Laparoscopic Core Techniques: Three Standard Approaches To Pneumoperitoneum Creation And Clinical Selection Strategies

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

With the rapid development of minimally invasive surgical techniques, laparoscopic surgery has become the mainstream operative modality in modern clinical surgery. Laparoscopic systems have been widely popularized in tertiary, secondary, and primary hospitals, covering most surgical procedures in general surgery, obstetrics and gynecology, thoracic surgery, and other disciplines. Since numerous senior scholars have elaborated on disease-specific laparoscopic techniques and operative details, this article avoids repetitive discussions on specialized surgical procedures. Instead, it focuses onpneumoperitoneum establishment, an essential and prerequisite core step for all laparoscopic operations. Based on years of clinical observation, hands-on experience, and updated industry guidelines, this paper systematically analyzes three standard pneumoperitoneum establishment techniques, including their operative procedures, indications, risk control, and clinical selection strategies.

As the fundamental prerequisite for successful laparoscopic surgery, stable and standardized pneumoperitoneum creates a sufficient and clear intra-abdominal operative space, isolates the abdominal wall from visceral organs, and effectively reduces intraoperative traction injury. Currently, three mainstream techniques are universally adopted for clinical pneumoperitoneum establishment: the Veress needle closed-entry method, the Hasson open-entry method, and the direct trocar puncture method. Each technique possesses unique advantages, limitations, and applicable scenarios, with no absolute superior solution for all clinical cases.

1. Veress Needle Closed-Entry Technique

Also known as the Veress needle-pneumoperitoneum-trocar access technique, this is the most classic and widely standardized laparoscopic entry method. It is primarily indicated for patients without a history of abdominal surgery and without preoperative abdominal adhesion risks, serving as the first-choice approach for routine minimally invasive laparoscopic procedures due to its minimal trauma, simple operation, and high efficiency.

Standard Operative Procedures

1. Incision preparation: The surgeon and assistant cooperatively fix the umbilical abdominal wall. A 2–3 cm curved elliptical skin incision is made at the supraumbilical or infraumbilical margin, limited to the skin and subcutaneous tissue. The fascia and peritoneum are kept intact to prevent premature intraperitoneal penetration and visceral injury. The umbilicus is the optimal primary port site due to its sparse vascular distribution, thin abdominal wall, and concealed postoperative scar.

2. Abdominal wall elevation and puncture positioning: Two towel clamps are symmetrically applied on both sides of the incision at the same horizontal plane, lifting the abdominal wall to a height of 5–7 cm to fully expand the potential peritoneal space. The surgeon inserts the Veress needle vertically or at a 45°–60° pelvic inclination with slow and uniform force. Two distinct breakthrough sensations can be detected during standard puncture: the first when penetrating the rectus fascia, and the second when crossing the peritoneum and entering the abdominal cavity, which serves as the key tactile indicator of successful needle placement.

3. Puncture verification (updated guideline standards): Traditional verification methods including fluid aspiration and saline drop tests are no longer recommended by the 2021 laparoscopic abdominal entry guidelines. Clinical evidence confirms that these auxiliary tests cannot accurately verify intraperitoneal needle position and carry a high false-negative rate. Currently, standardized clinical verification relies on real-time CO₂ insufflation parameters, stable intra-abdominal pressure changes, and symmetrical abdominal distension to confirm valid needle placement, ensuring higher accuracy and safety.

4. Pneumoperitoneum formation and main trocar insertion: After validating correct needle position, CO₂ is insufflated steadily to maintain a standard intra-abdominal pressure of 12–15 mmHg. Once stable pneumoperitoneum is established, the Veress needle is withdrawn gently. The main trocar is inserted along the original incision with mild steady force until a peritoneal breakthrough sensation is felt. The trocar is fixed after confirmed intraperitoneal placement to complete primary access establishment.

2. Hasson Open-Entry Technique

The Hasson open-entry technique is a direct visualization approach for pneumoperitoneum establishment, specifically designed for high-risk patients with previous abdominal surgery and elevated intra-abdominal adhesion risks. Direct visualization eliminates blind puncture injury to adhesed viscera, blood vessels, and intestinal tracts, delivering superior safety for complex cases. Its main drawbacks include a slightly larger incision, possible minimal intraoperative air leakage requiring suture tightening, and marginally prolonged operative time.

Standard Operative Procedures

1. Primary incision: A 2–3 cm curved skin incision is made at the supraumbilical or infraumbilical margin, with subcutaneous tissue dissected layer by layer to expose the linea alba and fascia while preserving peritoneal integrity.

2. Open abdominal entry under direct vision: The linea alba is longitudinally incised with a sharp scalpel. Curved hemostatic forceps are used to bluntly dissect and expand the peritoneal opening. The operative field is visualized thoroughly to exclude visceral adhesion and injury.

3. Trocar placement and sealing fixation: A blunt-tipped main trocar is inserted into the abdominal cavity under direct vision. A widely adopted clinical optimization technique is pre-placing two symmetrical【 】type silk sutures on both sides of the peritoneal incision without immediate knotting. This design stabilizes the main trocar intraoperatively to prevent displacement and facilitates rapid incision closure postoperatively, effectively reducing air leakage and shortening wound closure time.

3. Direct Trocar Puncture Technique

This technique achieves abdominal access and pneumoperitoneum establishment via one-step direct trocar puncture without preoperative Veress needle insufflation. It carries the highest intraoperative risk and has strict operative thresholds. It is strictly prohibited for junior and intermediate surgeons, and only permitted for senior surgeons with extensive laparoscopic experience (over 1,000 cases). Indications are limited to low-risk patients with standard body type, low BMI, thin abdominal wall, and no history of abdominal surgery or adhesion.

Body-Mass-Index-Based Puncture Angle Adjustment

Puncture angles require individualized adjustment according to patient physique: a 45° oblique angle is adopted for standard-weight patients, while a nearly 90° vertical angle is required for obese patients to penetrate the thickened abdominal wall completely and avoid subcutaneous trocar retention.

Standard Operative Procedures

1. Abdominal wall elevation and incision: The abdominal wall is lifted symmetrically with double towel clamps to maintain stable tension. A 2–3 cm standard umbilical incision is made to expose the puncture site.

2. Depth-controlled puncture: The trocar is held in the palm with the index finger limiting puncture depth. Slow rotational compression is applied for uniform penetration. Puncture is terminated immediately upon feeling the peritoneal breakthrough sensation to avoid excessive depth and deep visceral or vascular injury.

3. Laparoscopic confirmation: The assistant slowly inserts the laparoscope for immediate intraperitoneal visualization to verify complete trocar placement and exclude visceral or vascular injury before initiating CO₂ insufflation.

4. Port Placement Standardization and Neurovascular Protection Principles

Precise port placement is critical for minimizing laparoscopic complications. The umbilicus is routinely selected as the primary port for its sparse vascularity, concealed location, and superior cosmetic outcome. Auxiliary ports are conventionally placed two fingerbreadths above the anterior superior iliac spine on both sides and medial to the abdominal wall. This anatomical selection effectively avoids the main courses of the ilioinguinal nerve, iliohypogastric nerve, and inferior epigastric vessels, significantly reducing risks of nerve traction injury, vascular laceration, intraoperative hemorrhage, and postoperative abdominal numbness and pain.

Two core protective principles are enforced for high-risk lower abdominal puncture: avoiding anatomical nerve pathways and utilizing laparoscopic cold light transillumination to visualize subcutaneous and abdominal vascular distribution, so as to prevent vascular injury under direct visualization.

5. Clinical Selection Logic and Safety Summary

No single pneumoperitoneum establishment technique is universally superior. Clinical selection follows individualized principles, comprehensively considering the patient's surgical history, BMI, adhesion risk, abdominal wall anatomy, as well as the surgeon's operative experience and personal habits. Proficient mastery of all three techniques enables surgeons to handle diverse and complex laparoscopic scenarios safely and efficiently.

Although pneumoperitoneum establishment and trocar puncture are basic preliminary operations, they are high-risk links prone to severe laparoscopic complications. Blind puncture, excessive force, inappropriate angles, and misjudged access depth may lead to abdominal wall vascular injury, visceral contusion, intestinal perforation, and even emergency open conversion, seriously endangering patient safety.

Safety reminder: For junior and intermediate surgeons with fewer than 1,000 laparoscopic cases, patient safety is the absolute priority. Blind direct puncture should be strictly avoided. The safer Veress needle closed-entry or Hasson open visual-entry techniques are recommended to minimize operative risks and consolidate basic laparoscopic operative proficiency.