Transumbilical Versus Infraumbilical Pneumoperitoneum in Laparoscopic Cholecystectomy

The recognized standard care surgical therapy of symptomatic case of gallstone disease is laparoscopic cholecystectomy due to the provision of smaller wounds, lesser postoperative pain, happen faster to mobilize, hospital stay, and speedy restoration to usual activity relative to open surgery. Although this has these benefits, the process does not go without morbidity. They may occur when dissecting the gallbladder, clipping, cystous structures, extracting the specimen or sewing wounds of trocar but one of the most severe scenarios occurs when entering the peritoneal cavity and the formation of pneumoperitoneum. This is performed before direct intraperitoneal visualization is fully matured and, due to this, is prone to the problems of access, such as bowel trauma, vascular trauma, inability to enter and extraperitoneal incontinence, loss of gases, subcutaneous emphysema, postoperative bleeding and associated wound morbidity.

Safety of pneumoperitoneum safe creation has been a key issue in laparoscopic surgery. Various methods such as the closed Veress needle, open Hassan, optical trocar insertion and direct trocar access have been performed with mixed outcomes. In laparoscopic cholecystectomy, the main entry point is most frequently located at or around the umbilicus due to the access point being central, the abdominal wall is isotomically thin and the location of the cosmetically acceptable scar is located. Nevertheless, the exact site of umbilical access varies among surgeons. Clinical practice with infraumbilical, supraumbilical, periumbilical, and transumbilical is common, mostly depending on the preferences of the surgeon, the body habitus of the patient or any surgical history, and common institutional routine.

Infraumbilical type has long been popular as the initial mode of port insertion as it is common, technically easy and well taught. It can however leave a visible scar beneath the umbilicus and can be correlated with port-site bleeding, infection, hematoma, seroma, pain and hernia. There is clinical significance in port-site morbidity as it may influence recovery, patient satisfaction, visits to the hospital, antibiotic usage, and quality of life in the long run.6 Most port-site complications are harmless, but trocar-site hernia deserves attention since it can manifest itself late and in some cases necessitate operative intervention. There is recent evidence that site of extraction of the specimen can also contribute to the risk of trocar-site hernia, particularly in cases where the umbilical port is extended during gallbladder removal.

Due to its ability to utilise the natural umbilical depression, the transumbilical approach has become of growing interest as the surgical scar can be hidden within the umbilicus. This can enhance the cosmetic satisfaction which is a well-known patient-centered outcome in minimally invasive surgery. Transumbilical could also offer an alternative path through the most flakey section of the anterior abdominal wall and may help to decrease the number of other apparent cuts. Recent prospective trials of transumbilical and single-incision laparoscopic cholecystectomy have documented positive cosmetic and acceptable safety, and possibly advantages of postoperative recovery when carried out on trained surgeons. Nonetheless, these benefits need to be offset against potential issues like crowding of instruments, wound infection, umbilical pain, and incisional hernia threat.

The evaluation of transumbilical versus infraumbilical pneumoperitoneum presently compared is thus applicable in the aspects of safety in surgery as also patient satisfaction. Although serious complications remain rare, even minor variations in access time, gas leakage, bleeding, postoperative pain, infection or scar satisfaction can be significant since laparoscopic cholecystectomy can and often is practiced worldwide. Existing literature has compared open and closed entry methods, single incision with the traditional laparoscopic cholecystectomy entry methods, and transumbilical incision and periumbilical access but there is limited evidence comparing transumbilical and infraumbilical access when applied to routine laparoscopic cholecystectomy procedures.2,4,8 Furthermore, the results can be variable as they depend on patient features in a local area, experience of the surgeon, emergency or elective operation, and perioperative procedures.