Laparoscopic entry techniques: which should you prefer?

Background: Despite a debate spanning two decades, no consensus has been achieved about the safest laparoscopic entry technique. Objectives: To update the evidence about the safety of the main different laparoscopic entry techniques. Search strategy: Six electronic databases were searched from inception to February 2021. Selection criteria: All randomized controlled trials (RCTs) comparing different laparoscopic entry techniques were included. Data collection and analysis: Entry-related complications and total time for entry were compared among the different methods of entry calculating pooled odds ratios (ORs) and mean differences, with 95% confidence intervals (CIs); P < 0.05 was considered significant. Main results: In total, 25 RCTs (6950 patients) were included. Complications considered were vascular, visceral and omental injury, failed entry, extraperitoneal insufflation, bleeding and infection at the trocar site bleeding, and incisional hernia. Compared to direct trocar, the OR for Veress needle was significantly higher for omental injury (OR 3.65, P < 0.001), for failed entry (OR 4.19, P < 0.001), and for extraperitoneal insufflation (OR 5.29, P < 0.001). Compared to the open method, the OR for Veress needle was significantly higher for omental injury (OR 4.93, P = 0.001), for failed entry (OR 2.99, P < 0.001), for extraperitoneal insufflation (OR 4.77; P = 0.04), and for incisional hernia. Compared to the open method, the OR for direct trocar was significantly lower for visceral injury (OR 0.17, P = 0.002) and for trocar site infection (OR 0.27, P = 0.001). Conclusions: The direct trocar method may be preferred over Veress needle and open methods as a laparoscopic entry technique since it appears associated to a lower risk of complications.