumoperitoneum is a textbook-level operation. However, when dealing with complex situations such as obesity, previous abdominal surgery history, abdominal wall hernias, or pregnant patients, the traditional puncture points and methods encounter severe challenges. At this time, the application of the Veress needle is no longer simply "one needle to access the abdomen," but has evolved into a meticulous game that integrates anatomy, mechanics, and imaging.

Challenge One: The "Thick-Walled Fortress" of Obese Patients

For patients with pathological obesity whose BMI exceeds 35, the thick subcutaneous fat layer and thickened rectus sheath make it impossible for the standard length Veress needle (such as 120mm) to reach the abdominal cavity. The needle tip may remain within the fat layer or muscle layer, causing "pre-peritoneum" or "pre-synovium" to inflate, resulting in a false pneumoperitoneum. This not only hinders subsequent procedures but may also cause subcutaneous emphysema or even gas embolism. The solutions include:

• Using a longer specification (such as 150mm) of the Veress needle;
• Choosing areas on the abdominal wall that are relatively thin and fixed, such as above the umbilicus or below the costal margin;
• Using ultrasound or CT for positioning to measure the distance from the skin to the peritoneum, achieving precise puncture;
• During the puncture process, using the "pulling the abdominal wall" method to increase the abdominal cavity volume and reduce the puncture distance.

Challenge Two: The "Maze Trap" for Patients with Adhesions

Patients with a history of abdominal surgery may have dense adhesions between the omentum, the intestinal tract, and the abdominal wall. During blind puncture, the adhered intestinal tract is fixed along the puncture path, losing its normal ability to slide and avoid, and is highly prone to being punctured by the Veress needle. This is one of the most worrying risks of the closed method. For such patients, the mainstream strategy is to abandon the closed method and instead adopt the open approach (Hasson method). However, if the conditions are restricted and the Veress needle still needs to be used, it is necessary to choose an area far from the original surgical scar (such as the left upper abdomen, the Palmer point, which is 3 cm below the midline of the left clavicle rib margin), where it is usually considered the "safe zone" with the least adhesions. In addition, preoperative CT three-dimensional reconstruction to assess the range and degree of adhesions can provide a key basis for selecting the optimal puncture point.

Challenge Three: "Squares of Space" for Children and Special Populations

Children have a small abdominal cavity, thin abdominal wall, and relatively concentrated internal organs. The standard Veress needle may cause excessive penetration due to its length and puncture force. Special pediatric Veress needles (with a shorter length, such as 80mm) and a smaller inflation flow rate are crucial. For pregnant patients, the enlarged uterus requires the puncture point to be moved upward accordingly. Usually, the umbilicus or the lower edge of the right rib margin is chosen to avoid damaging the enlarged uterus.

In conclusion, the application of Veress needle technique in complex cases has transcended the mere "pinching technique" and has risen to become an "entry strategy." It requires the surgeon to possess a solid anatomical foundation, a sharp ability to predict risks, and the wisdom to make flexible tool selections. There is no universal "universal puncture point" but only an "optimal plan" based on the individualized circumstances of the patient. In the future, with the development of intraoperative navigation and augmented reality technologies, it may be possible to visualize the puncture path of the Veress needle in real time, fundamentally eliminating the risk of blind puncture. However, this does not prevent us from having a profound understanding and cautious implementation of its application principles today.