Laparoscopic access: complications, technologies, and techniques.
OBJECTIVE
To review laparoscopic access systems, insertion techniques, and the risks of complications associated with their use.


RESULTS
Access devices usually comprised an external cannula and a removable sharp pyramidal trocar for penetration of the abdominal wall, and were nearly universally positioned following establishment of a pneumoperitoneum. However, it is apparent that such devices and techniques contribute to patient morbidity through visceral and vascular injury, as well as incision-related complications such as dehiscence and hernia. There exist alternative approaches to positioning insufflation needles and the initial cannula, which may reduce the incidence of vascular and visceral injury particularly in the face of previous abdominal surgery. Inserting the initial cannula after minilaparotomy is associated with a reduced risk of vascular injury, but visceral complications still occur. Some new access instruments may reduce the risk of some complications associated with 'blind entry', and although not all seem to be effective in this regard, a set of blunt-tipped devices now exist, which are surprisingly easy to position and may limit the risk of injury while significantly reducing the size of the myofascial defect in the abdominal wall. Port site metastasis is a relatively newly recognized complication of oncological surgery and is a concern, but further investigation is required to determine whether such metastasis is related to a change in clinical outcome.


CONCLUSIONS
The incidence and spectrum of access-related complications is greater than previously perceived. Newer devices and modifications in technique may reduce the incidence of such adverse events.
Munro
Malcolm G
MG
Department of Obstetrics and Gynecology, David Geffen School of Medicine at UCLA, Los Angeles, California, USA. mgmunro@aol.com
D001808:Blood Vessels / Q000293:injuries; D004064:Digestive System / Q000293:injuries; D005260:Female; D013509:Gynecologic Surgical Procedures / Q000009:adverse effects* / Q000295:instrumentation / Q000379:methods*; D006547:Hernia / Q000209:etiology; D006801:Humans; D010535:Laparoscopy / Q000009:adverse effects* / Q000379:methods*; D009366:Neoplasm Seeding; D011027:Pneumoperitoneum / Q000209:etiology; D013529:Surgical Wound Dehiscence / Q000209:etiology