Laparoscopic Entry Points in the Abdomen

Overview of Access Methods

1. Closed (Direct Puncture) technique - using a Veress needle
2. Open (Hasson) technique - direct cut-down under vision

1. Primary Port (Camera Port) - Entry Sites

Umbilicus (Most Common)

• The abdominal wall is at its thinnest here, even in obese patients
• It provides a natural scar that heals well cosmetically
• The Veress needle, when angled toward the pelvis (away from the sacral promontory and great vessels), safely enters the peritoneal cavity

• Abdominal wall is elevated with fingers or penetrating towel clips
• A small skin incision is made in/below the umbilicus
• The spring-loaded Veress needle is advanced - two distinct "pops" are felt as it passes through the fascia, then peritoneum
• CO2 is insufflated to 14-15 mmHg
• A 5 or 10 mm trocar is then placed through the same site

• A small incision just below the umbilicus exposes the fascia under direct vision
• Two Kocher clamps are placed on the fascia; curved Mayo scissors incise the fascia and peritoneum
• A finger is inserted to confirm no adherent bowel
• A blunt, winged (Hasson) trocar is placed and secured with fascial sutures
• Preferred in: patients with previous abdominal surgery where bowel may be adherent to the undersurface of the anterior abdominal wall

Left Upper Quadrant - Palmer's Point

• Located in the left midclavicular line, 3 cm below the costal margin
• Used when the umbilical region is unsafe (previous midline laparotomy, umbilical hernia, suspected adhesions around the umbilicus)
• Accessed with a Veress needle or 5 mm optical trocar
• Also used as the initial entry site in laparoscopic ventral hernia repair and IPOM procedures

2. Secondary Ports (Working Ports)

• The abdominal wall must be transilluminated before puncture to avoid the inferior epigastric vessels (which run lateral to the rectus sheath)
• The trocar entry must be watched laparoscopically as it enters the abdomen
• Ports should not be placed too close together (to avoid "sword fighting" of instruments)

3. The "Diamond of Success" - Optimal Port Configuration

• Home plate = telescope port (periumbilical)
• Second base = surgical target (e.g., hiatus for fundoplication)
• First base = right-hand working port
• Third base = left-hand working port
• Ideal distance between telescope and target = 15 cm
• Ideal angle between the two working instruments at the target = 60-90 degrees

4. Anatomical Hazards at Each Entry Zone

5. Entry in Special Situations

• Previous midline surgery: Use Palmer's point (LUQ) or an area away from previous scars; Hasson technique preferred
• Pregnancy: Entry point moves cephalad as the uterus enlarges; left upper quadrant or supra-fundal entry
• Obesity: Umbilicus remains thin despite overall obesity; Veress needle angle must be more perpendicular (abdominal wall is thicker)
• Port-site metastasis risk (cancer surgery): Extract specimen in a bag; fascial closure of ports >10 mm
• Children: Smaller abdomen means reduced safe working distances; use 3 mm and 5 mm trocars

6. Confirming Correct Intraperitoneal Placement (Veress Needle Tests)

1. Hanging drop test - saline placed at needle hub is drawn in by negative intraperitoneal pressure
2. Aspiration test - no blood or bowel content on aspiration
3. Insufflation pressure - initial pressure <8 mmHg with free flow indicates intraperitoneal position; high pressure suggests extraperitoneal/omental placement
4. Volume of gas - first 1 L should insufflate easily and symmetrical abdominal distension should be visible

• Schwartz's Principles of Surgery, 11th ed. - Chapter 14 (Minimally Invasive Surgery)
• Maingot's Abdominal Operations - Chapter 4 (Port Placement, "Diamond of Success")
• Fischer's Mastery of Surgery, 8th ed.
• Mulholland and Greenfield's Surgery, 7th ed.