title: Three simple steps during closed laparoscopic entry may minimize major injuries.
abstract: OBJECTIVE
  To describe three steps: (1) the initial Veress pressure (VIP-Pressure), (2) transient high-pressure pneumoperitoneum (HIP-Entry) prior to trocar/cannula insertion, and (3) visual entry with a trocarless cannula during closed laparoscopic entry, which may reduce major injuries.
  
  
  METHODS
  Prospective observational cohort study (Canadian Task Force Classification II-2).
  
  
  METHODS
  University-affiliated teaching hospital.
  
  
  METHODS
  VIP-Pressure. During laparoscopic entry, the initial VIP pressure was measured and correlated against the body habitus and parity of 365 consecutive women. HIP-Entry was performed in 2,498 consecutive cases. In 100 women, the CO(2) volume, heart rate, blood pressure, oxygen saturation, and pulmonary compliance were recorded at pressures of 10, 15, 20, 25, and 30 mmHg. Visual entry with a trocarless blunt cannula was performed in 776 women. The cannula, housing a 0 degrees laparoscope, was rotated clockwise applying minimal downward force.
  
  
  RESULTS
  VIP-Pressure. Pneumoperitoneum was established after one, two or three Veress needle attempts at the umbilicus in 82.4%, 10.9%, and 4.0% of women, respectively. In seven (2.2%), pneumoperitoneum was established at the left upper quadrant (LUQ) during the fourth attempt, and in two (0.6%) entry was abandoned. Median initial Veress pressure was 4 mmHg (range 2-10 mmHg). The VIP pressure correlated positively with women's weight (r = 0.518, p < 0.001) and body mass index (BMI) (r=0.545, p<0.001), and negatively with parity (r= -0.179, p<0.001). HIP-Entry. The abdomen was insufflated to 25-30 mmHg prior to primary trocar/cannula insertion. There were no changes in cardiovascular parameters between 15 and 30 mmHg. A 21% decrease in pulmonary compliance from 15 to 30 mmHg was of no clinical significance. No injury has been experienced with the visual cannula in 776 cases.
  
  
  CONCLUSIONS
  (1) A VIP-Pressure (<10 mmHg) indicates intraperitoneal placement of the Veress needle. (2) The use of transient HIP-Entry does not adversely affect cardiopulmonary function in healthy women. (3) Visual cannula offers an additional step towards safer entry.
authors.affiliation: Department of Obstetrics and Gynecology, St. Joseph's Health Care, The University of Western Ontario, 268 Grosvenor St., London, ON, Canada N6A 4V2. george.vilos@sjhc.london.on.ca
authors.forename: George A
authors.initials: GA
authors.lastname: Vilos
authors.forename: Angelos G
authors.initials: AG
authors.lastname: Vilos
authors.forename: Basim
authors.initials: B
authors.lastname: Abu-Rafea
authors.forename: Jackie
authors.initials: J
authors.lastname: Hollett-Caines
authors.forename: Zohreh
authors.initials: Z
authors.lastname: Nikkhah-Abyaneh
authors.forename: Fawaz
authors.initials: F
authors.lastname: Edris
mesh_terms: D001808:Blood Vessels / Q000293:injuries*; D005260:Female; D005500:Follow-Up Studies; D005767:Gastrointestinal Diseases / Q000601:surgery*; D006801:Humans; D015994:Incidence; D007422:Intestines / Q000293:injuries*; D007431:Intraoperative Complications / Q000453:epidemiology / Q000517:prevention & control*; D010535:Laparoscopy / Q000379:methods / Q000592:standards*; D011028:Pneumoperitoneum, Artificial / Q000379:methods / Q000592:standards; D017410:Practice Guidelines as Topic; D011446:Prospective Studies