Access techniques: Veress needle--initial blind trocar insertion versus open laparoscopy with the Hasson trocar

The two most common techniques used to gain entry into the peritoneal cavity during laparoscopic general surgery are the blind Veress needle/trocar insertion and open trocar placement under direct visualisation. Once entry to the peritoneal cavity has been achieved, gas insufflation is used to establish pneumoperitoneum and enable visualisation of abdominal structures. Many of the complications associated with operative laparoscopy arise from creation of the pneumoperitoneum, such as subcutaneous emphysema and gas embolism, or from injury to internal structures during abdominal entry. Because of the relative infancy of laparoscopic general surgery, much of the information relating to these types of complications are associated with minimally invasive gynaecologic procedures. Compared to gynaecologic laparoscopy, general surgical interventions are typically more complicated, require longer operative times and a greater number of access sites, and are more likely to be performed in older patients. Therefore, complication rates associated with pneumoperitoneum or abdominal entry may actually turn out to be higher for laparoscopic general surgery, making selection of a blind versus open access technique more important. Two direct comparisons of these access approaches in laparoscopic cholecystectomy indicated that an open technique employing a peritoneal cut-down and trocar insertion under direct visualisation was safer than blind insertion of the Veress needle and primary trocar. We also favour the open access technique, believing that the risk for serious visceral or vascular complications is less than that with a blind approach.