The establishment of pneumoperitoneum and initial port placement is one of the most critical parts of a laparoscopic procedure. Three main options exist for laparo­scopic entry: an open (Hasson), closed (Veress), and optical port technique. The bulk of data that exists focuses on comparing the rst two techniques. A recent meta-analysis concluded that there is insufcient evidence to recommend one lapa­roscopic entry technique over another. An open-entry technique is associated with a reduction in failed entry when compared to a closed-entry technique, with no evi­dence of a difference in the incidence of visceral or vascular injury. An advantage of direct trocar entry over Veress needle entry was noted for failed entry and vascular injury. They found that the evidence was generally of very low quality with small numbers of participants in most studies and that the ndings should be interpreted with caution [3]. Further retrospective reviews suggest a trend toward reduction of the risk of major complications with either open access techniques or an optical port technique [4]. In terms of injury patterns for closed or Veress technique, 38 selected articles including 696,502 laparoscopic procedure cumulatively reported 1575 inju­ries (0.23%), 126 (8%) of which involving blood vessels or hollow viscera (0.018% of all laparoscopies). Of the 98 vascular injuries, 8 (8.1%) were injuries to major retroperitoneal vessels. There were 34 other reported retroperitoneal injuries, but the authors were not specic as to which vessel was injured. Of the 28 injuries to hollow viscera, 17 were considered major injuries, i.e., 60.7% (0.0024% of the total cases assessed) [5]. In the absence of denitive data to recommend one technique over another, surgeons are encouraged to employ whichever entry technique they are most comfortable with.

For the closed or Veress approach for abdominal access, inability to establish pneu­moperitoneum will be noted by low pressure and high ow on the insufator. Initial attempts may be tried at the same position, but if multiple attempts are unsuccessful, another site should be used. Palmer’s point, at two ngerbreadths below the costal margin in the left midaxillary line, is usually a safe position unless previous surgery has taken place in the left upper quadrant (Fig.10.1). If multiple attempts are unsuc­cessful, another entry technique should be used. If bile, enteric contents, or blood returns at placement of the Veress needle, the needle should be left in place, and alternative access gained immediately. The alternative access may be laparoscopic if it is safe to do so. If the bleeding is signicant or if hypotension is noted, open laparotomy is required.