Operational Strategies And Techniques For The Veress Needle in Diverse Scenarios

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

In laparoscopic surgery, Veress needle insertion is not a rigid, "one-size-fits-all" procedure. Facing patients of different ages, body habitus, and medical histories, the surgeon must act like an experienced artist-flexibly adjusting strategies and employing various techniques to achieve "successful access on the first attempt, ensuring safety and peace of mind." This article explores the application strategies and advanced techniques for using the Veress needle across different clinical scenarios.

I. The Standard Scenario: Normal BMI Patient with No Prior Surgery

For this most common patient group, the operation is relatively standardized.

• Entry Site:​ The base of the umbilicus is the preferred choice. It is a natural薄弱点 (weak point) where the abdominal wall is thinnest and vascularity is minimal.
• Patient Positioning:​ Supine.
• Operational Technique:
  1. Adequate Abdominal Wall Elevation:​ The surgeon or assistant should grasp the abdominal wall on both sides of the umbilicus or use two towel clamps to lift the skin cephalad. This creates a safety space of at least 5–10 cm between the wall and the underlying viscera.
  2. Insertion Angle:​ Hold the Veress needle at a 45–60-degree angle​ relative to the abdominal wall, directing it toward the sacral promontory (i.e., the pelvic cavity). Avoid vertical insertion.
  3. Slow Advancement:​ Advance steadily and gently with a rotary motion. Carefully perceive the "two pops"-the first through the rectus sheath, the second through the peritoneum. Entry into the peritoneal cavity yields a distinct sensation of "loss of resistance."
  4. Verification:​ Perform the hanging drop test or initiate low-pressure insufflation.

II. Challenge Scenario 1: The Obese Patient

Obese patients have an extremely thick subcutaneous fat layer, sometimes exceeding 10 cm. This can render standard-length Veress needles insufficient and dampen tactile feedback, making the "pop" sensation ambiguous.

• Adjusting the Entry Point:​ Select the "highest point" above or below the umbilicus. Sometimes, deviating from the umbilicus to the lateral border of the rectus abdominis is necessary, as the fat layer may be thinner there.
• Specialized Techniques:
  • "Long Needle" Strategy:​ Use a 120 mm or 150 mm long Veress needle.
  • Shallow Angle Insertion:​ Decrease the insertion angle (closer to 30–45 degrees) to increase effective penetration depth.
  • The "Swing Test":​ After insertion, gently rock the needle hub side-to-side. If intraperitoneal, the tip should swing freely; if embedded in tissue, movement will be restricted.
  • Pressure Monitoring:​ Initial insufflation pressure may be slightly higher (8–10 mmHg) in obese patients, but the pressure curve should stabilize. If pressure persistently exceeds 12 mmHg, suspect placement in the pre-peritoneal space.

III. Challenge Scenario 2: Patients with Prior Abdominal Surgery

This is a high-risk group for Veress insertion. Adhesions may tether bowel directly to the anterior abdominal wall, making any puncture potentially enteric.

• Consider Contraindications:​ For patients with multiple prior laparotomies or known extensive adhesions, strongly consider abandoning the Veress needle in favor of the open Hasson technique.
• Alternative Entry Sites:​ If the Veress must be used, select a site远离 (far from) the original surgical scar.
  • Left Upper Quadrant (Palmer's Point):​ Located 3 cm below the left costal margin in the mid-clavicular line. This area typically contains the greater curvature of the stomach, which is relatively empty and mobile, making it safer than potentially adhered bowel.
  • Right Upper Quadrant:​ Similar rationale applies, but care must be taken to avoid the liver edge.
• Operational Techniques:
  • "Two-Step Method":​ Use the Veress needle to penetrate the abdominal wall but do not rush to insufflate. Remove the stylet and pass a long, thin catheter or guidewire through the needle sheath into the abdomen. Then, dilate and place the first trocar over the wire. This allows for precise confirmation of peritoneal access.
  • "Visual Access" Technique:​ Use an optical Veress needle or a direct-viewing optical trocar to visualize the tissue layers in real-time, avoiding blind insertion.

IV. Special Scenarios: Pediatric and Geriatric Patients

• Pediatric Patients:​ Characterized by thin abdominal walls, small intraperitoneal volumes, and close organ proximity. Use shorter Veress needles (e.g., 80 mm), a shallower insertion angle, and lower insufflation pressures (6–8 mmHg). Abdominal wall elevation is paramount.
• Geriatric Patients:​ Often present with atrophied abdominal muscles and poor skin elasticity. The sensation of resistance during insertion is diminished, increasing the risk of over-penetration. Operate gently and monitor insufflator pressure closely.

V. Advanced Techniques and Reflections

• "Listening for Location":​ Some surgeons listen closely to the hub during insufflation. The sound of gas entering the peritoneal cavity is a distinct "hissing," unlike the muffled sound of gas entering subcutaneous tissue.
• "Water Injection Test":​ Inject a small amount of saline into the needle hub. If it flows in freely without resistance, the tip is likely intraperitoneal.
• Knowing When to Abandon:​ The most important skill is knowing when to stop. If you fail to confirm placement after 1–2 attempts, or if abnormalities arise (e.g., blood on aspiration, persistently high pressure), cease the attempt immediately and convert to the open Hasson technique. Persisting with an incorrect method is a primary cause of severe complications.

Conclusion

Veress needle insertion is a highly practical skill. As the saying goes, "Book knowledge is superficial; true understanding comes only from practice."Only through extensive clinical experience and the development of individualized strategies for diverse patients can one truly master this art, transforming the Veress needle into a safe and efficient instrument in the surgeon's hand.