Techniques to Access the
Peritoneal Cavity for Laparoscopic Procedures
D. Dean Potter, MD, and Michael L. Kendrick, MD
T his issue of Operative Techniques in General Surgery
focuses on the surgical aspects of laparoscopic proce-
dures. Currently, many procedures that were routinely
performed in an open fashion are now amenable to mini-
mally invasive techniques. To complete these minimally
invasive procedures safely, the peritoneal cavity must be
accessed without injury to major vascular or visceral struc-
tures or to vessels within the abdominal wall. This article
focuses on the incidence of complications associated with
accessing the peritoneal cavity for laparoscopic proce-
dures and the three most common methods for establish-
ing pneumoperitoneum— closed Veress insufflation, the
open Hasson technique, and optical trocar placement.
Complications
Injury to vascular or visceral structures may occur regard-
less of the method of peritoneal access largely because of
the close proximity of the abdominal wall to the great
vessels of the retroperitoneum and viscera.
Major vascular injuries have been reported to occur in
0.02% to 0.5% of laparoscopic procedures (Table 1).1-3
The most commonly injured vessels are the abdominal
aorta, inferior vena cava, and iliac vessels. Additionally,
injury of mesenteric or omental vessels have been re-
ported. A recent study of Medical Device Reports main-
tained by the Center for Devices and Radiological Health
reported 32 deaths from trocar injuries from 1993 to
1996.2 Twenty-six (81%) of these deaths were the result of
injury to vascular structures. Catarci et al surveyed 28
centers in Italy regarding methods of peritoneal access and
associated complications. Based on data from responding
centers, they found the open Hasson technique to have an
Department of Surgery, Division of Gastroenterologic and General Surgery,
Mayo College of Medicine, Mayo Clinic, Rochester, MN.
Address reprint requests to Michael L. Kendrick, MD, Department of Sur-
gery, Division of Gastroenterologic and General Surgery, Mayo College
of Medicine, Mayo Clinic, 200 First Street SW, Rochester, MN 55905.
E-mail: kendrick.michael@mayo.edu.
1524-153X/05/$-see front matter © 2005 Elsevier Inc. All rights reserved.
doi:10.1053/j.optechgensurg.2004.12.007
overall complication rate of 0.09%, which was signifi-
cantly lower than that of the Veress (0.18%) and optical
trocar techniques (0.27%).4
Injury to visceral structures including the alimentary
tract, liver, omentum, bladder, uterus, pancreas, and ure-
ters has a reported incidence of 0.06% to 0.12% (Table 1).
These injuries are more likely to occur in patients who
have had prior abdominal operations or adhesions to the
abdominal wall. Many of these injuries are unrecognized
at the time of laparoscopy and result in significant mor-
bidity and mortality. Death due to unrecognized bowel
injury occurred in 6 patients (accounting for 19% of 32
total deaths), according to Medical Device Reports.2
The incidence of injury to vessels of the abdominal wall
has not been widely reported. These injuries commonly in-
volve the inferior epigastric artery and are commonly related
to the positioning of secondary ports. Although these injuries
seem to be trivial, they can account for significant morbidity
from blood loss and hematoma formation or may require
open exploration to control hemorrhage.
Techniques to reduce vascular, visceral, or abdominal wall
injuries must be used for every laparoscopic procedure. First,
visualization of subcutaneous vessels may be improved by
transillumination. Second, stabilization by anterior retrac-
tion of the abdominal wall to maximize the distance from the
fascia to the major vascular structures of the retroperitoneum
and viscera should be used. This can be achieved by placing
perforating towel clamps on the skin or Kocher clamps on the
fascia and retracting anteriorly. Third, an adequate skin inci-
sion should be made to reduce resistance from the skin while
inserting the trocar. Fourth, a firm, twisting force should be
applied to the trocar. Common etiologies for excessive force
may be an inadequate skin incision or inadequate stabiliza-
tion of the abdominal wall. Fifth, the trocar should be di-
rected away from major vascular structures. Finally, gentle
force should halt when resistance from the abdominal wall
ceases.
Table 1 Reported Incidence of Major Vascular and Visceral
Injuries Following Laparoscopic Trocar Insertion
Vascular Visceral
injuries injuries
Reported incidence 0.04%-0.5% 0.06%-0.12%
3
4 D.D. Potter and M.L. Kendrick
Surgical Techniques
A. Closed Veress Needle
Current Veress needles consist of an outer hollow cutting
needle connected to a Luer adaptor with an inner blunt ob-
turator that deploys when resistance ceases (Fig. 1). An ade-
quate skin incision is made and the fascia exposed by blunt
dissection. The abdominal wall is stabilized by either perfo-
rating towel clamps on the skin or Kocher clamps placed on
the fascia. The needle is grasped at the Luer adaptor to allow
the spring obturator to function. The needle is introduced
into the peritoneal cavity with gentle force. When placing the
needle through the midline, two distinct points of resistance
are met—the fascia and the peritoneum. Three points of re-
sistance may be met when placing the needle more laterally
(ie, anterior rectus fascia, posterior rectus fascia, and perito-
neum). After passing the final point of resistance, air is aspi-
rated. If blood, succus, or stool is aspirated, the needle has
been incorrectly positioned. If air is aspirated, a small amount
of saline is injected and the syringe removed. The saline
should freely flow into the abdomen. An insufflation hose
may be connected and carbon dioxide low flow (2 mL/s)
started. If high filling pressures are encountered, the needle
may lie in the preperitoneal space or abut an intra-abdominal
structure. Gentle repositioning may relieve the obstruction. If
repositioning is unsuccessful, the needle is withdrawn and
the process is restarted. Percussion of the abdominal wall
assists in determining establishment of pneumoperitoneum.
Once the desired level of pneumoperitoneum has been ob-
Figure 1 Veress needle. (Reproduced with permission from the Mayo
Foundation for Medical Education and Research. All rights reserved.)
tained, insufflation is stopped, the needle is withdrawn, and
a safety-shielded trocar is placed. The insufflation hose is
connected to the trocar and the camera is inserted.
B. Open Hasson Technique
The open Hasson technique may be used to establish
pneumoperitoneum from any area of the abdomen and has
been suggested to be the safest method for accessing the
peritoneum laparoscopically. First, an adequate skin inci-
sion is created and the fascia is exposed by blunt dissec-
tion. Retractors are placed laterally to provide adequate
exposure. One or two Kocher clamps are placed on the
fascia for stabilization. The fascia is divided by electrocau-
tery, and the retractors are repositioned under the fascia.
At this time, fascial sutures may be placed to secure the
Hasson trocar after insertion. The peritoneum is grasped
between two tissue forceps and opened sharply. The Has-
son trocar is placed into the peritoneum under direct vi-
sion (Fig. 2). The balloon is inflated or the trocar secured
with fascial sutures, and the insufflation hose is connected.
Once adequate pneumoperitoneum has been achieved, a
camera may be inserted.
An adapted Hasson technique for placement of infra-umbili-
cal port sites is used frequently at the Mayo Clinic. This tech-
nique uses the anatomic features of the median umbilical liga-
ment. The base (“bottom of the pit”) of the umbilicus is grasped
with a Kocher clamp and gently everted. The umbilicus is re-
tracted anteriorly and cephalad. A 10-mm infra-umbilical inci-
sion is created along the resulting skin crease. The median um-
bilical ligament will be tented and the abdominal wall stabilized
by these maneuvers (Fig. 3). The surgeon should bluntly dissect
away any adipose tissue from the ligament, place two band or
S-shaped retractors inferiorly, and place a Kocher clamp on the
most superficial aspect of the median umbilical ligament. The
first clamp should be removed from the umbilicus and the fascia
exposed until the midline can be easily visualized. The surgeon
should incise the umbilical ligament longitudinally with electro-
cautery, spread the fascial edges, and retract each edge laterally
with a band or S-shaped retractor. The peritoneum is grasped
between two tissue forceps and incised sharply (Fig. 4). Next, a
Hasson trocar is inserted into the peritoneal cavity under direct
vision and the clamp is removed. This technique elevates the
fascia to the level of the skin and provides excellent exposure for
accessing the peritoneal cavity.
Accessing the peritoneal cavity 5

Figure 2 Placement of a Hasson trocar. Two fascial sutures stabilize the abdominal wall, and the trocar is inserted
under direct vision.

Figure 3 Median umbilical ligament (arrow). The superior clamp has everted the umbilicus and tented up the median
umbilical ligament. The inferior Kocher clamp has been placed on the most superficial aspect of the ligament. Two
retractors give adequate exposure by inferior and caudad retraction.
6 D.D. Potter and M.L. Kendrick

Figure 4 Sharp entry into the peritoneal cavity through the median umbilical ligament.

Figure 5 A schematic representation

demonstrating placement of a
bladeless optical trocar. The layers
of the abdominal wall are depicted
on the monitor when the trocar is
placed through an abdominus rec-
tus muscle.

C. Optical Trocar tip of the trocar as it is passed through the abdominal wall. A
The optical trocar technique is performed with a transparent skin incision is made and the optical trocar is inserted into the
bladeless trocar and a 0° laparoscope, which is inserted to the tip subcutaneous tissue. Direct pressure with simultaneous twisting
of the trocar (Fig. 5). This allows visualization of the tissue at the is performed to advance the trocar through the abdominal wall.
Accessing the peritoneal cavity
This allows sequential visualization of the subcutaneous adipose
tissue, myofascial layers, and finally the peritoneum (Fig. 5). We
prefer to place this trocar in a subcostal location if a trocar in this
region is indicated for the procedure. This allows entry at a fixed
site using the costal margin to provide counter-tension of the
abdominal wall, but also avoids major vessels (aorta, inferior
vena cava) in the midline. Advantages of the optical trocar tech-
nique include the avoidance of more extensive soft tissue dissec-
tion and the occasional difficulty of exposure in the open tech-
nique, particularly in obese patients. Contraindications for the
use of the optical trocar in the authors’ opinion include patients
where extensive adhesions are anticipated; in this setting, the
open Hasson technique is preferred to reduce the risk of inad-
vertent enterotomy.
Conclusions
Accessing the peritoneal cavity for laparoscopic proce-
dures can be performed safely with several techniques. At
7
the Mayo Clinic, the open Hasson technique is most
widely used; however, the closed Veress needle is com-
monly employed when a patient has not had prior abdom-
inal procedures. Optical trocars are most commonly used
for patients with morbid obesity. Regardless of the method
used, the following six principles are routinely followed to
minimize injury to vital structures: visualization, stabili-
zation, adequate incision, controlled penetration, proper
direction, and minimization of insertion.
References
1. Bhoyrul S, Vierra MA, Nezhat CR, et al: Trocar injuries in laparoscopic
surgery. J Am Coll Surg 192:677-683, 2001
2. Munro MG: Laparoscopic access: complications, technologies, and tech-
niques. Curr Opin Obstet Gynecol 14:365-374, 2002
3. Catarci M, Carlini M, Gentileschi P, et al: Major and minor injuries during
the creation of pneumoperitoneum. Surg Endosc 15:566-569, 2001
4. Mayol J, Garcia-Aguilar J, Ortiz-Oshiro E, et al: Risks of the minimal access
approach for laparoscopic surgery: multivariate analysis of morbidity related
to umbilical trocar insertion. World J Surg 21:529-533, 1997