Abdominal access in gynaecological laparoscopy: a comparison between direct optical and blind closed access by Verres needle. Direct trocar insertion vs Veress needle in nonobese patients undergoing laparoscopic procedures: a randomized prospective single-center study. Randomized trial comparing a radially expandable needle system with cutting trocars. Randomized, prospective, single-blind trial of a new parallel technique of Veress pneumoperitoneum needle insertion versus the conventional closed method. Direct trocar insertion vs. Verres needle use for laparoscopic sterilization. A randomized comparison of Verres needle and direct trocar insertion for laparoscopy. Direct trocar versus veress needle entry for laparoscopy: a randomized clinical trial. Prospective study comparing the bladeless optical access trocar versus Hasson open trocar for the establishment of pneumoperitoneum in laparoscopic renal procedures. Randomized double-masked comparison of radially expanding access device and conventional cutting tip trocar in laparoscopy.
Complications associated with initial abdominal entry are a prime concern for laparoscopic surgeons. In order to minimize first access-related complications in laparoscopy, several techniques and technologies have been introduced in the past years. This investigation compares two laparoscopic access techniques.
                194 women underwent laparoscopic surgery for simple ovarian cysts: 93 were assigned to direct optical access (DOA) abdominal entry (group I), and 101 women to classical closed method by Verres needle, pneumoperitoneum and trocar entry (group II). The following parameters were compared: time required for entry into abdomen, occurrence of vascular and/or bowel injury, blood loss. The results were analyzed using SAS software. p-value<0.05 was considered as significant.
                No statistically significant differences were observed in the occurrence of blood loss and minor vascular injury between the two techniques, as well as minor bowel injuries; time for of abdominal entry, instead, were significantly reduced in the DOA group.
                The results of the preliminary comparison between the DOA and the Verres methods, commonly used by gynecologists, suggests that the visual entry system confers a statistical advantage over closed entry technique with Verres needle, in terms of time saving and due to the minor vascular and bowel injuries, thus enabling a safe and expeditious, visually-guided, entry for surgeons.
                2009 Elsevier Ireland Ltd. All rights reserved. Nonobese patients undergoing laparoscopic procedures present a dilemma as to the correct mode of entry into the abdominal cavity because the Veress needle (VN) technique seems to be associated with a high risk of vascular and visceral injuries. Direct trocar insertion (DTI) has been reported as an alternative to the VN for creation of the pneumoperitoneum.
                An open comparative randomized prospective study was conducted on the feasibility and safety of DTI vs the VN technique in nonobese patients of any age category referred for urgent or scheduled laparoscopic procedures. Exclusion criteria were obesity (defined as a body mass index [BMI] > 27 kg/m(2)), major abdominal distension, and two or more previous abdominal operations. The study endpoints were the feasibility and safety of the DTI and VN techniques. Results were evaluated on an intention-to-treat basis. Statistical analysis was carried out with the t-test for independent samples, the chi-square tests, and the Fisher's exact tests, as appropriate. The level of significance was 0.01.
                Since January 2002, a total of 598 nonobese patients have been entered into the current trial; 46% (mean BMI 21.6 A+/- 4.4 kg/m(2)) were randomly allocated to DTI, whereas 54% (BMI 21.1 A+/- 5.3 kg/m(2)) were allocated to the VN techniques. Demographic features and type of procedures were similar for the two groups. DTI was feasible in 100% of patients vs 98.7% in the VN group (p = NS). Minor complications were nil in the DTI group and 5.9% in the VN group (p < 0.01). The latter group consisted of 11 cases (3.4%) of subcutaneous emphysema and eight cases (2.5%) of extraperitoneal insufflation. Major complications were nil in the DTI group and 1.3% among VN patients (p = NS). These latter cases consisted of two (0.3%) hepatic lesions managed laparoscopically; one (0.3%) misdiagnosed ileal perforation requiring reintervention, and one (0.3%) mesenteric laceration treated conservatively.
                In thin and very thin patients of any age category with no more than one previous abdominal operation, DTI is a safe alternative to the VN technique and is associated with fewer minor complications. In terms of major complications, there is no difference between the two techniques. Either technique of access is acceptable Thin and very thin patients undergoing laparoscopy, on condition that the basic principles of laparoscopic surgery are complied with. Sharp trocar insertion for laparoscopic procedures carries with it increased risk for vascular and visceral complications and incisional hernia. In a trial, which randomized 87 patients to treatment with either sharp trocars or a radially expanding needle system with blunt dilator, results showed that with the latter system there was statistically improved patient assessment of pain, a lower complications rate, and shorter procedure time. In the group of patients randomized to treatment with conventional trocars, there were a total of six instrument-related adverse events (6/42): four cases (five incidences) of abdominal wall injuries and one small bowel perforation caused by a Veress needle. Of the 45 patients randomized to the blunt dilator/cannula treatment, there was one adverse event (1/45) that was unrelated to the blunt dilator/cannula system: Veress needle injury to abdominal vasculature. The radially expanding access system demonstrates statistically improved patient postoperative comfort and improved patient safety. To evaluate the safety and effectiveness of a new closed parallel technique of Veress needle insertion and to compare this method with the conventional closed approach.
                Sequential, randomized, prospective, single-blind clinical trial.
                University hospital.
                Women undergoing elective diagnostic and/or operative laparoscopy. Subjects (n = 200) were assigned randomly to undergo the conventional closed method (group 1; n = 100) or the new parallel technique (group 2; n = 100) of Veress needle insertion.
                Randomization of the patients was performed in the operating room. The investigator performed both diagnostic and operative laparoscopy in both study groups.
                Safety and effectiveness of the needle insertion technique.
                There were no significant differences in demographics between the groups, or in the time required for Veress needle insertion to establish pneumoperitoneum. There were no nonlethal major or minor intraoperative complications associated with either laparoscopic approach.
                There is no significant disadvantage to the parallel technique of Veress pneumoperitoneum needle insertion compared with the conventional closed approach. This new technique avoids the anatomic location of large vessels during insertion and may serve as a safeguard to decrease the potential for lethal laceration of a major vessel. A randomized, prospective trial was designed to compare direct trocar insertion with prior peritoneal insufflation with a Verres needle for laparoscopic tubal sterilization. Direct trocar insertion resulted in fewer instrument insertions (21.8% vs. 7.8%) and use of smaller volumes of CO2 (2.67 vs. 2.32 L). Direct trocar use resulted in a decrease in operating time from 9 minutes, 40 seconds in the needle group to 7 minutes, 30 seconds in the trocar group. Minor omental injuries occurred in a small percentage of each group, while serious complications occurred once in each group. Two hundred and fifty-two women scheduled to undergo laparoscopy were randomly assigned to a Verres needle or direct insertion group. The groups were similar with respect to incidence of obesity, prior surgical treatment, indication for operation and level of training of the surgeon performing the procedure. There were no major complications associated with either technique. Minor complications (preperitoneal insufflation, failed entry or more than three attempts necessary to enter the peritoneal cavity with the trocar) were significantly more frequent (p < 0.05) in the Verres needle technique group. One hundred and thirteen of these patients underwent sterilization procedures. The mean times for performance of the laparoscopic procedure using the direct insertion and Verres needle techniques was 15.3 and 19.6 minutes, respectively. The time saved using the direct insertion technique is explained by a significant (p < 0.01) reduction in the mean laparoscope insertion time, which was 2.2 minutes and 5.9 minutes for the direct insertion and Verres needle techniques, respectively. We prefer the direct insertion technique for trocar placement because it has fewer minor complications and requires less operating time. To compare direct trocar (DT) to Veress needle (VN) entry for the creation of pneumoperitoneum during laparoscopy with regard to the duration of the procedure, volume of gas used, ease of performance, and frequency of complications.
                A randomized clinical trial. Subjects and
                One thousand patients scheduled to undergo diagnostic laparoscopy were recruited for the study. They were randomly allocated to either DT entry (group A, n = 500) or VN (group B, n = 500) for pneumoperitoneum. The laparoscopic procedures were performed by the same surgeon.
                The duration of the procedure, volume of gas consumption, ease of performance and frequency of complications were analyzed.
                Patients in the 2 groups had similar demographic characteristics. The mean duration of the procedure was significantly shorter in group A (2.2 +/- 0.7 min, 95% CI 2.14-2.26) than in group B (8.2 +/- 1.4 min, 95% CI 8.08-8.32; p < 0.0001). The mean gas consumption was significantly less in group A (2.6 +/- 0.9 liters, 95% CI 2.52-2.68) than in group B (8.4 +/- 2.6 liters, 95% CI 8.17-8.63; p < 0.0001). No major complications in both groups were encountered. Minor complications were significantly less in group A (0.4%, 95% CI 0.77-3.23) than in group B (14%, 95% CI 10.96-17.04; p < 0.0001).
                DT entry is a safe alternative to the VN entry technique for the creation of pneumoperitoneum. Such an approach has further advantages such as less cost and instrumentation and rapid creation of pneumoperitoneum.
                Copyright (c) 2010 S. Karger AG, Basel. To present a single centre prospective randomized study on the use of the bladeless Optiview system (Ethicon Endosurgery, Cincinnati, OH) to create the pneumoperitoneum in laparoscopic renal procedures reporting the results with regards safety, efficacy and complications and comparing it with the Hasson open technique.
                Sixty patients were randomly recruited, 27 to the open and 33 to the bladeless group at the Bristol Urological Institute, UK. Time to insertion, time to closure and any intraoperative and postoperative complication related to trocar insertion was recorded.
                All procedures were performed for renal pathology. BMI values were similar in both groups. The mean time to insertion of the 12 mm Hasson and Bladeless trocars were 443 and 125 seconds, respectively (p < 0.0001). The incision in the bladeless group was only closed when the defect exceeded 12 mm (38%) or extended for specimen removal (23%), resulting in a mean time to closure of 203 seconds. In the Hasson group, entry into the abdominal cavity could not be confirmed in two patients (7.4%) due to multiple adhesions. In the Bladeless group, there was one failed placement (3%) requiring conversion to the Hasson technique and two injuries to intraabdominal structures (peritoneal minor bruising, liver injury requiring conversion to open procedure, 6%), There was one incidence of gas leakage (3%). There were no reports of port site herniation at a mean follow up of 9 months.
                Direct placement of a bladeless trocar under direct vision in a desufflated abdomen can reduce port placement time when compared to the Hasson technique. The benefits are maximised by using the bladeless trocar for procedures not requiring intact specimen removal. However, despite visualisation of tissue layers, this port cannot prevent serious intra abdominal injuries that can occur in a higher percentage of cases in comparison to the Hasson technique. To compare postoperative wound pain associated with the radially expanding access device and the conventional disposable cutting-tip trocar.
                Our randomized, double-masked, self-controlled study involved 34 women scheduled for laparoscopic adnexal surgery. In each, a 10-mm radially expanding access device was inserted laterally on one side of the lower abdomen and a size-matched disposable cutting-tip trocar was placed on the other side, using random assignment. Postoperative pain for each studied wound and patient satisfaction toward the wounds were assessed using a visual analog scale. Any bleeding complication associated with insertion of the trocar was also recorded.
                The radially expanding access device was associated with significant reduction in severity (median 1.4 versus 5.0, P <.001) and duration (median 11 versus 21 days, P <.001) of postoperative wound pain, shorter wound scars (14 versus 17 mm, P <.001), a lower incidence of wound induration (0 versus 9, P <.01), and a higher patient satisfaction (median 9.7 versus 6.2, P <.001). There were four inferior epigastric artery injuries, all at the conventional trocar wound.
                The radially expanding access device was associated with less postoperative wound pain and more patient satisfaction than the conventional cutting-tip trocar.
An open-entry technique is associated with a significant reduction in failed entry when compared to a closed-entry technique, with no difference in the incidence of visceral or vascular injury. 
Significant benefits were noted with the use of a direct-entry technique when compared to the Veress Needle. The use of the Veress Needle was associated with an increased incidence of failed entry, extraperitoneal insufflation and omental injury; direct-trocar entry is therefore a safer closed-entry technique.
The low rate of reported complications associated with laparoscopic entry and the small number of participants within the included studies may account for the lack of significant difference in terms of major vascular and visceral injury between entry techniques. Results should be interpreted with caution for outcomes where only single studies were included.