To reduce the risk of retroperitoneal vascular injury while minimizing the chance of inadvertent preperitoneal insufﬂation, in women of average weight, the insufﬂation needle is directed to the patient’s spine at a 45-degree angle. In heavy to obese individuals, this angle may be increased incrementally to nearly 90 degrees, accounting for the increasing thickness of the abdominal wall and the tendency of the umbilicus to gravitate caudad with increasing abdominal girth (79,83). The needle’s shaft is held by the tips of the fingers and steadily but purposefully guided into position only far enough to allow the tip’s entry into the peritoneal cavity. The tactile and visual feedback created when the needle passes through the facial and peritoneal layers of the abdominal wall may provide guidance and help prevent overaggressive insertion attempts. This proprioceptive feedback is less apparent with disposable needles than with the classic Verres needle. With the former, the surgeon must listen to the “clicks” as the needle obturator retracts when it passes through the rectus fascia and the peritoneum. The needle should never be forced. Regardless of technique, the underlying retroperitoneal vessels are protected ultimately by limiting the insertion depth of the insufﬂation needle.
Figure 23.5 Insufﬂation needle. When pressed against tissue such as fascia or peritoneum, the spring-loaded blunt obturator (inset) is pushed back into the hollow needle, revealing its sharpened end. When the needle enters the peritoneal cavity, the obturator springs back into position, protecting the intraabdominal contents from injury. The handle of the hollow needle allows the attachment of a syringe or tubing for insufﬂation of the distention gas.
Figure 23.6 Insufﬂation needle and cannula insertion sites. In most instances, both the insufﬂation needle, if used, and the primary cannula are inserted through the umbilicus. When subumbilical adhesions are known or suspected, the insufﬂation needle may be placed through the pouch of Douglas or in the left upper quadrant after evacuation of the gastric contents with an orogastric tube.
2.
In instances where known or suspected intra-abdominal adhesions surround the umbilicus, alternative sites should be used for insufﬂation needle insertion. These sites include the left upper quadrant, most often at the left costal margin, the pouch of Douglas, and the fundus of the uterus (Fig. 23.6). The left upper quadrant is preferred if hepatosplenomegaly is not present and the patient has not previously had surgery in this area. In such patients, the stomach must be decompressed with a nasogastric or orogastric tube before the needle is inserted (84). While at this location the distance between the skin and the posterior peritoneum is generally more than 11 cm, in thin individuals, it may be as little as 7 cm, so the angle of insertion should take this into account. The needle should be directed medially, about 10 to 15 degrees to avoid the kidney and renal artery; in women of relatively high body mass index it can be placed at a 90-degree angle to the skin, and in thin women, this angle should be reduced to about 45 degrees (84,85).
3.