The Royal College of obstetricians and gynecologists has published a guideline for preventing entry related gynecological laparoscopic injuries [25] and in this guideline they have recommended the use of the trans-umbilical open technique in morbidly obese patient to gain access to the intraperitoneal cavity. The guideline also recommends that if a Veress needle is used, then the incision should be made vertically as deep as possible in the base of the umbilicus.

Pulosi published a case series of 67 obese patients undergoing laparoscopic surgery and showed that there were no failures with a transumbilical open approach after realignment of the umbilical access. This entailed assessing the position of the umbilicus in relation to a line drawn between the two anterior superior iliac spines. The umbilicus then was repositioned 8 cm above this line in its “anatomical” position prior to initiating open dissection [26].

Santala et al. published a prospective, randomized study comparing transumbilical and transuterine Veress needle placement in obese patients found the latter approach useful, but recorded a single case of postoperative

Chlamydial pelvic inflammatory disease. Thus, preoperative testing for sexually transmitted disease is recommended for this approach [27].

The Cochrane of laparoscopic entry techniques included 28 randomised controlled trials with 4,860 patients undergoing laparoscopy. Although there was no overall advantage using any single techniques in terms of preventing major vascular or visceral complications. However the cumulative data shows that by using open entry technique compared to a Veress needle, there was a reduction in the incidence of failed entry (odds ratio; (OR)0.12 (95 % CI 0.02–0.92). There was also an advantage with radially expanding access system (STEP) when compared with standard trocar entry, in terms of trocar site bleeding (OR 0.31: 95 % CI 0.15–0.62). Finally there was an advantage of not lifting the abdominal wall before Veress needle insertion when compared to lifting in terms of failed entry (OR 4.44; 95 % CI 2.16–9.13), without an increase in the complication rate [28].

It is very important to visualise the inferior epigastric vessels prior to placement of secondary lateral ports. These vessels are quite often difficult to visualise in the morbidly obese patients. Therefore incision should be made extremely lateral to the edge of the rectus sheath, ensuring avoidance of injury to the pelvic sidewall vessels. The increased thickness of the abdominal wall is more likely to result in inadvertent displacement of the lateral ports when instruments are being removed or replaced, therefore the use of cuffed ports, which will not become displaced during the procedure, should also be considered.

In our practice, laparoscopic surgeons pair up for each case. The initial insertion of ports and patient preparation for the procedure are carried out before the Trendelenburg position is introduced. Following the initial insufflations at 20 mmHg, the pressure is reduced to 15 mmHg while maintaining good visualisation. We believe that these practical points could help to reduce operating time and reduce the length of time of head down position and thereby the anaesthetic challenges.

Every effort should be made to avoid a post operative haematoma which increases the risk of pelvic infection and consideration should be given to leaving a drain in situ whenever there is a significant risk of intraperitoneal bleeding post-operatively.

Obese women are more prone to post operative hernias and this risk can be either reduced by the use of 5 mm ports or by using a formal deep sheath closure [25].