For a previously operated abdomen with a midline incision, the Veress needle should be placed in the upper left quadrant of the abdomen just lateral to the rectus sheath. Transrectus insertion of the Veress needle is discouraged because of risk of injury to the inferior epigastric vessels.
The Veress needle at the upper quadrant region needs to be passed more deeply into the abdomen in order to enter the peritoneal cavity because all layers of the abdominal wall are present here and the risk of preperitoneal insufflation is higher. Always insert the needle at a right angle from the skin surface. Another site of insufflation should be chosen in the presence of splenomegaly. The right upper quadrant is not the most optimal site because of the size of the liver and the presence of the falciform ligament. There are some reports of liver injury in cases of hepatomegaly.
In a patient with an upper abdominal scar, the Veress needle should be placed in the right lower quadrant. The left lower quadrant should generally be avoided in older patients since there are usually adhesions between the sigmoid colon and the abdominal wall secondary to subclinical episodes of diverticulitis. For patient with a previously operated abdomen in multiple quadrants, an open technique is optimal.
Was this article helpful?