Step 5: Insufflate the abdomen at the primary camera/caudal portal site
Using your caudal hand, grasp the movable outer portion of the Veress needle hub (not yet connected to the insufflation hose),
and, with your cranial hand, carefully grasp the abdominal wall on the midline at the umbilical area and elevate it without
incorporating any intestine or the spleen. Place the tip of the Veress needle perpendicular to the elevated abdominal wall,
about one-fourth of the distance caudally from the umbilicus to the pelvic brim. I place the Veress needle in this caudal
portal location to decrease the risk of inadvertent damage or insufflation to the stomach, spleen, or liver. Place the index
finger and thumb of your caudal hand on the needle hub, and place your ring finger on the shaft of the needle far enough up
to just allow abdominal penetration. This finger-brace depth-stop helps prevent excessive abdominal penetration.
Next, direct the needle in a cranial dorsal direction through the elevated abdominal wall (Figure 5). When you think the abdomen has been penetrated, use the hanging drop test9 to check: put the Veress needle valve in the open position, place a drop or two of sterile saline solution in the needle's
hub, and watch for the saline solution to go into the needle as a result of the negative abdominal pressure. If the drop does
not disappear into the hub, carefully advance the needle a millimeter at a time while watching the drop in the hub.
Once the saline solution disappears into the needle, attach the insufflation line to the Veress needle, turn the carbon dioxide
gas on, and start insufflation. The Veress needle is guarded, so the safety obturator will cover the needle point once in
the abdomen.10 Once pneumoperitoneum to 15 mm Hg is achieved, turn off the stopcock on the Veress needle, and remove the needle from the
abdomen. If the pressure is greater than 15 mm Hg, disconnect the insufflation tubing and use the stopcock on the side of
the Veress needle to deflate the abdomen to 15 mm Hg. If the abdominal pressure exceeds 15 mm Hg, patient respiration will
Step 6: Place the laparoscope at the primary camera/caudal portal site
After removing the Veress needle, use a No. 11 blade to make a careful stab incision in the center of the caudal portal site.
After penetrating the abdomen, place the threaded EndoTIP cannula tip in the incision, and rotate it clockwise with its valve
open until you hear gas releasing through the valve. Then turn its valve off, and rotate the cannula tip one to three full
rotations more to fully place it intra-abdominally. Attach the insufflation hose to this cannula, and reestablish a pneumoperitoneum
pressure of 12 to 15 mm Hg.
If you do not have an EndoTIP cannula, use a Versaport 5-mm cannula-trocar assembly or equivalent with an insufflation stopcock.
Remove the trocar, and at the intended camera/caudal portal, make a midline impression with the cannula in the skin caudally
one-fourth the distance between the umbilicus and the brim of the pelvis. With a No. 15 blade, make a small full-thickness
skin incision across the cannula impression on the midline, plus 2 mm (total incision length should be about 7 mm—just long
enough for the cannula-trocar unit to pass).
Then use the same technique as for the caudal portal incision to make a skin incision for the operative/cranial portal (to
make the correct incision length, add 2 mm to the cannula diameter) on the midline, at a point exactly between the umbilicus
and xiphoid process.
At the caudal portal site with the trocar in place, angle the instrument toward the bladder, and gently penetrate the abdomen
with the cannula-trocar combination. When using Versaport-type cannula-trocar assemblies with cutting blades, grip them properly
so that they are armed. To do so, squeeze both the upper (trocar) and lower (cannula hand-grip) portions together so that
the blade will protrude with pressure on the tip. Again, use your free hand to grasp the cannula and provide a safety depth
stop so that you do not penetrate too deeply. Keep the blade centered on and parallel to, not perpendicular to, the linea
alba. Attach the insufflation line to the stopcock, and maintain the abdominal insufflation pressure at 12 to 15 mm Hg.
Next, attach the camera head and light cable to the laparoscope (the camera head, which has a cable that connects it to the
camera unit in the tower, attaches with a C mount to the end of the laparoscope, while the light cable connects directly to
the light post on the laparoscope), and always keep the camera head cord tail pointed toward the floor. With a 30-degree laparoscope,
keep the light post directed toward 12 o'clock (to maintain the visual field down toward the ovaries) to help orientation.
With a 0-degree scope, the light post position is not important, but the camera head tail position should be directed toward
the floor (6 o'clock) to help maintain orientation. Place the laparoscope tip on a piece of sterile gauze, and have a technician
perform a white balance adjustment. Then place the laparoscope through the caudal camera portal, and direct the laparoscope
cranially until the intended cranial portal entry site is seen.