An electronic search was performed through PubMed, Scopus, and Google Scholar for relevant literature published from the date of the databases inception to April 2020 based on a preliminary scope of studies involving the safety of alternative access sites for abdominal entry in gynecologic laparoscopy. The following keywords were used: laparoscopy, previous laparotomy, Palmer's point, Lee-Huang point, Jain point, intercostal, subcostal, transvaginal, and transuterine.
To ensure that the searches were comprehensive, the titles of all relevant articles were identified via Google Scholar, and then further related searches were conducted focusing on the first 20 records identified 8. We excluded studies published in languages other than English 9.
We also examined the citation lists of previous reviews for potentially relevant references 1, 10-13. In cases in which there were multiple publications by the same team on a similar topic, the report that contained the largest number of patients or the most complete data was included.
Left upper quadrant of the abdomen
Palmer's point has been proposed as an alternative access site for pelvic laparoscopy 14. It was first described by Raoul Palmer in 1974 as the point located in the left upper quadrant 3 cm below the costal margin in the midclavicular line (Fig1). Palmers point has also been proposed as an initial access site for obese patients, exceptionally thin patients, and when prominent aortic pulsations are palpated near the umbilicus to avoid the potential of vascular injury 10-12. This access technique should be avoided in patients who have previously undergone splenic or gastric surgery or have significant hepatosplenomegaly, portal hypertension, or gastropancreatic masses 10. Gastric decompression is required before initiating this procedure 10.
Figure 1 Umbilical and alternative access sites for abdominal entry including Lee-Huang point, Palmers point and Jain point.
A report by Granata et al. 15 noted that Palmers point was used as a location for gas insufflation and primary trocar insertion in one-third of women undergoing gynecologic laparoscopy at their institute. The common reasons for using Palmers point in this study were a history of laparotomy, the presence of large uterine fibroids, and intra-abdominal adhesions documented during a previous surgery. Entry via Palmers point was successful in 98.5% of the patients, and there were no entry-related complications 15.
Recently, Abd Ellatif et al. 16 noted an approximately 4.1% rate of entry-related complications when using Palmers point as an access site for a gas insufflation needle in patients with at least one of the following conditions: (i) obesity, (ii) previous midline laparotomy, (iii) previous intestinal surgery, (iv) irreducible ventral hernia, and (v) three failed attempts to create pneumoperitoneum through the periumbilical area. The most commonly injured organs were the omentum (2.6%), stomach (1.1%), and large intestine (0.4%)16.
Because the skin, fascial layers, and parietal peritoneum at the left upper quadrant of the abdomen do not attach together, placing a gas insufflation needle through Palmers point is more difficult than at the umbilicus 17. Abdominal entry using an optical entry trocar may eliminate this potential problem. Aust et al. 17 found no entry-related complications with direct optical entry through Palmers point during gynecologic laparoscopy, indicating that the technique is safe.
Another alternative point for placing a gas insufflation needle and primary trocar in the left upper quadrant is the subcostal margin in the midclavicular line (Fig2). Entry via the left subcostal margin is successful in 98.5% to 100% of cases 18,19. One of the most common entry-related complication is puncture of the left lobe of the liver, which occurs in approximately 1% of cases 18.
Left intercostal space port entry
Left intercostal spaces (usually the ninth or tenth) have been proposed as alternative sites for a gas insufflation needle placement. The entry site is on the left anterior axillary line or at the site of an acute change in direction of the costal margin (Fig2) 6,7,20,21.
Figure 2 Alternative access sites for abdominal entry including Latifs point, Intercostal space, and subcostal margin.
In a study by Ngu et al. 6, insertion of the gas insufflation needle at the ninth or tenth intercostal space (at the site of an acute change in direction of the costal margin) followed by insertion of the primary trocar just below the left subcostal margin was performed in approximately 5% of women undergoing gynecologic laparoscopy. The common reasons inserting the gas insufflation needle at left intercostal spaces included history of abdominal laparotomy (79.0%), the patient being pregnant (11.1%), and the presence of a large pelvic mass (6.2%). Initial access was successful in all patients. One woman developed subcutaneous emphysema over the entry site followed by an uneventful recovery 6.
A study by Kumakiri et al. 7, which was undertaken to assess the safety of microlaparoscope insertion via the ninth intercostal space (on the left anterior axillary line), found no abdominal entry-related complications among 172 women undergoing gynecologic laparoscopy.
In a series of women with a previous vertical abdominal laparotomy incision extending close to or through the umbilicus who underwent gynecologic laparoscopy, abdominal entry by placing Veress needle at the ninth or tenth intercostal space (at the site of an acute change in direction of the costal margin) for insufflation followed by insertion of primary trocar just below left subcostal margin was successfully carried out in all women without any entry-related complications 20.
In the 918 gynecologic laparoscopies in which the left ninth intercostal space was used for Veress needle entry, there were two (0.39%) Veress-needle related injuries: iatrogenic pneumothorax and stomach perforation 21.
Middle upper abdominal port entry or Lee-Huang point
The Lee-Huang point lies in the midline between the umbilicus and the sternal xiphoid process (Fig1) 10. This alternative entry site for a Veress needle and primary trocar insertion was introduced by Lee et al. in 2001 22, and its use is recommended in women with an elevated risk of subumbilical adhesions due to previous abdominal surgeries or a history of gynecologic cancer 10. Lee et al. 22 reported that none of the procedures in which this point was used were converted to laparotomy, and 98.4% of the patients experienced no complications. The complications that did occur were injury to the omentum (1.1%) and large bowel (0.5%) 22. Subsequent studies have confirmed the safety and feasibility of the Lee-Huang point as an alternative portal for insertion of a gas insufflation needle and primary trocar in women with a risk of abdominal entry-related complications 23-25.
There are two fundamental advantages of using Lee-Huang point as the first entrance site for gynecologic laparoscopy. First, obstacles, such as periumbilical adhesions and large pelvic masses, can be avoided. The second advantage is that it provides central vision of the operative field, which allows the surgeons to have easy access to both sides of the pelvic cavity 10. The only contraindication is a prior history of abdominal surgery at the supra-umbilical region 10.
Left lateral abdominal port entry (Jain point)
The Jain point lies in the left paraumbilical region vertically upward from a point 2.5 cm medial to the anterior superior iliac spine (Fig1) 26. This entrance site was proposed by Jain et al. 26 in 2006 as an alternative access site for patients with prior history of laparotomy, particularly those with a history of upper abdominal surgery. This is due to the risk involved in placing a gas insufflation needle and primary trocar via a site located in the upper abdomen (i.e., Palmers point or the Lee-Huang point). In a series of 624 patients with a history of abdominal surgeries who underwent initial abdominal entry at the Jain point, there were no reported complications associated with entry 26.
Because the Jain point is lower and more lateral than Palmers point and the Lee-Huang point, the risk of injury to some visceral organs (i.e., the stomach, spleen, liver, and kidneys) when using it as first entrance site may be lower. In addition, there are no major blood vessels beneath the Jain point 27.
Right upper quadrant of the abdomen (Latifs point)
Latifs point, proposed by Abd Ellatif et al. in 2018 16, is in the right angle between the xiphoid process and the right costal margin (Fig2). The Veress needle is introduced through the incision at a 45º angle relative to the skins surface, directed toward the right axilla. In a series of 570 patients undergoing this entry technique, 13 (2.3%) experienced entry-related complications (liver puncture) but required no specific treatment. No other viscera were punctured. This entry site should be avoided in cases right upper abdominal operations and right upper abdominal masses 16.
The fundamental advantage for using Latifs point as the initial entry site is less prominent of fat layer even in obese patients 16. Although this new entry point seems to be a promising alternative access site for laparoscopic surgery, additional data from further studies are required to confirm its clinical safety and feasibility.
Transvaginal and transuterine port entry
Pneumoperitoneum can be created via the insertion of a long gas insufflation needle transvaginally through the fundus of the uterus or posterior vaginal fornix. This entry technique may be considered in obese women in whom transabdominal laparoscopic entry may be risky or difficult. However, these methods are not commonly used as they carry the risk of infection and injury to the rectum, especially in women with pelvic adhesions 13.
The most used alternative sites for an abdominal entry during gynecologic laparoscopy are Palmers point and the Lee-Huang point. Available evidence has shown both points to be both feasible and safe as the initial entry site during gynecologic laparoscopy. Other alternative access sites include the subcostal margin in the midclavicular line and left intercostal spaces (usually the ninth or tenth) on the left anterior axillary line or at the site of an acute change in direction of the costal margin. Although new laparoscopic entry sites (i.e., the Jain point and Latifs point) have been proposed, further studies are needed to verify their safety and feasibility.
What is already known on this topic
Creating pneumoperitoneum is an important initial step in laparoscopy. Traditionally, the periumbilical area is the most common access site in gynecologic laparoscopy. However, entry through this site may be harmful in patients with periumbilical adhesions, who are pregnant, or who have large pelvic masses. Various alternative access sites, such as Palmers point and the Lee-Huang point, have thus been proposed.
What this study adds
Palmers point and the Lee-Huang point are the most used alternative access site for gynecologic laparoscopy and carry a less than 3% risk of severe entry-related complications. Novel access sites, such as the Jain point and Latifs point, have also been proposed. Entry through the Jain point may lower the risk of visceral organ injury (i.e., stomach, spleen, liver, and kidneys). Entry via Latifs point is easier and less time-consuming than other methods due to the thinness of the fat layer at this site. However, more studies are needed to determine the clinical feasibility of abdominal access via these two alternative sites.
The authors are grateful to Dylan Southard for his assistance in editing the manuscript.
Conflicts of interest
The authors declare no conflict of interest.
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