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J Minim Access Surg. 2023 Jan-Mar; 19(1): 162–164. PMCID: PMC10034789

Published online 2022 Jan 6. doi: 10.4103/jmas.jmas_271_21 PMID: 35046186

Open Veress assisted technique for laparoscopic entry

Roberto Peltrini, Marcello De Luca, Ruggero Lionetti, Umberto Bracale, and Francesco Corcione

Abstract

Background:

The creation of the pneumoperitoneum is the first step for any minimally invasive surgical procedure.
Although rare, iatrogenic vascular or visceral injuries are reported and they are mainly related to the inser‐
tion of the first trocar. The Open Veress Assisted (OVA) technique allows a safe maneuver of the first tro‐
car in order to minimize the risk of intraoperative complications during positioning of the first trocar. The
purpose of this study was to describe the OVA technique and discuss the use in our current surgical
practice.

Patients and Methods:

Each step of OVA technique is described in the text. A retrospective review of prospectively maintained in‐
stitutional databases was performed to report clinical outcomes related to OVA technique use.

Results:

Between December 2018 and July 2021 OVA technique was used in a total of 324 laparoscopic procedures
categorized in 259 colorectal resection and 24 subtotal or total gastrectomies. No intraoperative and post‐
operative complications related to creation of the peritoneum occurred.

Conclusion:
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OVA technique can be considered a safe alternative procedure for laparoscopic entry. By avoiding poten‐
tially dangerous insertion-related forces, this technique can be used even in previously operated patients,
when the first trocar needs to be positioned away from the umbilicus or abdominal scar.

Keywords: Laparoscopy, pneumoperitoneum, Veress

INTRODUCTION

Different procedures to create pneumoperitoneum have been described over time but a recently updated
Cochrane review does not offer the possibility of recommending one technique over another on the basis of
related (very low) major complication rates.[1] Although trocar and Veress needle are the instruments
causing most bowel injury during laparoscopy,[2] major vascular injuries are related to the trocar insertion
in more than half of cases compared to Veress needle when a closed-entry technique is performed.[3] We
describe and discuss the Open Veress Assisted (OVA) technique for laparoscopic entry that is routinely
used in our surgical practice.

STANDARD TECHNIQUES

Open technique

Open technique involves skin and subcutaneous layer incision up to cutting down the peritoneum. Once in
the peritoneal cavity, a blunt trocar is placed under direct visualization. Gas insufflation is provided and the
laparoscope is inserted.[4]

Closed technique

Closed technique starts with the insertion of a Veress needle into the peritoneal cavity, after a little incision
of the skin. The needle is pushed in until it gives a double click, ensuring that it is in the intraperitoneal
space. Once into peritoneal cavity, gas insufflation is provided. After the incision of the skin, the first trocar
is placed through the abdominal wall up to cutting down muscular layers and the peritoneum with blunt
manoeuvres.

Modification of standard techniques

The OVA technique allows a safe first trocar insertion, in a previously tested abdominal wall site, after the
creation of pneumoperitoneum using Veress needle in the upper left quadrant.[5]

After a little incision of the skin with a scalpel, a Veress needle is placed in the left hypochondrium two or
three cm below the costal margin, laterally to the rectus abdominis muscles [Figures ​1 and ​2].
Figure 1

Incision of the skin for Veress needle in the left hypochondrium two or three cm below the costal margin, laterally to the
rectus abdominis muscles
 Figure 2

Veress needle insertion

A gas tube is connected to the needle and CO2 insufflation starts with high flow.

When intra-abdominal pressure reaches 12 mmHg, the insertion site of the first trocar is checked with the
aspiration test: the needle of a 10 mL syringe containing 3 mL of saline is introduced perpendicularly into
the abdominal cavity with simultaneous suction manoeuvres [Figure 3].
 Figure 3

Aspiration test

This hydro-pneumatic test can detect a free intra-peritoneal area when CO2 backs into the syringe, whereas
evidence of resistance, blood or stools show a no safe zone.

In the chosen area, a 10-mm full-thickness incision of abdominal wall including the peritoneum is per‐
formed [Figure 4]. The gas leakage confirms access so that the first trocar can be inserted into the abdomi‐
nal cavity without any effort, avoiding potential vascular or visceral injuries [Figure 5].
Figure 4

A 10-mm full-thickness incision of abdominal wall, including muscular fascia and peritoneum, is performed in the chosen
area. The gas leakage confirms access in abdominal cavity
 Figure 5

First trocar insertion into the abdominal cavity without any effort, avoiding potential vascular or visceral injuries

The procedure ends with the check of Veress needle position by optics and its removal.

This method differs from the closed technique for a full-thickness incision of the abdominal wall at the first
trocar site, avoiding the blind application of potentially dangerous insertion-related forces. Compared with
the open technique, OVA laparoscopic entry provides a smaller muscular fascia incision because there is
no need for layer-by-layer abdominal wall dissection. This could affect trocar site incisional hernia
development.

OVA technique is also applicable to obese patients. Furthermore, it is advantageous in previously operated
patients because of the risk of adhesions under the midline laparotomy scar and in the operations that need
to place optical trocar outside the umbilicus.

RESULTS

Between December 2018 and July 2021, OVA technique was used in a total of 324 surgical procedures cat‐
egorised in 259 laparoscopic colorectal resection and 24 subtotal or total gastrectomies. A total of 125 pro‐
cedures were performed in previously operated patients. No vascular or visceral injuries occurred after
Veress or first trocar insertion. Likewise, there were not abdominal wall seromas or haematomas in the
post-operative period.
CONCLUSION

OVA technique can be considered a safe alternative procedure for laparoscopic entry. By avoiding poten‐
tially dangerous insertion-related forces, even in previously operated patients, when the first trocar needs to
be positioned away from the umbilicus or abdominal scar, we consider the technique safe and most
advantageous.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

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