Systematic review of the safety and effectiveness of methods used to establish pneumoperitoneum in laparoscopic surgery

Background: A systematic review was conducted to determine which of the methods of obtaining peritoneal access and establishing pneumoperitoneum is the safest and most effective. Methods: Studies that met the inclusion criteria were identified from six bibliographic databases up to May 2002, the internet, hand‐searches and reference lists. They were critically appraised using a validated checklist and data were extracted using standardized protocols. Results: Meta‐analysis of prospective, non‐randomized studies of open versus closed (needle/trocar) access indicated a trend during open access towards a reduced risk of major complications (pooled relative risk (RRp) 0·30, 95 per cent confidence interval (c.i.) 0·09 to 1·03). Open access was also associated with a trend towards a reduced risk of access‐site herniation (RRp 0·21, 95 per cent c.i. 0·04 to 1·03) and, in non‐obese patients, a 57 per cent reduced risk of minor complications (RRp 0·43, 95 per cent c.i. 0·20 to 0·92) and a trend for fewer conversions to laparotomy (RRp 0·21, 95 per cent c.i. 0·04 to 1·17). Data on major complications in studies of direct trocar versus needle/trocar access were inconclusive. Minor complications in randomized controlled trials were fewer with direct trocar access (RRp 0·19, 95 per cent c.i. 0·09 to 0·40), predominantly owing to a reduction in extraperitoneal insufflation. Conclusion: The evidence on the comparative safety and effectiveness of the different access methods was not definitive, but there were trends in the data that merit further exploration. Copyright © 2003 British Journal of Surgery Society Ltd. Published by John Wiley & Sons, Ltd. Evidence not definitive due to low overall complication rate