- 1Laparoscopic entry using the Veress needle–pneumoperitoneum–trocar (or “closed”) technique is practised by the majority of gynaecologists worldwide (I).
- 2During closed entry, caudal umbilical displacement below the sacrum and great vessels facilitates intraperitoneal placement of the Veress needle and maximizes the success of entry and avoidance of injury (I).
- 3The Veress needle can be inserted intraperitoneally at umbilical or left upper quadrant sites. Left upper quadrant placement is associated with fewer attempts and fewer conversions to alternative sites (I).
- 4Initial Veress intraperitoneal pressure of <10 mm Hg is the most reliable indicator of correct Veress needle placement (I).
- 5Shielded trocars do not result in fewer visceral or vascular injuries during laparoscopic access (II-2).
- 6The blunt tip of the radially expanding trocars may provide protection from injuries, but the force required for entry is significantly greater than for disposable trocars (I).
- 7Single-use, push-through, optical trocars are not superior to blind methods of inserting trocars and do not avoid visceral or vascular injury (II-2).
- 8Reusable visual entry cannulas have no sharp or pointed trocar, minimize port wound size, and reduce insertional force; as a consequence, they may be safer than trocars (II-2).
- 9Direct trocar insertion is associated with fewer insufflation complications and failed entries. However, there is insufficient evidence to conclude that direct insertion is associated with fewer major complications (I).
- 10Open entry is neither superior nor inferior to other entry techniques. Open entry has a lower incidence of vascular injuries but a potentially higher incidence of bowel injury (I).
- 11Laparoscopy can be performed in pregnancy (II-2).
- 1Alternative insertion sites for the Veress needle (e.g., left upper quadrant [Palmer's point], transvaginal, or transuterine) should be considered (1) when an umbilical entry is considered complicated, based on patient history and characteristics (e.g., suspected or known periumbilical adhesions, history or presence of umbilical hernia, low or high body mass index) or (2) after 3 failed attempts at umbilical Veress needle insertion (I-A).
- 2Elevation of the abdominal wall during insertion of a Veress needle or primary trocar is not routinely recommended because it does not avoid visceral or vessel injury (II-2E).
- 3Because the position of the umbilicus in relation to the aortic bifurcation varies according to the patient's body mass index, the angle of insertion of the Veress needle at the umbilicus should be adjusted accordingly—from 45° in women of normal body mass to 90° in women with obesity (I-A).
- 4Previously recommended Veress needle safety checks or tests, such as the saline drop test and aspiration for fluid, have not been found to confirm position and therefore are no longer recommended as best practice (I-A).
- 5Wiggling the Veress needle from side to side should be avoided; this can increase the risk of complications (II-1E).
- 6It is appropriate to to leave the source of gas attached to the Veress needle so that the surgeon can use the pressure gauge to measure the intraperitoneal pressure (<10 mm Hg) as the most reliable indicator of correct placement of the Veress needle (I-A).
- 7The volume of CO2 insufflated with the Veress needle before trocar insertion should depend on intra-abdominal pressure. Adequate pneumoperitoneum insufflation should be determined by a pressure of 20–30 mm Hg rather than by CO2 volume (II-1 A).
- 8During entry using Veress needle insufflation, intraperitoneal pressure may be increased immediately before insertion of the trocars. Transiently high intraperitoneal pressure does not adversely affect cardiopulmonary function in healthy patients (II-1 A).
- 9The threaded, reusable, visual cannula may be considered a safer instrument for peritoneal entry than conventional trocars (II-2 B).
- 10Direct trocar insertion may be used in accordance with the surgeon's training, experience, and preference (I B).
- 11Open (Hasson) entry may be used in accordance with the surgeon's training, experience, and preference (II-2 C).
- 12Because there is no clear consensus on the optimal method of peritoneal entry, surgeons should use the technique with which they are most comfortable and experienced (II-2 C).
- 13In women requiring intra-abdominal surgery in pregnancy, Veress needle insufflation at the umbilical site can be employed until 14 weeks gestation (if there are no contraindications), and open (Hasson) entry or left upper quadrant insufflation are preferable after 14 weeks gestation (II-2 B). After 24 weeks gestation, an open (Hasson) entry is recommended (II-2 B).
ABBREVIATIONS:DTI (Direct trocar insertion), LUQ (Left upper quadrant), VIP (Veress intraperitoneal pressure)
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Weeks Gestation Notation: The authors follow the World Health Organization's notation on gestational age: the first day of the last menstrual period is day 0 (of week 0); therefore, days 0 to 6 correspond to completed week 0, days 7 to 13 correspond to completed week 1, etc.