The first step in most abdominal laparoscopic procedures is insufflation of the intraperitoneal space with carbon dioxide (CO2) gas and introduction of the videoscope system. The original and most established technique uses the Veress needle, described in Chapter 14. The Veress needle can be placed in any quadrant of the abdomen but is most frequently inserted just below the umbilicus, where a skin incision has been made for the introduction of a large 10-mm port for the videoscope. General surgeons, however, have been cautious in adopting this technique of blind puncture because their training has emphasized the importance of complete visualization of the anatomy and of the planned action of their surgical instruments. Accordingly, the open, or Hasson, technique for entering the abdomen under direct vision has become more popular and safer.
This technique can be used to enter into any quadrant of the abdomen but is most commonly employed at the central umbilical site (FIGURE 1). A vertical or transverse skin incision approximately 10 to 12 mm in length is made just below (FIGURE 2) or above the umbilicus. The choice of site may be based on the surgeon’s preference or the presence of a previous regional incision that may have adhesions. The subcutaneous fat and tissues are bluntly dissected apart using small, narrow finger retractors or a Kelly hemostat. The white linea alba is visualized and grasped on either side with hemostats. The linea alba is elevated with the hemostats, and a vertical 10-mm incision is made through the fascia (FIGURE 2). Further dissection with a hemostat will reveal the thickened white peritoneum, which is grasped with a pair of laterally placed hemostats. The peritoneum is elevated and opened cautiously with a scalpel. A dark, empty peritoneal space is seen, and a pair of lateral stay sutures is placed (FIGURE 3). These sutures incorporate the peritoneum and linea alba and are later used to secure the Hasson port.
The next step is to verify that the intraperitoneal space has been entered freely. The surgeon’s fifth finger is inserted (FIGURE 4). This maneuver sizes the hole for the port and allows the surgeon to palpate the region. Usually this space is clear, but occasionally there are some filmy omental adhesions that can be swept away. The Hasson port with its blunt, rounded-tip obturator is introduced into the abdomen (FIGURE 5). The spiral collar is screwed into the fascia so as to provide a snug gas seal, and lateral stay sutures are secured to the notches on the collar.
The obturator is removed, the CO2 line is attached, and the stopcock is opened. The surgeon sets the rate of CO2 flow and maximum pressure (15 mm Hg). He or she observes the intra-abdominal pressure and the total volume of CO2 infused as the abdomen ...