title: Systematic review of the safety and effectiveness of methods used to establish pneumoperitoneum in laparoscopic surgery.
abstract: BACKGROUND
  A systematic review was conducted to determine which of the methods of obtaining peritoneal access and establishing pneumoperitoneum is the safest and most effective.
  
  
  METHODS
  Studies that met the inclusion criteria were identified from six bibliographic databases up to May 2002, the internet, hand-searches and reference lists. They were critically appraised using a validated checklist and data were extracted using standardized protocols.
  
  
  RESULTS
  Meta-analysis of prospective, non-randomized studies of open versus closed (needle/trocar) access indicated a trend during open access towards a reduced risk of major complications (pooled relative risk (RR(p)) 0.30, 95 per cent confidence interval (c.i.) 0.09 to 1.03). Open access was also associated with a trend towards a reduced risk of access-site herniation (RR(p) 0.21, 95 per cent c.i. 0.04 to 1.03) and, in non-obese patients, a 57 per cent reduced risk of minor complications (RR(p) 0.43, 95 per cent c.i. 0.20 to 0.92) and a trend for fewer conversions to laparotomy (RR(p) 0.21, 95 per cent c.i. 0.04 to 1.17). Data on major complications in studies of direct trocar versus needle/trocar access were inconclusive. Minor complications in randomized controlled trials were fewer with direct trocar access (RR(p) 0.19, 95 per cent c.i. 0.09 to 0.40), predominantly owing to a reduction in extraperitoneal insufflation.
  
  
  CONCLUSIONS
  The evidence on the comparative safety and effectiveness of the different access methods was not definitive, but there were trends in the data that merit further exploration.
authors.affiliation: Department of Public Health, University of Adelaide, Adelaide, South Australia, Australia.
authors.forename: T L
authors.initials: TL
authors.lastname: Merlin
authors.forename: J E
authors.initials: JE
authors.lastname: Hiller
authors.forename: G J
authors.initials: GJ
authors.lastname: Maddern
authors.forename: G G
authors.initials: GG
authors.lastname: Jamieson
authors.forename: A R
authors.initials: AR
authors.lastname: Brown
authors.forename: A
authors.initials: A
authors.lastname: Kolbe
mesh_terms: D018849:Controlled Clinical Trials as Topic; D006801:Humans; D010535:Laparoscopy / Q000379:methods*; D011028:Pneumoperitoneum, Artificial / Q000009:adverse effects* / Q000379:methods / Q000592:standards; D016032:Randomized Controlled Trials as Topic; D012449:Safety; D016896:Treatment Outcome