Complications during the establishment of laparoscopic pneumoperitoneum.

BACKGROUND: A safe establishment of the laparoscopic pneumoperitoneum is of the utmost importance, as potentially fatal complications, such as vascular or visceral injury or gas embolism, may occur during the procedure.

OBJECTIVE: We used the published studies and our own experience to evaluate the advantages and disadvantages of various techniques for the establishment of the laparoscopic pneumoperitoneum, thus aiming to contribute to the reduction in the rate of fatal complications.

METHODS: We performed a retrospective review of 4940 medical charts of patients without prior history of abdominal surgeries who had the laparoscopic pneumoperitoneum established by using a modified closed method (i.e., the patient is in an anti-Trendelenburg's position 20-30 degrees and a left lateral tilt of 10-15 degrees, with the Veress needle and the first trocar introduced through the umbilicus and directed toward the intersection of the anterior axial line and the right costal arc). Additionally, we searched Medline, Embase, and the Cochrane libraries with a cut-off date of December 2006, using specific key-words (i.e., trocar injury, complication, laparoscopic surgery, Veress needle, open vs. closed pneumoperitoneum, prospective study).

RESULTS: There were no reports of injuries to the major blood vessels or visceral organs. However, liver capsule injury was reported in 432 (8.2%) patients, pneumo-omentum in 55 (1.1%) patients, and subfascial insufflations in 45 (0.9%) patients.

CONCLUSIONS: No reliable conclusions regarding advantages or disadvantages of different techniques for the laparoscopic pneumoperitoneum can be drawn in the absence of adequately powered, prospective, comparative studies. Based on the fact that no major blood vessel or visceral organ injuries were observed in our experience, we conclude that the modified closed method deserves further multicentric prospective evaluation.