INTRODUCTION — In gynecology, laparoscopic surgery is used for many procedures that were traditionally performed via laparotomy. These are performed for benign and malignant diseases. Conventional (also referred to as "straight stick") and robotic approaches are used.
General issues related to gynecologic laparoscopic procedures will be reviewed here. Laparoscopic access, instrumentation, and complications, as well as robot-assisted laparoscopy, are discussed separately. (See "Abdominal access techniques used in laparoscopic surgery" and "Instruments and devices used in laparoscopic surgery" and "Complications of laparoscopic surgery" and "Robot-assisted laparoscopy".)
Specific uses of laparoscopy are discussed in individual topic reviews, including:
●(See "Hysterectomy: Laparoscopic".)
In this topic, when discussing study results, we will use the terms "woman/en" or "patient(s)" as they are used in the studies presented. However, we encourage the reader to consider the specific counseling and treatment needs of transgender and gender-expansive individuals.
LAPAROSCOPY VERSUS LAPAROTOMY — Potential advantages of laparoscopy over laparotomy include less postoperative pain, shorter operative time (for some, but not all, procedures), smaller scars, faster recovery, decreased adhesion formation, and decreased cost [1-3]. A meta-analysis of 27 randomized trials comparing laparoscopy with laparotomy for benign gynecologic conditions found the overall risk of minor complications (eg, fever, wound or urinary tract infection) was lower in women undergoing laparoscopic procedures (relative risk 0.55, 95% CI 0.45-0.66) . In comparison, both groups had the same risk of major complications, such as pulmonary embolus, transfusion, fistula formation, and major additional unplanned surgery.
PREOPERATIVE EVALUATION AND PREPARATION — Preoperative evaluation and preparation for gynecologic surgery is discussed in detail separately. (See "Overview of preoperative evaluation and preparation for gynecologic surgery".)
In brief, issues that are included in the preoperative evaluation and preparation for gynecologic laparoscopic surgery include:
●Medical comorbidities that impact hemostasis or the ability to tolerate surgery. A particular issue in laparoscopic surgery is the ability to tolerate the increased intraabdominal pressure due to pneumoperitoneum and Trendelenburg position.
●Risk factors for adhesive disease or umbilical or ventral hernia repair. These may impact the choice of site of laparoscopic access and increase the risk of complications related to laparoscopic entry (see 'Choice of access site and techniques' below). In addition, extensive pelvic adhesions may increase the likelihood of conversion to laparotomy, and this possibility should be included in the informed consent process.
●Appropriate preoperative testing, including pregnancy testing in reproductive-age women.
●Planning for antibiotic prophylaxis and thromboprophylaxis, depending upon the patient characteristics and procedure.
●Initiation of an enhanced recovery after surgery (ERAS) protocol in appropriate cases. (See "Enhanced recovery after gynecologic surgery: Components and implementation".)
Bowel preparation is no longer standard practice prior to gynecologic surgery. (See "Overview of preoperative evaluation and preparation for gynecologic surgery", section on 'Bowel preparation'.)
Removal of umbilical jewelry is required prior to laparoscopic surgery. This is discussed separately. (See "Overview of preoperative evaluation and preparation for gynecologic surgery", section on 'Piercings and tattoos'.)
PATIENT POSITIONING AND PREPARATION — The patient is placed in a supine or dorsal lithotomy position for laparoscopic surgery. It is important to carefully position the patient to avoid neurologic injury, provide for ergonomic surgeon positioning, and allow adequate access to the vagina, if necessary.
The patient's arms may be tucked carefully by her sides with appropriate padding and access to intravenous lines. Many surgeons find this provides the best access to the operative field. If the arms are tucked, they are placed in military position (palms facing toward lateral thighs) with padding protecting the posteromedial aspect of the elbows, wrists and hands. Alternatively, if the arms are abducted and placed on arm boards, careful attention should be paid to maintaining neutral shoulder positioning at a <90° angle to avoid brachial plexus injury . Surgical positioning to avoid neural injury is discussed in detail separately. (See "Nerve injury associated with pelvic surgery", section on 'Prevention of nerve injury'.)
Dorsal lithotomy position provides access to the vagina for examination or use of instruments. If the dorsal lithotomy position is used, the patient's legs are placed in booted stirrups (eg, Allen-type stirrups). Stirrups may be fixed or allow for adjustment of the leg position during the procedure. It is important to maintain moderate flexion at the knee and hip with minimal abduction or external rotation at the hip [5,6]. It may also be helpful to utilize a bolster underneath the patient's buttocks to elevate the hips and enhance mobilization of intestines into the upper abdomen. The buttocks should be a few centimeters beyond the edge of the table to allow uterine manipulation.
At the start of the procedure, the table should be in level position, with the height lowered to allow for relaxed arm positioning for all operators. We find it convenient to place a video monitor directly facing each surgeon at or 15° below eye level to decrease neck strain with a distance of approximately 60 cm . This is based on emerging evidence of work-related musculoskeletal disorders due to improper ergonomics during laparoscopic surgery [8,9].
Trendelenburg position is typically used to displace the intestines to allow visualization of the pelvic viscera. Several methods may be used to prevent migration in Trendelenburg position: egg-crate foam directly beneath the patient , a vacuum-beanbag mattress, or shoulder braces. Steep Trendelenburg (30° to 45°) and the use of braces may contribute to brachial plexus injury .
Further details on patient positioning to avoid neural injury are discussed separately. (See "Nerve injury associated with pelvic surgery", section on 'Avoid patient malposition'.)
A bladder catheter is useful to decompress the bladder. Bladder distension increases the risk of bladder perforation and may obscure the operative field. (See "Complications of laparoscopic surgery", section on 'Entry-related bladder injuries'.)
INSTRUMENTATION — Instruments and devices used in laparoscopic surgery including laparoscopes (picture 1), imaging systems, devices for dissection (picture 2 and picture 3) and hemostasis, suction (picture 4), and tissue removal (picture 5) are discussed elsewhere. (See "Instruments and devices used in laparoscopic surgery".)
Almost all instruments available for laparotomy are now available for use during laparoscopy. Laparoscopic instruments are reviewed in detail separately. (See "Instruments and devices used in laparoscopic surgery".)
Uterine cannula and manipulators — The uterine cannula is an instrument that is unique to gynecologic laparoscopy. It is used to manipulate the uterus and thereby facilitate access to and inspection of pelvic structures. Most cannulas also permit injection of a dye solution (chromopertubation) to assess tubal patency. A variety of uterine manipulators are available. The most widely used reusable manipulators are the Cohen cannula (picture 6) and the Hulka uterine manipulator (picture 7).
A uterine cannula should not be used for uterine manipulation when:
●An intrauterine pregnancy is suspected
●The uterus is absent
●Anomalies exist that prevent exposure of or access to the cervix
●The patient is prepubescent
Of note, disposable and reusable manipulators, which delineate the vaginal fornices and allow for motion at the axis of the cervix, are more commonly used than the uterine cannula for advanced laparoscopic surgery, including hysterectomy and procedures treating severe endometriosis, large uteri, and significant pelvic adhesions. They also often provide options for preventing loss of pneumoperitoneum if culdotomy is performed (ie, surgical incision from posterior vaginal fornix into cul-de-sac). For women who have undergone prior hysterectomy, a sponge stick, or examining hand, may be positioned in the vagina to manipulate the vaginal cuff.
ABDOMINAL ACCESS SITES
Umbilical access — Gynecologic laparoscopic entry is commonly at or through the umbilicus . Initial entry can also be performed through other sites on the abdominal wall or through the vagina or uterus. It is important to consider alternative access sites when umbilical entry is risky or difficult. (See 'Non-umbilical access' below.)
The traditional technique for laparoscopic entry for gynecologic laparoscopy is to blindly pass a sharp Veress needle, typically at the umbilicus, insufflate, and then to pass a sharp trocar. Veress techniques for entry and other direct entry methods, such as open access (Hasson) or the use of optical trocars or radially-expanding trocars, are discussed in detail elsewhere (see "Abdominal access techniques used in laparoscopic surgery", section on 'Initial port placement'). Two systematic reviews of umbilical entry techniques concluded that there is no evidence that one approach is superior to another [12,13]. The choice of approach is best determined by the clinical scenario and surgeon skill set. As an example, patients who are likely to have adhesions may benefit from an open approach because any injury would be more likely identified.
Trocar placement — For multi-port laparoscopic hysterectomy (as opposed to a single port technique), port placement typically involves a primary port at the umbilicus with two accessory ports in the bilateral lower quadrants (figure 1). To avoid injury to nerves or blood vessels in the abdominal wall (notably the ilioinguinal and iliohypogastric nerves, superficial and inferior epigastric arteries), the lower quadrant ports are placed approximately 2 cm medial and at or superior to the anterior superior iliac spine, lateral to the border of the rectus [14,15].
A fourth port may be useful, particularly in cases involving extensive dissection or laparoscopic suturing, and can be placed suprapubically or in the lateral abdominal wall at the level of the umbilicus. In cases of enlarged uteri where the fundus approaches the level of the umbilicus, it may be necessary to place the ports higher on the abdominal wall to ensure proper distance for visualization and instrument operation.
Techniques for abdominal access in laparoscopy are discussed in detail separately. (See "Abdominal access techniques used in laparoscopic surgery".)
Non-umbilical access — Certain factors increase the risk for complications when an umbilical access site is used. These include periumbilical adhesions, periumbilical mesh, umbilical or ventral hernia, large pelvic mass, and pregnancy. In addition, umbilical entry may be dangerous, difficult or impossible in patients who are obese, extremely thin, highly muscular, or have extreme abdominal wall laxity. Non-umbilical access (abdominal or non-abdominal) may be preferred under these circumstances and the choice of which site to use is discussed below. (See 'Candidates for non-umbilical access' below and 'Choice of non-umbilical abdominal site' below.)
Abdominal sites — Non-umbilical abdominal access sites can be used for initial entry and/or insufflation. Sites commonly used in gynecologic laparoscopy include the left 9th intercostal space or the left costal margin at Palmer's point (3 cm below the left costal margin in the left mid-clavicular line) (figure 2), but other sites in the midline abdomen and hypogastric region can also be used. Anatomy and techniques for access at these other sites are discussed in detail elsewhere. (See "Abdominal access techniques used in laparoscopic surgery", section on 'Access locations' and "Abdominal access techniques used in laparoscopic surgery", section on 'Initial port placement'.)
Non-abdominal sites — Non-abdominal access through the uterus or posterior vaginal cul-de-sac has been reported, but is rarely used.
Transvaginal — The pouch of Douglas or posterior cul-de-sac is posterior to the uterus and cervix. It has long been accessed through the posterior vaginal fornix for diagnostic purposes (culdocentesis) or for surgical access (colpotomy). Access through this site is also referred to as culdolaparoscopy. (See "Culdocentesis" and "Hysterectomy: Vaginal".)
The posterior vaginal fornix is a useful site for laparoscopic entry. It has primarily been used for insufflation, but there are reports of vaginal port placement . Data regarding this approach are from the 1970s and 1980s, a time when gynecologists were more familiar with culdocentesis and with colpotomy for procedures other than vaginal hysterectomy [17,18]. Nevertheless, this is still a valid approach for a surgeon who is familiar with the use of this site. There has been renewed interest in natural orifice transluminal endoscopic approaches through the vagina for both gynecologic and nongynecologic procedures. (See "Hysterectomy: Vaginal", section on 'Use of vaginal laparoscopy'.)
The posterior cul-de-sac is in close proximity to the uterine vessels, ureter, and rectum. However, the uterus may be adherent to the rectum if the patient has had prior posterior fornix surgery or if fixed uterine retroversion is present. Thus, these factors are relative contraindications to using the posterior vaginal fornix approach.
The utility of this procedure was evaluated in a series of patients who underwent laparoscopy using the posterior vaginal fornix entry; insufflation was successful in 103 of 107 patients . One failure was due to instrumentation, and the other three were due to lateral placement of the Veress needle. No serious complications were reported.
The following steps are involved in using the posterior vaginal fornix for laparoscopic entry:
●Place the patient in moderate Trendelenburg position to allow the bowel to fall away from the cervix and uterus.
●Place a tenaculum on the posterior lip of the cervix and elevate the cervix (figure 3). This exposes the posterior fornix and places the vaginal mucosa under tension.
●Insert the Veress needle through the posterior fornix at a point approximately 1.75 cm posterior to the cervicovaginal junction . Stay in the midline to avoid injury to the uterine vessels or ureters, which are lateral. A longer Veress needle (150 mm rather than 120 mm) is typically easier to use. Do not advance the needle more than 3 cm to avoid injury to the presacral vessels.
●Insufflate; a 10 mmHg pressure reading indicates peritoneal placement.
●Remove the Veress needle and return the patient to horizontal to insert a trocar at another site.
Transuterine — The transuterine approach to insufflation is not commonly used, and data are limited [19,20]. There is the theoretical risk for gas embolism if the needle has not completely exited the myometrium. In current practice, it is of historical interest only.
CHOICE OF ACCESS SITE AND TECHNIQUES — An umbilical access site is typically chosen unless deemed too risky. The use of optical trocars, radially expanding trocars, or open techniques helps to avoid failed insufflation or injury during umbilical entry. Risk factors that suggest the need to choose a non-umbilical site are discussed in the next section. (See 'Candidates for non-umbilical access' below.)
Closed (Veress) needle, visual entry techniques, and open techniques for umbilical access are discussed elsewhere.
Candidates for non-umbilical access — Certain anatomic factors or conditions may increase the risk for complications with umbilical entry such that a non-umbilical access site should be used. These include known or suspected periumbilical adhesions, periumbilical mesh, umbilical or ventral hernia, large pelvic mass, and pregnancy. For individuals with extreme obesity, thinness, or abdominal wall laxity, umbilical access may be dangerous, difficult, or impossible.
Suspected adhesive disease — Adhesive disease may be suspected in patients with bowel obstruction or a history of prior intraabdominal surgery, malignancy, or infection. Those who have had a prior periumbilical incision (eg, postpartum tubal ligation, laparoscopy, umbilical or other ventral hernia repair) are at particular risk for adhesions of omentum or bowel to the anterior abdominal wall [11,21].
In a systematic review, the estimated risks for umbilical and/or anterior abdominal wall adhesions were 0 to 5 percent for women with no prior surgery, 20 to 30 percent for those with a previous transverse suprapubic laparotomy, and 50 to 65 percent for those with a previous midline laparotomy . The reported risk of adhesions after prior laparoscopic surgery ranges from 2 to 21 percent in series of over 100 patients [22,23]. Avoidance of umbilical entry in patients who have had a previous laparotomy is supported by a multivariate analysis of over 25,000 laparoscopies in which previous laparotomy was a significant risk factor for a complication . It is difficult to quantify the increase in risk of visceral injury in women with versus without adhesions. Thus, while the safest approach is to use non-umbilical entry in patients with prior laparotomy, many surgeons do enter through the umbilicus.
Periumbilical tattoos or jewelry do not cause intraabdominal adhesions and are not a contraindication to umbilical entry. However, umbilical jewelry should be removed prior to surgery. (See "Overview of preoperative evaluation and preparation for gynecologic surgery", section on 'Piercings and tattoos'.)
Prior ventral hernia repair — Umbilical entry should be avoided in patients who have undergone umbilical or other ventral wall herniorrhaphy and have surgical mesh at or near the umbilicus. In such patients, there is a high likelihood of adhesions to the mesh sites and it is also possible that umbilical entry will disrupt the hernia repair [25,26].
Large pelvic mass — Puncture of a mass should be avoided as it may lead to bleeding or to rupture of an ovarian malignancy, thereby worsening prognosis. (See "Oophorectomy and ovarian cystectomy", section on 'Spillage of malignant cells'.)
The surgeon can calculate the point of contact of the insufflating instrument. The standard Veress needle is 12 cm long from tip to hub, and thus may puncture a mass within this distance from the point of entry. If a 45° angle from the plane of the abdominal wall is used for entry, such a mass would be palpable at approximately 8.5 cm inferior to the umbilicus. However, entry would require adding a margin of safety to this measurement to allow for variations in the insertion angle and changes in the plane of the abdominal wall with elevation or pressure during insertion.
Pregnancy — The risk of trauma during umbilical entry depends upon the size of the gravid uterus and its position relative to the umbilicus. Laparoscopy in pregnancy is reviewed separately. (See "Laparoscopic surgery in pregnancy".)
Obesity — Proximity of the aortic bifurcation to the umbilicus is a primary factor in determining the risk of injury to the major vessels during initial umbilical entry. Surgeons attempt to avoid vascular injury in patients without obesity by elevating the abdominal wall and inserting the initial instrument at a 45° angle from vertical (aimed in the direction of the pelvis).
In patients with obesity, use of an angle more than 45° from vertical often results in preperitoneal insertion and failure of insufflation [27-29]. In a review of 138 women with obesity (weight greater than 114 kg) undergoing laparoscopy, insufflation failure rates were significantly higher with transumbilical insufflation compared with transuterine insufflation (13.9 versus 3.6 percent) .
To address this issue in patients with obesity, many surgeons position the initial Veress needle or trocar at an angle closer to vertical. This is based on the assumption that the umbilicus is likely to be inferior to the level of the aortic bifurcation in obese women.
Extreme thinness — Patients who are extremely thin are also at increased risk, particularly when the sacral promontory is easily palpable [30-32]. In such patients, the great vessels may be within centimeters of the umbilicus and use of a 45° angle from the vertical may not be protective.
Abdominal wall laxity — Extreme abdominal wall laxity can occur due to prior pregnancy or current or prior obesity. Upon attempted initial entry in this setting, the abdominal wall may indent with pressure from the instrument. As a result, the instrument cannot enter the peritoneal cavity, and umbilical entry is not possible.
Choice of non-umbilical abdominal site — For patients in whom there is a need for non-umbilical abdominal access, whether planned or not, the first decision is whether to use the site for insufflation alone or for insufflation and trocar insertion. This choice depends upon the indication for non-umbilical entry. If blind insertion of any instrument at the umbilicus is contraindicated, then insufflation and trocar insertion should be performed at a non-umbilical site. On the other hand, insufflation may ameliorate or alter the concerning anatomical relationships (eg, close proximity of the abdominal wall to the aortic bifurcation). Under this circumstance, trocar insertion can then be performed at the umbilicus.
Palmer's point (3 cm below the left costal margin in the left mid-clavicular line) (figure 2) can be used for insufflation and trocar insertion. Other sites are predominantly used only for insufflation in gynecology, followed by trocar insertion at Palmer's point or the umbilicus. This site is contraindicated in patients with previous splenectomy. Care should be taken to empty the stomach prior to attempting insertion at this site.
An alternate site has been proposed that is lower and more lateral in position compared with Palmer's point and may therefore be more easily used as the main operating port throughout the surgery. Supporting data are limited to a single-case series, and thus routine use is not advised until further studies are available .
Insufflation with trocar insertion at the same site — Patients in whom periumbilical adhesions are suspected should have both insufflation and trocar insertion at a non-umbilical site. In this setting, the peritoneal surface of the umbilicus cannot be assessed until the trocar and port have been placed and the camera inserted.
Thus, in patients with possible adhesive disease or prior periumbilical hernia repair, Palmer's point entry is preferred to other sites since insufflating and inserting the trocar at a single site avoids additional skin puncture.
Following initial entry, it is often possible to use the umbilicus as a secondary port site in patients with suspected adhesive disease. Once the camera is in place, the peritoneal surface of the umbilicus may be found to be free of adhesions or, in many cases, adhesions can be removed. In such patients, an umbilical trocar and port can then be placed safely under direct vision if this is surgically useful.
Insufflation and trocar insertion at separate sites — In patients without suspected adhesive disease or a history of periumbilical hernia repair, it is potentially useful to insufflate at a non-umbilical site followed by trocar insertion at the umbilicus. This is because insufflation ameliorates the original reasons for avoiding umbilical entry in these patients, including:
●Required use of an angle approaching vertical to avoid preperitoneal insufflation – Obesity (see 'Obesity' above)
●Inability to penetrate the peritoneum – Abdominal wall laxity (see 'Abdominal wall laxity' above)
After insufflation, the initial trocar can be placed at Palmer's point or the umbilicus.
The second decision, therefore, is which site to use when insufflation alone is planned. As noted above, if Palmer's point is planned for trocar insertion, insufflation should also be performed at this site to avoid unnecessary skin incisions.
However, if umbilical trocar insertion is planned, the choice of insufflation site depends on surgeon preference. There are no studies comparing the use of different non-umbilical sites in obese or other patients. In current practice, there is greater familiarity with use of the left upper quadrant than the vaginal or uterine approaches.
The left upper quadrant approach has been reported to be successful in patients with class II or III obesity with slight modifications . In a series of 600 successful consecutive left upper quadrant Veress needle placements, a site <1 cm beneath the left costal margin, between the mid-clavicular line and the anterior axillary line was used with only one injury to the muscularis of the transverse colon . During insufflation in this study, intraperitoneal pressures between 7 to 14 mmHg were associated with successful entry and those greater than 20 mmHg with abdominal wall insufflation.
COMPLICATIONS — Severe complications related to laparoscopy in gynecologic patients are rare.
●Overall complication rate – The overall complication rate of laparoscopy is 5.7 per 1000 procedures [24,34,35].
●Vascular complications – A review of 66 studies representing over 197,000 gynecologic surgeries reported an overall vascular complication rate of 0.09 percent (95% CI 0.08-0.10) . Of the 179 reported major vascular injuries, anatomic sites (from most to least common) were:
•Inferior epigastric vessels (47 percent)
•Other or not specified (36 percent)
•Iliac vessels, artery, and/or vein (11 percent)
•Aorta (4 percent)
•Inferior vena cava (2 percent)
●Timing of complications – A review including over 1.5 million gynecologic patients reported complications (any type) in 0.1 to 10 percent of procedures . Over 50 percent of these complications occurred at entry, and 20 to 25 percent of complications were not recognized until the postoperative period. In the above review of vascular complications, 82 percent of injuries occurred during abdominal entry, 93 percent were recognized intraoperatively, and approximately half (55 percent) required laparotomy for repair .
●Risk factors – Risk factors for complications include prior surgery or intraabdominal disease (endometriosis, pelvic inflammatory disease), bowel distension, bladder distension and large pelvic/abdominal masses, among others. (See "Complications of laparoscopic surgery", section on 'Risk factors'.)
Complications of laparoscopic surgery and their management are discussed in detail separately. (See "Complications of laparoscopic surgery".)
SOCIETY GUIDELINE LINKS — Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: Laparoscopic and robotic surgery".)
SUMMARY AND RECOMMENDATIONS
●Advantages of laparoscopy – Laparoscopic surgery has several advantages compared with laparotomy, including less postoperative pain, shorter operative time (for some, but not all, procedures), smaller scars, faster recovery, decreased adhesion formation, and decreased cost. (See 'Laparoscopy versus laparotomy' above.)
●Preoperative evaluation – Preoperative evaluation prior to laparoscopy includes a review of medical comorbidities, appropriate preoperative testing, assessment for risk factors for adhesive disease and other conditions that may alter the anatomy of the abdominal wall and peritoneal cavity (eg, umbilical hernia, appendicitis, pelvic inflammatory disease). (See 'Preoperative evaluation and preparation' above.)
●Intraoperative patient positioning – The standard patient positions for gynecologic laparoscopy are supine or dorsal lithotomy. If the dorsal lithotomy position is used, the patient's legs are placed in stirrups. (See 'Patient positioning and preparation' above.)
●Instruments – Almost all instruments available for laparotomy are now available for use at laparoscopy. Instruments that are particular to laparoscopy include the telescope (camera), instruments for laparoscopic entry, the uterine cannula to manipulate the uterus, and bags and morcellators used for tissue removal. (See 'Instrumentation' above.)
●Entry into abdominal cavity
•Entry at umbilicus – Gynecologic laparoscopic access is commonly through the umbilicus, frequently using a Veress needle for insufflation followed by trocar placement. The use of optical trocars, radially expanding trocars, or open techniques are alternative options for entry. Approximately half of laparoscopic complications are related to initial entry into the peritoneal cavity. There are no data that one entry approach is better than another for reducing the risk of injury upon entry. (See 'Abdominal access sites' above and 'Complications' above.)
-Surgical candidates – Candidates for non-umbilical access include patients with suspected adhesive disease, prior periumbilical surgery or laparotomy, umbilical hernia or prior hernia repair, a large pelvic mass, pregnancy, obesity, extreme thinness, and abdominal wall laxity. (See 'Choice of access site and techniques' above.)
-Anatomic sites of entry – Non-umbilical abdominal sites commonly used in gynecologic laparoscopy include Palmer's point (3 cm below the left costal margin in the left mid-clavicular line) and the left ninth intercostal space (figure 2). Non-abdominal sites include the posterior vaginal fornix, and through the uterus. Palmer's point and the posterior uterine cul-de-sac can be used for both insufflation and trocar insertion. The transuterine approach is largely of historical use, but is used for insufflation alone, followed by trocar insertion at Palmer's point or the umbilicus. (See 'Non-umbilical access' above and 'Non-abdominal sites' above.)
●Prior periumbilical surgery – For patients with a history of periumbilical laparotomy who are undergoing laparoscopy with a non-optical trocar:
•We suggest use of Palmer's point rather than other non-umbilical, abdominal sites for insufflation (Grade 2C). (See 'Insufflation with trocar insertion at the same site' above.)
●Impact of body mass index
•Patients with obesity – For patients with obesity who are undergoing laparoscopy, we suggest non-umbilical entry over umbilical entry (Grade 2C). We use an angle closer to vertical rather than 45°. (See 'Obesity' above.)
•Patients with low BMI – For extremely thin patients in whom the sacral promontory is palpable and is within the insertion path of the insufflating instrument, reasonable approaches include a non-umbilical entry site or entry at the umbilicus using an open technique or an optical trocar. (See 'Extreme thinness' above.)
●Pelvic mass or pregnancy – For patients with a pelvic mass or pregnancy which is palpable and is within the insertion path of the insufflating instrument, reasonable approaches include a non-umbilical entry site or entry at the umbilicus using an open technique or an optical trocar. (See 'Large pelvic mass' above and 'Pregnancy' above.)
●Abdominal wall laxity – For patients with extreme abdominal wall laxity in whom umbilical entry is unsuccessful, a non-umbilical entry or an open technique is a reasonable option. (See 'Abdominal wall laxity' above.)
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