Safe laparoscopic access begins before an incision is ever made.
It begins when you review the patient's history, which includes any pertinent previous surgeries. It extends to the examination, which should rule out pelvic or abdominal masses, hepatomegaly, or an enlarged spleen. If questions about the patient's anatomy arise, imaging may be helpful. I recently had an in vitro fertilization patient with ovarian torsion for whom ultrasound was needed to locate the limits of the ovaries, which reached the umbilicus.
During surgical preparation in the operating room, the patient's bladder should be drained with a Foley catheter to ensure that it is deflated; otherwise, it may extend into the operative field and be punctured on initial access. The anesthesiologist should drain the stomach contents with oral or nasogastric suction.
Optimal patient positioning is critical.
Keep the table at waist height. You want the movement of the trocar to be as controlled as possible, optimizing proprioception and fine muscle control of your hand so that the entry force arises from small, controlled muscle movements of the forearm, hand, and wrist—not from large, less-controlled movements from your shoulder girdle. By keeping your forearms perpendicular to the patient, the force is directed along the axis of the trocar. It is essential that you maintain control of that force upon entry, so that you neither push the trocar too far nor exert lateral force.
Ensure that the table is flat. Placing the patient into premature Trendelenburg's position will change the physical relationship of the major vessels. The patient's body should lie flat from left to right to allow better anticipation of the side wall and iliac vessels.
There are several schools of thought regarding trocar placement. I enter directly in the center of the umbilicus. Some surgeons prefer an infraumbilical approach; however, I have never seen a wound infection in the center of the umbilicus when it has been meticulously disinfected with swabs during preparation of the patient. Here in the center of the umbilicus, the abdominal wall is at its thinnest, and all layers of the abdominal wall are fused. Above or below the umbilicus, there are thicker, unfused layers of tissue that are more difficult to cut through, increasing the risk of false passage.
Before initial trocar placement, palpate the promontory of the sacrum and the bifurcation of the aorta, which may be above (in most cases), at the level of, or even below the umbilicus, and make a mental map of your entry angle.
When you prepare to enter, place the trocars perfectly centrally from right to left and perpendicular to the skin; do not angle them laterally. Maintain control over the angle as you push. Iliac vessel injuries can occur when the surgeon thinks the trocar is straight, but the angle of his or her hand shifts as more force is applied. It is difficult to push straight down with force. A right-handed surgeon will tend to angle to the left; a left-handed surgeon will tend to angle to the right. Recognize this tendency and avoid it.
Remember that the abdominal-peritoneal cavity is a potential space until you enter and air or gas is allowed to enter. During initial entry, keep the valve to the Veress or trocar open so that air can enter and allow organs to fall away from the abdominal wall. At this point, it is crucial to elevate the anterior abdominal wall as much as possible, either by hand or with towel clips. On my side of the patient, I grasp the anterior wall very firmly with my hand lateral to the umbilicus while, on the other side, my assistant elevates the wall with her hand lateral to the umbilicus. I find that this technique allows sharp retraction more effectively than grasping singly inferior to the umbilicus.
Other surgeons prefer to use two perforating towel clips on the umbilical ring. During your next case, when the laparoscope is already in, try different methods of abdominal wall elevation and see which grasping strategy lifts the abdominal wall most effectively in your hands.
Keep in mind that you may have to adjust your angle of entry depending on the patient's degree of obesity; otherwise, you may find yourself tunneling in subcutaneous fat. The more obese the patient, the more perpendicular the angle of your initial entry should be.
Although you do have to tailor your technique to the obese patient's anatomy, obesity generally is not a contraindication to laparoscopic surgery. Surgical and postsurgical risks are elevated in obese patients; however, open surgery poses significant risks to these patients as well.