Skip to main content

Laparoscopic Access

Primary access is a distinct risk period in minimally invasive GU reconstruction. Entry can injure adherent bowel, abdominal-wall vessels or retroperitoneal great vessels before the intended procedure begins. Choose the site, instrument and technique together, considering previous surgery, anatomy, the planned reconstruction and operator experience. No approach guarantees freedom from major injury.[1][2][3]

Entry Techniques​

MethodSequence and useful featuresImportant limitations
Veress needleNeedle placement → confirmation and pneumoperitoneum → primary trocar.Both needle and trocar can injure viscera or vessels. Failed entry and extraperitoneal insufflation occur more often than with direct trocar insertion in comparative trials.
Open (Hasson)Controlled incision through the abdominal wall and peritoneum → blunt cannula → insufflation.Adherent bowel may be immediately beneath the peritoneum. Open entry does not eliminate injury; gas leakage and a thick wall can make access difficult.
Direct trocar insertion (DTI)Trocar insertion without prior pneumoperitoneum → immediate inspection → insufflation.Requires controlled insertion by a trained operator.
Optical entryA compatible laparoscope displays tissue layers as the access device advances. Devices may be used with or without prior insufflation according to their instructions.Visualization is not a protective shield against adherent bowel or uncontrolled advancement. Optical trocars and threaded visual cannulas are different devices.

These distinctions are supported by Cochrane and society guidance; the comparison should not be reduced to a zero-risk “winner.”[2][3][4]

What comparative evidence establishes​

  • Cochrane 2019: direct trocar insertion reduced failed entry versus Veress. Evidence for differences in visceral and vascular injury was limited by rare events, imprecision and trial quality. Many studies excluded patients with previous surgery or high BMI, limiting applicability to complex reconstruction.[2]
  • Pairwise meta-analysis, 2023: 25 trials involving 6,950 patients favored DTI for several entry outcomes. Heterogeneity and sparse major injuries limit a universal safety ranking; pooled entry-time estimates were particularly heterogeneous.[5]
  • Network meta-analysis, online 2025 / journal issue 2026: reported signals favoring direct entry for major or minor complications and open entry for vascular injury. Its networks had different denominators: 7,584 participants in 29 studies for major injuries, versus 8,984 in 33 for minor injuries.[6]

Maintain proficiency in an alternative entry plan when the initial method is unsuitable or unsuccessful.

Planning and Performing Entry​

Before insertion​

Review previous incisions, stomas, mesh, hernias and available imaging. Choose an entry site with a plausible safe route to the intended working space. Empty the bladder and decompress the stomach when indicated, particularly for left-upper-quadrant entry. Check the access device and insufflator, and ensure that conversion and hemorrhage-control equipment are available.[3]

Prior incision type is associated with, but does not reliably predict, adhesions to the abdominal wall. In an appraisal of 360 women undergoing operative laparoscopy after prior laparotomy, adhesions between the abdominal wall and underlying omentum or bowel were found in 70 of 258 patients (27%) with a prior Pfannenstiel incision versus 58 of 102 (57%) with a prior midline incision, and adhesions to bowel were significantly more frequent after midline incisions above the umbilicus. This observational association does not by itself dictate the entry site for a given patient.[35]

Veress placement and confirmation​

Use an adequate skin opening and controlled advancement. At an umbilical site, the insertion angle depends on habitus and anatomy; ISGE describes approximately 45° in non-obese women toward 90° in obesity, not a fixed angle for every patient or entry site. Routine lifting of the lower abdominal wall has not been shown to reduce injury and may increase failed entry. Avoid lateral sweeping of an inserted needle.[3][4]

Low initial insufflation pressure is more useful than isolated tactile or saline tests. ISGE uses an initial pressure ≤8 mmHg as a placement indicator; pressure must be interpreted with flow and the clinical situation. High or unexpected pressure, poor flow, asymmetric distension or blood or enteric aspiration should trigger reassessment. “Two pops,” a negative aspiration test or a hanging drop alone is insufficient to confirm safe placement or exclude injury.[7][8][3]

Avoid repeated blind attempts at the same site. Reassess early and change the site or method when entry is unsuccessful; ISGE specifically recommends an alternative after three failed umbilical Veress attempts.[3]

Insufflation and trocar placement​

Use pressure and the patient's physiology to guide insufflation rather than a fixed gas volume. ISGE suggests transient insufflation to 25 mmHg in healthy women for trocar entry (Grade II-1/A), then reduction to 12–16 mmHg after all trocars are placed; its recommendation has not been established for patients with compromised cardiopulmonary function or prolonged robotic positioning.[3][4]

After initial access, inspect the entry region and underlying viscera. Place secondary ports under direct laparoscopic vision, identifying abdominal-wall vessels and the actual underlying anatomy. Surface transillumination does not reliably locate deep epigastric vessels. Fixed distances from the midline and the instruction “always lateral to rectus” are not substitutes for visualization.[9][3]

Entry Sites​

SiteWhen it may helpLimits and safeguards
UmbilicusA thin abdominal-wall access point in many patients.Umbilical hernia, mesh or suspected adhesions may change the plan. Vessel depth and level vary with habitus and position.
Palmer's pointApproximately 3 cm below the left costal margin in the midclavicular line; an option when umbilical adhesions or failed entry are concerns.Avoid with suspected LUQ adhesions, relevant previous gastric/splenic surgery, gastric distension, splenomegaly or portal-hypertensive vessels. Decompress the stomach and assess the actual anatomy.
Supraumbilical / other alternative siteMay improve access for selected body habitus, masses or previous scars.Imaging studies describe average distances, not guaranteed safety margins. Select the site and direction for that patient.

The historical 8-mm aortic-bifurcation measurement describes its caudal level relative to the umbilicus, not an 8-mm skin-to-aorta depth. It must not be used to determine a safe insertion depth.[10][11][12][3]

Pneumoperitoneum Physiology​

Carbon dioxide is the standard insufflation gas because it is non-combustible and cleared rapidly by the lungs. Nitrous oxide supports combustion and can distend bowel; the poorly blood-soluble inert gases (helium, argon, xenon) carry a higher embolism risk if entrained. Working intra-abdominal pressure is commonly 15 mmHg, but renal and cardiopulmonary effects can occur at that pressure, particularly in patients with limited reserve; use the lowest pressure that provides adequate exposure. A transient increase to 20 mmHg may tamponade venous bleeding and should be returned to the working pressure once no longer needed.[28][29][41]

Elevated intra-abdominal pressure affects several systems. Reduced diaphragmatic excursion and functional residual capacity raise peak inspiratory pressure and worsen ventilation-perfusion mismatch; poor pulmonary reserve (for example COPD) may require open conversion. Inferior vena cava compression combined with hypovolemia can reduce preload, and hypercarbia-driven sympathetic and renin-angiotensin activation raises systemic vascular resistance and afterload; net cardiac output varies with position, volume status and time under pneumoperitoneum and can fall, partly offset by tachycardia, while rapid insufflation can produce vagally mediated bradyarrhythmia.[45] Glomerular filtration rate and urine output may fall during pneumoperitoneum as parenchymal compression, impaired renal venous outflow, reduced cardiac output when present, and renin-angiotensin/ADH activation alter perfusion; oliguria often improves after desufflation. Fluid treatment should follow assessment of volume status and other causes of oliguria rather than routine prehydration.[46] Splanchnic blood flow to the liver, pancreas, stomach, spleen and bowel can fall as pressure rises. In the laparoscopic arm (20 patients) of a 40-patient randomized left-sided colectomy trial, colonic tissue oxygen pressure was lower at 15 than 10 mmHg (63.2 versus 76.6 mmHg; p = 0.03).[42] A 2023 colorectal-surgery review identified one trial in older patients with less postoperative ileus after laparoscopy, while a right-hemicolectomy synthesis it discussed found no difference.[43][28][29]

Pressure selection​

A Cochrane review of low versus standard pressure during laparoscopic cholecystectomy found low- or very-low-certainty evidence and too few serious events to establish comparative safety.[30] A randomized trial of ultralow (6 mmHg) versus standard (15 mmHg) pneumoperitoneum during robotic prostatectomy found lower immediate and maximum pain scores and less shoulder and groin pain at 6 mmHg, similar blood loss, no significant difference in morphine equivalents, and a modestly longer console time (135 versus 128 minutes, p = 0.02); oncologic outcomes were not reported.[31] A 2026 synthesis of five randomized RARP trials (576 patients) found no pooled pain or opioid benefit at the assessed postoperative time points with pressure below 12 mmHg; blood loss and operative time increased modestly, without a detected difference in transfusion or complications. The five RARP trials did not assess pressure choice for GU reconstruction.[37]

Hypercarbia​

CO₂ absorption across the peritoneum worsens with high intra-abdominal pressure, prolonged operative time, Trendelenburg positioning and the retroperitoneal approach; COPD and other restrictive pulmonary disease raise the risk. For intraoperative hypercarbia, coordinate ventilation adjustment with anesthesia and consider reducing insufflation pressure when surgical exposure permits.[38] When hypercarbia risk is anticipated (COPD, prolonged Trendelenburg, long cases, extensive subcutaneous insufflation), minimizing Trendelenburg and targeting 6–8 mmHg insufflation can help prevent it. If ventilation adjustment and pressure reduction fail, release pneumoperitoneum and reverse Trendelenburg at a safe stopping point; persistent hypercarbia may require open conversion.[28][29] A valveless system provided more stable pressure but did not improve blood-gas measures in a 100-patient randomized prostatectomy trial.[32] Helium has been explored as an alternative insufflation gas, but its clinical safety remains unestablished, particularly in high anesthetic-risk patients.[44]

Gas conditioning and valveless insufflation​

Dry, room-temperature CO₂ is conventional. A 2015 review reported less hypothermia and pain with warmed, humidified gas.[33] A 2024 review of six colorectal randomized trials (418 patients, including some open-surgery comparisons) did not detect a core-temperature difference in the three trials pooled for that endpoint; a three-trial pain analysis reported higher day-1 pain scores with warmed, humidified gas. Both pooled results were very low certainty.[47] A valveless trocar insufflation system maintains more stable intra-abdominal pressure during instrument exchange and suction and improves smoke evacuation. A randomized comparison during robotic prostatectomy at ultralow pressure found the valveless system achieved a lower maximum peritoneal pressure than a conventional insufflator (7.9 versus 9.9 mmHg, p < 0.001), without a difference in blood-gas or pain outcomes.[32] Gasless laparoscopy, using mechanical abdominal-wall retraction instead of gas, has been described as an alternative that avoids CO₂-related physiologic effects but is not in routine use.

Entry-Related Complications​

Major vascular injury​

Suspect great-vessel injury with unexplained hemodynamic deterioration, brisk bleeding or an expanding retroperitoneal hematoma. Alert anesthesia, activate hemorrhage support and obtain vascular help. A trocar may tamponade an injury: do not remove it blindly before a control plan is established. Uncontrolled bleeding or instability requires prompt open exposure and hemorrhage control. Selected laparoscopic repairs reported in stable patients do not justify delaying conversion.[13]

While personnel and equipment are mobilized, initial temporizing measures can include raising pneumoperitoneum pressure to 20–25 mmHg for tamponade, holding direct pressure on the injury (typically with a mini-laparotomy pad) with adequate suction available, and cautery or clips for small bleeding vessels. Small venous tears of the renal vein or inferior vena cava can often be controlled for several minutes with direct pressure from a mini-laparotomy pad or another hemostatic product. Moderate or severe injury usually needs sutured repair: adding trocars, placing a hand-port or converting to open, with laparoscopic bulldog clamps for proximal and distal control before suturing. Keeping a pre-prepared rescue stitch on the field, a short prolene suture with a Vicryl clip on the tail, allows rapid suturing without knot-tying. Involve vascular surgery intraoperatively according to injury severity and the operating surgeon's experience.[13]

See Vascular Management & Damage Control.

Abdominal-wall vessel injury​

Control bleeding under direct vision. Options include compression or trocar tamponade, energy when safely applicable, or suture ligation; persistent bleeding or a postoperative hematoma may require surgical or interventional-radiology treatment. Inspect ports as they are removed because a cannula can temporarily hide bleeding. Avoid blind full-thickness sutures that could capture bowel.[9][14]

Balloon-catheter tamponade. For an inferior epigastric artery injury at a 5-mm port, one described option is to pass a 10- or 12-Fr Foley catheter through the port, inflate its balloon with the fluid and volume specified for the selected catheter (sterile water when permitted), then withdraw the trocar and apply traction (clamping the catheter against the skin if needed) until hemostasis is achieved; the catheter can be left under traction for a period of observation before removal.[40] If catheter tamponade and bipolar control fail, interrupted sutures placed on both sides of the port and tied externally are an alternative.[36]

Bowel injury​

Inspect a suspected injury completely and seek appropriate surgical help. Management depends on depth, mechanism, tissue viability, location, contamination and patient stability. A superficial serosal abrasion with intact viable bowel is different from an enterotomy, devascularization or thermal injury; not every abrasion needs repair, and not every perforation needs resection.

Missed injuries can present after an initially reassuring recovery, including several days later. Increasing pain, distension, persistent ileus, fever, tachycardia or systemic deterioration merit urgent assessment. A normal white count does not exclude injury. Stable patients may need prompt contrast-enhanced CT and surgical review; peritonitis, sepsis with a suspected uncontrolled source or instability requires urgent source control. Do not wait for a fixed 96-hour window or a particular symptom constellation.[15][16][17][18]

Use Intraoperative Bowel Handling & Injury Management for the repair, resection and delayed-recognition pathway.

Gas embolism​

CO₂ can enter an injured vessel during initial insufflation or later dissection. Clinical severity ranges from subclinical echocardiographic bubbles to collapse; a single incidence number cannot describe both. Sudden changes in end-tidal CO₂, hypoxemia, hypotension or arrhythmia warrant immediate evaluation. End-tidal CO₂ may briefly rise or fall; a “mill-wheel” murmur is not required.[19]

Stop insufflation, release pneumoperitoneum and initiate coordinated anesthetic resuscitation with 100% oxygen. Treat shock and perform standard CPR when indicated. The 2025 AHA guideline considers level supine or recovery positioning reasonable; CPR requires supine positioning. It does not make routine head-down positioning mandatory. In adults, aspiration may be reasonable for known, accessible right-ventricular gas; it is not a reason to delay resuscitation.[20][19]

Seek hyperbaric expertise urgently for life-threatening gas embolism, particularly suspected arterial or cerebral involvement. AHA considers hyperbaric oxygen reasonable, while acknowledging limited evidence and uncertainty across gas types and mechanisms. It is not an automatic treatment for every transient CO₂ microbubble finding.[20]

A randomized liver-resection study found fewer high-grade TEE-detected gas emboli at 10 versus 15 mmHg.[21]

Subcutaneous emphysema, capnothorax and pneumothorax​

Improper Veress-needle position or CO₂ leakage around a trocar can track gas into the extraperitoneal tissues, producing crepitus of the abdomen or thorax and, occasionally, pneumoscrotum. Because CO₂ is absorbed rapidly, subcutaneous emphysema typically resolves within 24–48 hours; extensive tracking can progress to pneumomediastinum, pneumothorax or pneumopericardium and can contribute to hypercarbia. Pneumothorax can present with increased airway pressure and falling oxygen saturation and may be confirmed by chest radiograph. Capnothorax is a CO₂ pneumothorax that can follow diaphragmatic injury during laparoscopic renal surgery; after release of pneumoperitoneum and supplemental oxygen, selected stable patients may be observed as CO₂ is absorbed. Symptomatic patients or those with a large diaphragmatic defect generally require chest drainage.[39] Prevention rests on proper Veress placement and a skin incision sized to avoid gas leakage around the trocar without being so small that it increases the force needed for insertion.[28][29]

Trocar-site hernia​

The EHS/AHS guideline suggests closing fascial defects ≥10 mm, especially umbilical and single-incision sites.[22] Assess the final defect after extraction or stretching. Evidence for the optimal closure method is limited. A small trial studied prophylactic mesh at the umbilical extraction site after selected high-risk cholecystectomies.[22][23]

Trocar design affects this risk. Dilating (radially expanding or blunt-tip) trocars separate rather than cut fascial fibers, leaving a smaller defect than a cutting or bladed trocar of the same diameter; the EHS/AHS guideline weakly suggests suturing the fascial defect for trocar sites of 10 mm or larger, especially at umbilical and single-incision sites, without a trocar-design exception.[22] A Cochrane review found very-low-certainty evidence of less trocar-site bleeding with radially expanding than cutting trocars (assumed risks 11.5% versus 3.5%; Peto OR 0.28, 95% CI 0.14–0.54; five trials, 553 participants).[34] Major visceral and vascular injuries were too rare to rank trocar types.[34] Inspect the final defect at removal. For a trocar site of 10–12 mm, the EHS/AHS guideline weakly suggests suturing the fascial defect; a fingertip test alone is not a validated exception.[22]

See Incisions & Closure for incision selection, closure and interpretation of hernia rates.

High-Risk Patients​

SituationPractical approach
ObesityAssess wall thickness, needle/trocar length, pannus position and trajectory. Optical, open and Veress methods each have limitations. Average imaging distances do not mean that abdominal organs are beyond the reach of the needle.[24][3]
Extensive prior surgeryAnticipate adhesions and choose access away from likely adherent viscera. Open or optical entry can help visualize wall layers but can still injure bowel attached immediately underneath.
Portal hypertension / cirrhosisReview cross-sectional imaging and consider ultrasound mapping when abdominal-wall collaterals are a concern. Plan with anesthesia and hepatology according to liver severity, portal hypertension and the operation. No access device substitutes for disease-specific risk assessment.[25][26]
Very low BMIGreat vessels may be close to the wall. Limit force and insertion depth, and choose an entry route suited to the anatomy; a routine fixed angle or wall lift does not guarantee protection.[3]

A small randomized study of subxiphoid optical access in previously operated patients compared it with a combined Palmer's-point Veress plus subumbilical optical strategy. It was not a simple comparison of two needle sites, and liver injuries occurred with subxiphoid access. Treat it as a selected technical option rather than a general recommendation.[27]

Operative Pearls​

  1. Plan an alternative site and technique before repeated failed entry.
  2. Interpret pressure, flow and anatomy together; no placement test excludes all injuries.
  3. Inspect the initial entry and place secondary ports under direct vision.
  4. Respond to suspected vascular, bowel or gas-embolism complications promptly, with conversion or resuscitation as required.
  5. Inspect port sites for bleeding and close appropriate final fascial defects.

See Also​

References​

1. Recknagel JD, Goodman LR. "Clinical perspective concerning abdominal entry techniques." J Minim Invasive Gynecol. 2021;28(3):467-474. doi:10.1016/j.jmig.2020.07.010

2. Ahmad G, Baker J, Finnerty J, Phillips K, Watson A. "Laparoscopic entry techniques." Cochrane Database Syst Rev. 2019;1:CD006583. doi:10.1002/14651858.CD006583.pub5

3. Djokovic D, Gupta J, Thomas V, et al. "Principles of safe laparoscopic entry." Eur J Obstet Gynecol Reprod Biol. 2016;201:179–188. doi:10.1016/j.ejogrb.2016.03.040

4. Miguel A, Brás S, Pinto MG, Djokovic D. "Principles of safe laparoscopic entry: a summary of the International Society for Gynecologic Endoscopy guidelines and the search for updates." The Trocar. 2021;2(2). Society publication

5. Raimondo D, Raffone A, Travaglino A, et al. "Laparoscopic entry techniques: which should you prefer?" Int J Gynaecol Obstet. 2023;160(3):742-750. doi:10.1002/ijgo.14412

6. Gardella B, Dominoni M, Cassani C, et al. "Does the abdominal entry method in laparoscopy really matter? A network meta-analysis of rare events in randomized trials." Eur J Obstet Gynecol Reprod Biol. 2026;318:114925. Published online December 29, 2025. doi:10.1016/j.ejogrb.2025.114925

7. Yoong W, Saxena S, Mittal M, et al. "The pressure profile test is more sensitive and specific than Palmer's test in predicting correct placement of the Veress needle." Eur J Obstet Gynecol Reprod Biol. 2010;152(2):210-213. doi:10.1016/j.ejogrb.2010.06.007

8. Teoh B, Sen R, Abbott J. "An evaluation of four tests used to ascertain Veres needle placement at closed laparoscopy." J Minim Invasive Gynecol. 2005;12(2):153-158. doi:10.1016/j.jmig.2005.01.011

9. Saber AA, Meslemani AM, Davis R, Pimentel R. "Safety zones for anterior abdominal wall entry during laparoscopy: a CT scan mapping of epigastric vessels." Ann Surg. 2004;239(2):182-185. doi:10.1097/01.sla.0000109151.53296.07

10. Sriprasad S, Yu DF, Muir GH, Poulsen J, Sidhu PS. "Positional anatomy of vessels that may be damaged at laparoscopy: new access criteria based on CT and ultrasonography to avoid vascular injury." J Endourol. 2006;20(7):498-503. doi:10.1089/end.2006.20.498

11. Giannios NM, Gulani V, Rohlck K, et al. "Left upper quadrant laparoscopic placement: effects of insertion angle and body mass index on distance to posterior peritoneum by magnetic resonance imaging." Am J Obstet Gynecol. 2009;201(5):522.e1-522.e5. doi:10.1016/j.ajog.2009.07.017

12. Stanhiser J, Goodman L, Soto E, et al. "Supraumbilical primary trocar insertion for laparoscopic access: the relationship between points of entry and retroperitoneal vital vasculature by imaging." Am J Obstet Gynecol. 2015;213(4):506.e1-506.e5. doi:10.1016/j.ajog.2015.05.060

13. Sandadi S, Johannigman JA, Wong VL, et al. "Recognition and management of major vessel injury during laparoscopy." J Minim Invasive Gynecol. 2010;17(6):692-702. doi:10.1016/j.jmig.2010.06.005

14. Chatzipapas IK, Magos AL. "A simple technique of securing inferior epigastric vessels and repairing the rectus sheath at laparoscopic surgery." Obstet Gynecol. 1997;90(2):304-306. doi:10.1016/S0029-7844(97)00211-1

15. van der Voort M, Heijnsdijk EA, Gouma DJ. "Bowel injury as a complication of laparoscopy." Br J Surg. 2004;91(10):1253-1258. doi:10.1002/bjs.4716

16. Bishoff JT, Allaf ME, Kirkels W, et al. "Laparoscopic bowel injury: incidence and clinical presentation." J Urol. 1999;161(3):887-890. doi:10.1016/s0022-5347(01)61797-x

17. Schrenk P, Woisetschläger R, Rieger R, Wayand W. "Mechanism, management, and prevention of laparoscopic bowel injuries." Gastrointest Endosc. 1996;43(6):572-574. doi:10.1016/s0016-5107(96)70193-1

18. Schwartz MJ, Faiena I, Cinman N, et al. "Laparoscopic bowel injury in retroperitoneal surgery: current incidence and outcomes." J Urol. 2010;184(2):589-594. doi:10.1016/j.juro.2010.03.133

19. Park EY, Kwon JY, Kim KJ. "Carbon dioxide embolism during laparoscopic surgery." Yonsei Med J. 2012;53(3):459–466. doi:10.3349/ymj.2012.53.3.459

20. Cao D, et al. "Part 10: Adult and Pediatric Special Circumstances of Resuscitation: 2025 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care." Circulation. 2025;152(suppl 2):S578–S672. Section 13, Gas Embolism. doi:10.1161/CIR.0000000000001380. AHA guideline

21. Luo W, Jin D, Huang J, et al. "Low pneumoperitoneum pressure reduces gas embolism during laparoscopic liver resection: a randomized controlled trial." Ann Surg. 2024;279(4):588-597. doi:10.1097/SLA.0000000000006130

22. Deerenberg EB, Henriksen NA, Antoniou GA, et al. "Updated guideline for closure of abdominal wall incisions from the European and American Hernia Societies." Br J Surg. 2022;109(12):1239-1250. doi:10.1093/bjs/znac302

23. Armañanzas L, Ruiz-Tovar J, Arroyo A, et al. "Prophylactic mesh vs suture in the closure of the umbilical trocar site after laparoscopic cholecystectomy in high-risk patients for incisional hernia: a randomized clinical trial." J Am Coll Surg. 2014;218(5):960-968. doi:10.1016/j.jamcollsurg.2014.01.049

24. Chaves KF, Apple AN, Johnson JC, Jesse NJ, Yunker AC. "Abdominal wall thickness at Palmer's point and distance to adjacent structures across the body mass index spectrum." J Minim Invasive Gynecol. 2022;29(7):848-854. doi:10.1016/j.jmig.2022.03.007

25. Criss CN, Ralls MW, Jarboe MD. "Ultrasound-guided access into the abdomen in the setting of portal hypertension: a novel technique." J Laparoendosc Adv Surg Tech A. 2017;27(3):328-331. doi:10.1089/lap.2016.0514

26. Mahmud N, Fricker ZP, McElroy LM, et al. "ACG clinical guideline: perioperative risk assessment and management in patients with cirrhosis." Am J Gastroenterol. 2025;120(9):1968-1984. doi:10.14309/ajg.0000000000003616

27. Elbanna MR, Helmy RF, Sabry AM, El Zemeity AO. "A new laparoscopic entry point in patients with previous laparotomy: a prospective comparative study." Surg Laparosc Endosc Percutan Tech. 2022;32(4):420-424. doi:10.1097/SLE.0000000000001069

28. Gerges FJ, Kanazi GE, Jabbour-Khoury SI. "Anesthesia for laparoscopy: a review." J Clin Anesth. 2006;18(1):67-78. doi:10.1016/j.jclinane.2005.01.013

29. Henny CP, Hofland J. "Laparoscopic surgery: pitfalls due to anesthesia, positioning, and pneumoperitoneum." Surg Endosc. 2005;19(9):1163-1171. doi:10.1007/s00464-004-2250-z

30. Gurusamy KS, Vaughan J, Davidson BR. "Low pressure versus standard pressure pneumoperitoneum in laparoscopic cholecystectomy." Cochrane Database Syst Rev. 2014;2014(3):CD006930. doi:10.1002/14651858.CD006930.pub3

31. Abaza R, Ferroni MC. "Randomized Trial of Ultralow vs Standard Pneumoperitoneum during Robotic Prostatectomy." J Urol. 2022;208(3):626-632. doi:10.1097/JU.0000000000002729

32. Abaza R, Martinez O, Murphy C. "Randomized Controlled Comparison of Valveless Trocar (AirSeal) vs Standard Insufflator with Ultralow Pneumoperitoneum During Robotic Prostatectomy." J Endourol. 2021;35(7):1020-1024. doi:10.1089/end.2020.1025

33. Binda MM. "Humidification during laparoscopic surgery: overview of the clinical benefits of using humidified gas during laparoscopic surgery." Arch Gynecol Obstet. 2015;292(5):955-971. doi:10.1007/s00404-015-3717-y

34. la Chapelle CF, Swank HA, Wessels ME, et al. "Trocar types in laparoscopy." Cochrane Database Syst Rev. 2015;2015(12):CD009814. doi:10.1002/14651858.CD009814.pub2

35. Brill AI, Nezhat F, Nezhat CH, Nezhat C. "The Incidence of Adhesions After Prior Laparotomy: A Laparoscopic Appraisal." Obstet Gynecol. 1995;85(2):269–272. doi:10.1016/0029-7844(94)00352-E

36. Yeung E, Maher C. Prevention, Recognition and Treatment of Complications in Laparoscopic Pelvic Floor Surgery. In: Cardozo L, Staskin D, eds. Textbook of Female Urology and Urogynecology. Vol 2: Surgical Perspectives. 5th ed. CRC Press; 2023:1098–1108. doi:10.1201/9781003144243-110

37. Ramirez-Paliza Y, Kasimieh O, Sanha V, et al. "Low-pressure pneumoperitoneum in robot-assisted radical prostatectomy: a systematic review, meta-analysis and trial sequential analysis of randomized controlled trials." Int Urol Nephrol. 2026. doi:10.1007/s11255-026-05383-y

38. Carey BM, Jones CN, Fawcett WJ. "Anaesthesia for minimally invasive abdominal and pelvic surgery." BJA Educ. 2019;19(8):254–260. doi:10.1016/j.bjae.2019.04.001

39. Msezane LP, Zorn KC, Gofrit ON, Schade GR, Shalhav AL. "Case report: conservative management of a large capnothorax following laparoscopic renal surgery." J Endourol. 2007;21(12):1445-1447. doi:10.1089/end.2007.0122

40. European Association of Urology Nurses. "Indwelling catheterisation in adults: urethral and suprapubic." 2024. §5.2.4. Guideline.

41. Villa G, Fiorentino M, Cappellini E, Lassola S, De Rosa S. "Renal implications of pneumoperitoneum in laparoscopic surgery: mechanisms, risk factors, and preventive strategies." Korean J Anesthesiol. 2024;77(6):575-586. doi:10.4097/kja.24011

42. Gianotti L, Nespoli L, Rocchetti S, Vignali A, Nespoli A, Braga M. "Gut oxygenation and oxidative damage during and after laparoscopic and open left-sided colon resection: a prospective, randomized, controlled clinical trial." Surg Endosc. 2011;25(6):1835-1843. doi:10.1007/s00464-010-1475-2

43. Chaouch MA, Daghmouri MA, Lahdheri A, et al. "How to prevent postoperative ileus in colorectal surgery? a systematic review." Ann Med Surg (Lond). 2023;85(9):4501-4508. doi:10.1097/MS9.0000000000001099

44. Yang X, Cheng Y, Cheng N, et al. "Gases for establishing pneumoperitoneum during laparoscopic abdominal surgery." Cochrane Database Syst Rev. 2022;3(3):CD009569. doi:10.1002/14651858.CD009569.pub4

45. Hirvonen EA, Poikolainen EO, Pääkkönen ME, Nuutinen LS. "The adverse hemodynamic effects of anesthesia, head-up tilt, and carbon dioxide pneumoperitoneum during laparoscopic cholecystectomy." Surg Endosc. 2000;14(3):272-277. doi:10.1007/s004640000038

46. Tallarico RT, McCoy IE, Dépret F, Legrand M. "Meaning and management of perioperative oliguria." Anesthesiology. 2024;140(2):304-312. doi:10.1097/ALN.0000000000004746

47. Sharma S, McKechnie T, Khamar J, Wu K, Hong D, Eskicioglu C. "The role of warmed-humidified carbon dioxide insufflation in colorectal surgery: a systematic review and meta-analysis." Colorectal Dis. 2024;26(1):7-21. doi:10.1111/codi.16798