Definitions of the levels of evidence (I, II-1, II-2, II-3, and III) and grades of recommendations (A-E and I) are provided at the end of the "Major Recommendations" field.
Establishment of Pneuperitoneum: The Veress Needle
- Left upper quadrant (LUQ, Palmer's) laparoscopic entry should be considered in patients with suspected or known periumbilical adhesions or history or presence of umbilical hernia, or after three failed insufflation attempts at the umbilicus. (II-2 A) Other sites of insertion, such as transuterine Veress CO2 insufflation, may be considered if the umbilical and LUQ insertions have failed or have been considered and are not an option. (I-A)
- The various Veress needle safety tests or checks provide very little useful information on the placement of the Veress needle. It is therefore not necessary to perform various safety checks on inserting the Veress needle; however, waggling of the Veress needle from side to side must be avoided, as this can enlarge a 1.6 mm puncture injury to an injury of up to 1 cm in viscera or blood vessels. (II-1 A)
- The Veress intraperitoneal (VIP-pressure <10 mm Hg) is a reliable indicator of correct intraperitoneal placement of the Veress needle; therefore, it is appropriate to attach the CO2 source to the Veress needle on entry. (II-1 A)
- Elevation of the anterior abdominal wall at the time of Veress or primary trocar insertion is not routinely recommended, as it does not avoid visceral or vessel injury. (II-2 B)
- The angle of the Veress needle insertion should vary according to the body mass index (BMI) of the patient from 45 degrees in non-obese women to 90 degrees in obese women. (II-2 B)
- The volume of CO2 inserted with the Veress needle should depend on the intra-abdominal pressure. Adequate pneumoperitoneum should be determined by a pressure of 20 to 30 mm Hg and not by predetermined CO2 volume. (II-1 A)
- In the Veress needle method of entry, the abdominal pressure may be increased immediately prior to insertion of the first trocar. The high intraperitoneal (HIP-pressure) laparoscopic entry technique does not adversely affect cardiopulmonary function in healthy women. (II-1 A)
Open Laparoscopic Entry or Hasson Technique
- The open entry technique may be utilized as an alternative to the Veress needle technique, although the majority of gynaecologists prefer the Veress entry. There is no evidence that the open entry technique is superior to or inferior to the other entry techniques currently available. (II-2 C)
Direct Trocar Entry
- Direct insertion of the trocar without prior pneumoperitoneum may be considered as a safe alternative to Veress needle technique. (II-2)
Summary Statement
- Direct insertion of the trocar is associated with less insufflation-related complications such as gas embolism, and it is a faster technique than the Veress needle technique. (I)
Disposable Shielded Trocars
- Shielded trocars may be used in an effort to decrease entry injuries. There is no evidence that they result in fewer visceral and vascular injuries during laparoscopic access. (II-B)
Radially Expanding Access System
- Radially expanding trocars are not recommended as being superior to the traditional trocars. They do have blunt tips that may provide some protection from injuries, but the force required for entry is significantly greater than with disposable trocars. (I-A)
Visual Entry System
- The visual entry cannula system may represent an advantage over traditional trocars, as it allows a clear optical entry, but this advantage has not been fully explored. The visual entry cannula trocars have the advantage of minimizing the size of the entry wound and reducing the force necessary for insertion. Visual entry trocars are non-superior to other trocars since they do not avoid visceral and vascular injury. (2 B)
Definitions:
Quality of Evidence Assessment*
I: Evidence obtained from at least one properly randomized controlled trial
II-1: Evidence from well-designed controlled trials without randomization
II-2: Evidence from well-designed cohort (prospective or retrospective) or case-control studies, preferably from more than one centre or research group
II-3: Evidence obtained from comparisons between times or places with or without the intervention. Dramatic results in uncontrolled experiments (such as the results of treatment with penicillin in the 1940s) could also be included in this category
III: Opinions of respected authorities, based on clinical experience, descriptive studies, or reports of expert committees
Classification of Recommendations**
A. There is good evidence to recommend the clinical preventive action.
B. There is fair evidence to recommend the clinical preventive action.
C. The existing evidence is conflicting and does not allow to make a recommendation for or against use of the clinical preventive action; however, other factors may influence decision-making.
D. There is fair evidence to recommend against the clinical preventive action.
E. There is good evidence to recommend against the clinical preventive action.
I. There is insufficient evidence (in quantity or quality) to make a recommendation; however, other factors may influence decision-making.
*The quality of evidence reported in these guidelines has been adapted from the Evaluation of Evidence criteria described in the Canadian Task Force on Preventive Health Care.
**Recommendations included in these guidelines have been adapted from the Classification of Recommendations criteria described in the Canadian Task Force on Preventive Health Care.
