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Introduction: The advent of laparoscopic surgery is one of the most important advances in modern surgical technique. In order to perform laparoscopic procedures it is necessary to access the peritoneal cavity and establish a pneumoperitoneum. Placement of the first port remains a critical and unavoidable step in laparoscopic surgery. In order to minimize complications associated with placement of the first trocar, several techniques have been reported. Herein we describe the per-umbilical technique (PUT) approach developed by our surgical group that takes advantage of the anatomical defect left by the umbilical vessels at the umbilicus after birth. PUT provides a quick, safe, and reliable initial surgical access to the peritoneal cavity that has produced excellent functional and cosmetic results.
Methods: Retrospective cohort of patients who underwent various laparoscopic procedures by our surgical group using PUT for access to the peritoneum from January 2000 to September 2012 at the ABC Medical Center, in Mexico City. Patients with prior midline laparotomy involving the umbilicus were excluded, but not those with previous transverse umbilical herniorraphies.
Results: Within that timeframe there were 963 patients (M=419; F=544) with an average age of 40 years (range: 15-83). With a median follow up time of 6-years In our cohort no complications occurred during the insertion of the first trocar. A small abdominal wall defect, were the obliterated umbilical vessels cross the musculoaponeurotic layer, was identified in all patients except those with a previous surgical procedure at this site. Postoperative complications occurred in 39 patients (1.5%) of which the main one was postoperative seroma (N=24 patients). Superficial surgical site infection occurred in eight patients (0.84%), hematoma in two patients (0.21%), and incisional hernia at the umbilical port site occurred in five patients (0.51%). The average time to place the first trocar using PUT was 1.5 minutes (range: 1-7minutes).
Conclusion: We describe a modified open technique that has not been previously reported in the literature for placement of the first trocar taking advantage of a constant anatomical defect left by the obliterated umbilical vessels which is almost universally present. The PUT is quick, safe, reliable, simple, and easy to learn. It is associated with minimal morbidity and has excellent cosmetic results. Based on our experience, we believe that this method provides surgeons with an effective and safe way to insert the first trocar and we recommend it as a routine procedure for the accessing the peritoneal cavity for abdominal laparoscopic surgery.