Laparoscopic entry techniques

Gaity Ahmad, Jade Baker, John Finnerty, Kevin Phillips, Andrew Watson, Gaity Ahmad, Jade Baker, John Finnerty, Kevin Phillips, Andrew Watson

Abstract

Background: Laparoscopy is a common procedure in many surgical specialties. Complications arising from laparoscopy are often related to initial entry into the abdomen. Life-threatening complications include injury to viscera (e.g. bowel, bladder) or to vasculature (e.g. major abdominal and anterior abdominal wall vessels). No clear consensus has been reached as to the optimal method of laparoscopic entry into the peritoneal cavity.

Objectives: To evaluate the benefits and risks of different laparoscopic entry techniques in gynaecological and non-gynaecological surgery.

Search methods: We searched the Cochrane Gynaecology and Fertility (CGF) Group trials register, CENTRAL, MEDLINE, Embase, PsycINFO, and trials registers in January 2018. We also checked the references of articles retrieved.

Selection criteria: We included randomised controlled trials (RCTs) that compared one laparoscopic entry technique versus another. Primary outcomes were major complications including mortality, vascular injury of major vessels and abdominal wall vessels, visceral injury of bladder or bowel, gas embolism, solid organ injury, and failed entry (inability to access the peritoneal cavity). Secondary outcomes were extraperitoneal insufflation, trocar site bleeding, trocar site infection, incisional hernia, omentum injury, and uterine bleeding.

Data collection and analysis: Two review authors independently selected studies, assessed risk of bias, and extracted data. We expressed findings as Peto odds ratios (Peto ORs) with 95% confidence intervals (CIs). We assessed statistical heterogeneity using the I² statistic. We assessed the overall quality of evidence for the main comparisons using GRADE methods.

Main results: The review included 57 RCTs including four multi-arm trials, with a total of 9865 participants, and evaluated 25 different laparoscopic entry techniques. Most studies selected low-risk patients, and many studies excluded patients with high body mass index (BMI) and previous abdominal surgery. Researchers did not find evidence of differences in major vascular or visceral complications, as would be anticipated given that event rates were very low and sample sizes were far too small to identify plausible differences in rare but serious adverse events.Open-entry versus closed-entryTen RCTs investigating Veress needle entry reported vascular injury as an outcome. There was a total of 1086 participants and 10 events of vascular injury were reported. Four RCTs looking at open entry technique reported vascular injury as an outcome. There was a total of 376 participants and 0 events of vascular injury were reported. This was not a direct comparison. In the direct comparison of Veress needle and Open-entry technique, there was insufficient evidence to determine whether there was a difference in rates of vascular injury (Peto OR 0.14, 95% CI 0.00 to 6.82; 4 RCTs; n = 915; I² = N/A, very low-quality evidence). Evidence was insufficient to show whether there were differences between groups for visceral injury (Peto OR 0.61, 95% CI 0.06 to 6.08; 4 RCTs; n = 915: I² = 0%; very low-quality evidence), or failed entry (Peto OR 0.45, 95% CI 0.14 to 1.42; 3 RCTs; n = 865; I² = 63%; very low-quality evidence). Two studies reported mortality with no events in either group. No studies reported gas embolism or solid organ injury.Direct trocar versus Veress needle entryTrial results show a reduction in failed entry into the abdomen with the use of a direct trocar in comparison with Veress needle entry (OR 0.24, 95% CI 0.17 to 0.34; 8 RCTs; N = 3185; I² = 45%; moderate-quality evidence). Evidence was insufficient to show whether there were differences between groups in rates of vascular injury (Peto OR 0.59, 95% CI 0.18 to 1.96; 6 RCTs; n = 1603; I² = 75%; very low-quality evidence), visceral injury (Peto OR 2.02, 95% CI 0.21 to 19.42; 5 RCTs; n = 1519; I² = 25%; very low-quality evidence), or solid organ injury (Peto OR 0.58, 95% Cl 0.06 to 5.65; 3 RCTs; n = 1079; I² = 61%; very low-quality evidence). Four studies reported mortality with no events in either group. Two studies reported gas embolism, with no events in either group.Direct vision entry versus Veress needle entryEvidence was insufficient to show whether there were differences between groups in rates of vascular injury (Peto OR 0.39, 95% CI 0.05 to 2.85; 1 RCT; n = 186; very low-quality evidence) or visceral injury (Peto OR 0.15, 95% CI 0.01 to 2.34; 2 RCTs; n = 380; I² = N/A; very low-quality evidence). Trials did not report our other primary outcomes.Direct vision entry versus open entryEvidence was insufficient to show whether there were differences between groups in rates of visceral injury (Peto OR 0.13, 95% CI 0.00 to 6.50; 2 RCTs; n = 392; I² = N/A; very low-quality evidence), solid organ injury (Peto OR 6.16, 95% CI 0.12 to 316.67; 1 RCT; n = 60; very low-quality evidence), or failed entry (Peto OR 0.40, 95% CI 0.04 to 4.09; 1 RCT; n = 60; very low-quality evidence). Two studies reported vascular injury with no events in either arm. Trials did not report our other primary outcomes.Radially expanding (STEP) trocars versus non-expanding trocarsEvidence was insufficient to show whether there were differences between groups in rates of vascular injury (Peto OR 0.24, 95% Cl 0.05 to 1.21; 2 RCTs; n = 331; I² = 0%; very low-quality evidence), visceral injury (Peto OR 0.13, 95% CI 0.00 to 6.37; 2 RCTs; n = 331; very low-quality evidence), or solid organ injury (Peto OR 1.05, 95% CI 0.07 to 16.91; 1 RCT; n = 244; very low-quality evidence). Trials did not report our other primary outcomes.Other studies compared a wide variety of other laparoscopic entry techniques, but all evidence was of very low quality and evidence was insufficient to support the use of one technique over another.

Authors' conclusions: Overall, evidence was insufficient to support the use of one laparoscopic entry technique over another. Researchers noted an advantage of direct trocar entry over Veress needle entry for failed entry. Most evidence was of very low quality; the main limitations were imprecision (due to small sample sizes and very low event rates) and risk of bias associated with poor reporting of study methods.

Conflict of interest statement

None known for any review author.

Figures

1
1
Study flow diagram.
2
2
Risk of bias summary: review authors' judgements about each risk of bias item for each included study.
3
3
Risk of bias graph: review authors' judgements about each risk of bias item presented as percentages across all included studies.
4
4
Forest plot of comparison: 1 Open‐entry technique vs closed‐entry technique (primary port entry), outcome: 1.2 Vascular injury (major vessels and abdominal wall vessels).
5
5
Forest plot of comparison: 1 Open‐entry technique vs closed‐entry technique (primary port entry), outcome: 1.3 Visceral injury (bladder or bowel).
6
6
Forest plot of comparison: 2 Direct trocar entry vs Veress needle entry (primary port entry), outcome: 2.1 Vascular injury (major vessels and abdominal wall vessels).
7
7
Forest plot of comparison: 2 Direct trocar entry vs Veress needle entry (primary port entry), outcome: 2.2 Visceral injury (bladder or bowel).
8
8
Forest plot of comparison: 2 Direct trocar entry vs Veress needle entry (primary port entry), outcome: 2.4 Failed entry.
1.1. Analysis
1.1. Analysis
Comparison 1 Open‐entry technique vs closed‐entry technique (primary port entry), Outcome 1 Mortality.
1.2. Analysis
1.2. Analysis
Comparison 1 Open‐entry technique vs closed‐entry technique (primary port entry), Outcome 2 Vascular injury (major vessels and abdominal wall vessels).
1.3. Analysis
1.3. Analysis
Comparison 1 Open‐entry technique vs closed‐entry technique (primary port entry), Outcome 3 Visceral injury (bladder or bowel).
1.4. Analysis
1.4. Analysis
Comparison 1 Open‐entry technique vs closed‐entry technique (primary port entry), Outcome 4 Failed entry.
1.5. Analysis
1.5. Analysis
Comparison 1 Open‐entry technique vs closed‐entry technique (primary port entry), Outcome 5 Extraperitoneal insufflation.
1.6. Analysis
1.6. Analysis
Comparison 1 Open‐entry technique vs closed‐entry technique (primary port entry), Outcome 6 Trocar site bleeding.
1.7. Analysis
1.7. Analysis
Comparison 1 Open‐entry technique vs closed‐entry technique (primary port entry), Outcome 7 Trocar site infection.
1.8. Analysis
1.8. Analysis
Comparison 1 Open‐entry technique vs closed‐entry technique (primary port entry), Outcome 8 Incisional hernia.
1.9. Analysis
1.9. Analysis
Comparison 1 Open‐entry technique vs closed‐entry technique (primary port entry), Outcome 9 Omental injury.
2.1. Analysis
2.1. Analysis
Comparison 2 Direct trocar entry vs Veress needle entry (primary port entry), Outcome 1 Vascular injury (major vessels and abdominal wall vessels).
2.2. Analysis
2.2. Analysis
Comparison 2 Direct trocar entry vs Veress needle entry (primary port entry), Outcome 2 Visceral injury (bladder or bowel).
2.3. Analysis
2.3. Analysis
Comparison 2 Direct trocar entry vs Veress needle entry (primary port entry), Outcome 3 Solid organ injury.
2.4. Analysis
2.4. Analysis
Comparison 2 Direct trocar entry vs Veress needle entry (primary port entry), Outcome 4 Failed entry.
2.5. Analysis
2.5. Analysis
Comparison 2 Direct trocar entry vs Veress needle entry (primary port entry), Outcome 5 Extraperitoneal insufflation.
2.6. Analysis
2.6. Analysis
Comparison 2 Direct trocar entry vs Veress needle entry (primary port entry), Outcome 6 Trocar site infection.
2.7. Analysis
2.7. Analysis
Comparison 2 Direct trocar entry vs Veress needle entry (primary port entry), Outcome 7 Omental injury.
3.1. Analysis
3.1. Analysis
Comparison 3 Direct vision entry vs Veress needle entry (primary port entry), Outcome 1 Vascular injury (major vessels and abdominal wall vessels).
3.2. Analysis
3.2. Analysis
Comparison 3 Direct vision entry vs Veress needle entry (primary port entry), Outcome 2 Visceral injury (bladder or bowel).
3.3. Analysis
3.3. Analysis
Comparison 3 Direct vision entry vs Veress needle entry (primary port entry), Outcome 3 Trocar site bleeding.
4.1. Analysis
4.1. Analysis
Comparison 4 Direct vision entry vs open‐entry technique (primary port entry), Outcome 1 Visceral injury (bladder or bowel).
4.2. Analysis
4.2. Analysis
Comparison 4 Direct vision entry vs open‐entry technique (primary port entry), Outcome 2 Solid organ injury.
4.3. Analysis
4.3. Analysis
Comparison 4 Direct vision entry vs open‐entry technique (primary port entry), Outcome 3 Failed entry.
4.4. Analysis
4.4. Analysis
Comparison 4 Direct vision entry vs open‐entry technique (primary port entry), Outcome 4 Trocar site bleeding.
5.1. Analysis
5.1. Analysis
Comparison 5 Radially expanding (STEP) trocars vs standard (non‐expanding) trocars (primary port entry), Outcome 1 Vascular injury (major vessels and abdominal wall vessels).
5.2. Analysis
5.2. Analysis
Comparison 5 Radially expanding (STEP) trocars vs standard (non‐expanding) trocars (primary port entry), Outcome 2 Visceral injury (bladder or bowel).
5.3. Analysis
5.3. Analysis
Comparison 5 Radially expanding (STEP) trocars vs standard (non‐expanding) trocars (primary port entry), Outcome 3 Solid organ injury.
5.4. Analysis
5.4. Analysis
Comparison 5 Radially expanding (STEP) trocars vs standard (non‐expanding) trocars (primary port entry), Outcome 4 Trocar site bleeding.
6.1. Analysis
6.1. Analysis
Comparison 6 Comparisons of sites of entry, Outcome 1 Transfundal vs infraumbilical insertion of the Veress needle.
6.2. Analysis
6.2. Analysis
Comparison 6 Comparisons of sites of entry, Outcome 2 Left upper quadrant vs caudally displaced umbilical insertion of the Veress needle.
7.1. Analysis
7.1. Analysis
Comparison 7 SILS vs Veress needle entry, Outcome 1 Mortality.
7.2. Analysis
7.2. Analysis
Comparison 7 SILS vs Veress needle entry, Outcome 2 Visceral injury (bladder or bowel).
7.3. Analysis
7.3. Analysis
Comparison 7 SILS vs Veress needle entry, Outcome 3 Trocar site bleeding.
7.4. Analysis
7.4. Analysis
Comparison 7 SILS vs Veress needle entry, Outcome 4 Trocar site infection.
7.5. Analysis
7.5. Analysis
Comparison 7 SILS vs Veress needle entry, Outcome 5 Incisional hernia.
8.1. Analysis
8.1. Analysis
Comparison 8 SILS vs Hasson entry technique, Outcome 1 Mortality.
8.2. Analysis
8.2. Analysis
Comparison 8 SILS vs Hasson entry technique, Outcome 2 Vascular injury (major vessels and abdominal wall vessels).
8.3. Analysis
8.3. Analysis
Comparison 8 SILS vs Hasson entry technique, Outcome 3 Failed entry (inability to access the peritoneal cavity).
8.4. Analysis
8.4. Analysis
Comparison 8 SILS vs Hasson entry technique, Outcome 4 Trocar site infection.
8.5. Analysis
8.5. Analysis
Comparison 8 SILS vs Hasson entry technique, Outcome 5 Incisional hernia.
9.1. Analysis
9.1. Analysis
Comparison 9 Comparisons of other laparoscopic entry techniques for primary or secondary port insertion, Outcome 1 Lifting vs not lifting the abdominal wall before Veress needle insertion.
9.2. Analysis
9.2. Analysis
Comparison 9 Comparisons of other laparoscopic entry techniques for primary or secondary port insertion, Outcome 2 Carbon dioxide gas insufflation vs gasless abdominal wall retractor.
9.3. Analysis
9.3. Analysis
Comparison 9 Comparisons of other laparoscopic entry techniques for primary or secondary port insertion, Outcome 3 Closed technique vs a parallel technique of Veress needle insertion.
9.4. Analysis
9.4. Analysis
Comparison 9 Comparisons of other laparoscopic entry techniques for primary or secondary port insertion, Outcome 4 Cutting trocar vs blunt trocar.
9.5. Analysis
9.5. Analysis
Comparison 9 Comparisons of other laparoscopic entry techniques for primary or secondary port insertion, Outcome 5 5‐mm vs 3‐mm secondary port trocars.
9.6. Analysis
9.6. Analysis
Comparison 9 Comparisons of other laparoscopic entry techniques for primary or secondary port insertion, Outcome 6 Radially expanding (STEP) trocars vs standard (non‐expanding) trocars (secondary port entry).
9.7. Analysis
9.7. Analysis
Comparison 9 Comparisons of other laparoscopic entry techniques for primary or secondary port insertion, Outcome 7 X‐cone vs Veress needle entry.
9.8. Analysis
9.8. Analysis
Comparison 9 Comparisons of other laparoscopic entry techniques for primary or secondary port insertion, Outcome 8 X‐cone vs SILS.
9.9. Analysis
9.9. Analysis
Comparison 9 Comparisons of other laparoscopic entry techniques for primary or secondary port insertion, Outcome 9 IAP 25 mmHg vs IAP 15 mmHg.
9.10. Analysis
9.10. Analysis
Comparison 9 Comparisons of other laparoscopic entry techniques for primary or secondary port insertion, Outcome 10 IAP 25 mmHg vs IAP 25 mmHg with external compression.
9.11. Analysis
9.11. Analysis
Comparison 9 Comparisons of other laparoscopic entry techniques for primary or secondary port insertion, Outcome 11 IAP 15 mmHg vs IAP 25 mmHg with external compression.

References

References to studies included in this review Agresta 2004 {published data only}

    1. Agresta F, DeSimone P, Ciardo LF, Bedin N. Direct trocar insertion vs Veress needle in nonobese patients undergoing laparoscopic procedures: a randomized prospective single‐center study. Surgical Endoscopy 2004;18(12):1778‐81.
Akbar 2008 {published data only}
    1. Akbar M, Khan IA, Naveed D, Khattak I, Zafar A, Wazir MS, et al. Comparison of closed and open methods of pneumoperitoneum in laparoscopic cholecystectomy. Journal of Ayub Medical College Abbottabad 2008;20(2):85‐9.
Angioli 1 2013 {published data only}
    1. Angioli R, Terranova C, Cicco Nardone C, Cafà EV, Damiani P, Portuesi R, et al. A comparison of three different entry techniques in gynaecological laparoscopic surgery: a randomized prospective trial. European Journal of Obstetrics & Gynaecology and Reproductive Biology 2013;171:339‐42.
Angioli 2 2013 {published data only}
    1. Angioli R, Terranova C, Cicco Nardone C, Cafà EV, Damiani P, Portuesi R, et al. A comparison of three different entry techniques in gynaecological laparoscopic surgery: a randomized prospective trial. European Journal of Obstetrics & Gynaecology and Reproductive Biology 2013;171:339‐42.
Angioli 3 2013 {published data only}
    1. Angioli R, Terranova C, Cicco Nardone C, Cafà EV, Damiani P, Portuesi R, et al. A comparison of three different entry techniques in gynaecological laparoscopic surgery: a randomized prospective trial. European Journal of Obstetrics & Gynaecology and Reproductive Biology 2013;171:339‐42.
Bemelman 2000 {published data only}
    1. Bemelman WA, Dunker MS, Busch OR, Boer KT, Wit LT, Gouma DJ. Efficacy of establishment of pneumoperitoneum with the Veress Needle, Hasson trocar, and modified blunt trocar (TrocDoc): a randomized study. Journal of Laparoendoscopic and Advanced Surgical Techniques 2000;10(6):325‐30.
Bhoyrul 2000 {published data only}
    1. Bhoyrul S, Payne J, Steffes B, Swanstrom L, Way LW. A randomized prospective study of radially expanding trocars in laparoscopic surgery. Journal of Gastrointestinal Surgery 2000;4(4):392‐7.
Bisgaard 2007 {published data only}
    1. Bisgaard T, Jakobsen HL, Jacobsen B, Olsen SD, Rosenberg J. Randomized clinical trial comparing radially expanding trocars with conventional cutting trocars for the effects on pain after laparoscopic cholecystectomy. Surgical Endoscopy 2007;21:2012‐6.
Borgatta 1990 {published data only}
    1. Borgatta L, Gruss L, Barad D, Kaali SG. Direct trocar Insertion vs. Veress needle use for laparoscopic sterilization. Journal of Reproductive Medicine 1990;35(9):891‐4.
Briel 2000 {published data only}
    1. Briel JW, Plaisier PW, Meijer WS, Lange JF. Is it necessary to lift the abdominal wall when preparing a pneumoperitoneum?. Surgical Endoscopy 2000;14:862‐4.
Byron 1993 {published data only}
    1. Byron JW, Markenson G, Miyazawa K. A randomized comparison of Veress needle and direct trocar insertion for laparoscopy. Surgery 1993;177:259‐62.
Carter 2013 {published data only}
    1. Carter JT, Kaplan JA, Nguyen JN, Lin MYC, Rogers S, Harris HW. A prospective, randomised controlled trial of single‐incision laparoscopic vs conventional 3‐port laparoscopic appendectomy for treatment of acute appendicitis. American College of Surgeons 2014;218(5):950‐9.
Chang 2015 {published data only}
    1. Chang SKY, Wang YL, Shen L, Iyer SG, Madhavan, K. A randomized controlled trial comparing post‐operative pain in single‐incision laparoscopic cholecystectomy versus conventional laparoscopic cholecystectomy. World Journal of Surgery 2015;39:897‐904.
Channa 2009 {published data only}
    1. Channa AC, Siddiqui AJ, Zafar SN. Open versus closed method of establishing pneumoperitoneum for laparoscopic cholecystectomy. Journal of the College of Physicians and Surgeons Pakistan 2009;19(9):557‐60.
Cogliandolo 1998 {published data only}
    1. Cogliandolo A, Manganaro T, Saitta FP, Micali B. Blind versus open approach to laparoscopic cholecystectomy. Surgical Laparoscopy and Endoscopy 1998;8(5):353‐5.
Cravello 1999 {published data only}
    1. Cravello L, D'Ercole C, Roger V, Samson D, Blanc B. Laparoscopic surgery in gynaecology: randomized prospective study comparing pneumoperitoneum and abdominal wall suspension. European Journal of Obstetrics, Gynecology, and Reproductive Biology 1999;83:9‐14.
Deveci 2013 {published data only}
    1. Deveci U, Barbaros U, Kapakli MS, Manukyan MN, Simsek S, Kebudi A, et al. The comparison of single incision laparoscopic cholecystectomy and three port laparoscopic cholecystectomy: prospective randomized study. Jounal of the Korean Surgical Society 2013;85:275‐82.
Ertugrul 2015 {published data only}
    1. Ertugrul I, Kayaalp C, Yagci MA, Sumer F, Karagul S, Tolan K. Comparison of direct trocar entry and Veress needle entry in laparoscopic bariatric surgery: randomized controlled trial. Journal of Laparoendoscopic & Advanced Surgical Techniques. Part A 2015;25:875‐9.
Feste 2000 {published data only}
    1. Feste JR, Bojahr B, Turner DJ. Randomized trial comparing a radially expandable needle system with cutting trocars. Journal of the Society of Laparoendoscopic Surgeons 2000;4:11‐5.
Fonollosa 2012 {published data only}
    1. Fonollosa EH, Andorrà EC, Domingo MIG, Lasa JC, Castejon RP, Lopez FC, et al. A randomised prospective comparative study between laparoscopic cholecystectomy and single port cholecystectomy in a major outpatient surgery unit. Cirugia Espanola 2012;90(10):641‐6.
Ghezzi 2005 {published data only}
    1. Ghezzi F, Cromi A, Colombo G, Uccella S, Bergamini V, Serati M, et al. Minimizing ancillary ports size in gynaecologic laparoscopy: a randomized trial. Journal of Minimally Invasive Gynaecology 2005;12:480‐5.
Gunenc 2005 {published data only}
    1. Gunenc MZ, Yesildaglar N, Bingol B, Onalan G, Tabak S, Gokmen B. The safety and efficacy of direct trocar insertion with elevation of the rectus sheath instead of the skin for pneumoperitoneum. Surgical Laparoscopy, Endoscopy and Percutaneous Techniques 2005;15(2):80‐1.
Guo 2015 {published data only}
    1. Guo W, Liu Y, Han W, Liu J, Jin L, Li JS, et al. Randomized trial of immediate postoperative pain following single‑incision versus traditional laparoscopic cholecystectomy. Chinese Medical Journal 2015;128:3310‐6.
Hamade 2007 {published data only}
    1. Hamade AM, Issa ME, Haylett KR, Ammori BJ. Fixity of ports to the abdominal wall during laparoscopic surgery: a randomized comparison of cutting versus blunt trocars. Surgical Endoscopy 2007;21:965‐9.
He 1 2015 {published data only}
    1. He GL, Jiang ZS, Cheng Y, Lai QB, Zhou CJ, Liu HY, et al. Tripartite comparison of single‐incision and conventional laparoscopy in cholecystectomy: a multicenter trial. World Journal of Gastrointestinal Endoscopy 2015;7:540‐6.
He 2 2015 {published data only}
    1. He GL, Jiang ZS, Cheng Y, Lai QB, Zhou CJ, Liu HY, et al. Tripartite comparison of single‐incision and conventional laparoscopy in cholecystectomy: a multicenter trial. World Journal of Gastrointestinal Endoscopy 2015;7:540‐6.
He 3 2015 {published data only}
    1. He GL, Jiang ZS, Cheng Y, Lai QB, Zhou CJ, Liu HY, et al. Tripartite comparison of single‐incision and conventional laparoscopy in cholecystectomy: a multicenter trial. World Journal of Gastrointestinal Endoscopy 2015;7:540‐6.
Huang 2012 {published data only}
    1. Huang SY, Wang SY, Yeh CN, Cheng CT, Tsai YY, Liu CC, et al. Bladeless trocar versus traditional trocar for patients undergoing laparoscopic cholecystectomy. European Surgery 2012;44:408‐12.
Imran 2014 {published data only}
    1. Imran M, Chohan MZ, Mehmood Z, Mehmood K, Asif K. Comparison of Veress needle and direct trocar insertion in establishing pneumoperitoneum for laparoscopic cholecystectomy. Pakistan Journal of Medical and Health Sciences 2014;8(3):652‐4.
Johnson 1997 {published data only}
    1. Johnson PL, Sibert KS. Laparoscopy: gasless vs. CO2 pneumoperitoneum. Journal of Reproductive Medicine 1997;42(5):255‐9.
Karaca 2014 {published data only}
    1. Karaca AS, Çapar M, Ali R. The first trocar entry in the laparoscopic cholecystectomy, which technique? [Laparoskopik Kolesistektomide İlk Trokar Girişi, Hangi Teknik?]. Journal of Clinical and Analytical Medicine 2014;5(1):1‐3.
Kitano 1993 {published data only}
    1. Kitano S, Iso Y, Tomikawa M, Moriyama M, Sugimachi K. A prospective randomized trial comparing pneumoperitoneum and U‐shaped retractor elevation for laparoscopic cholecystectomy. Surgical Endoscopy 1993;7:311‐4.
Köstü 1 2016 {published data only}
    1. Köstü B, Ercan Ö, Özer A, Bakacak M, Özdemir Ö, Avci F. Assessment of the safety of the supraumbilical compression technique in closed laparoscopic entry. Journal of Clinical and Analytical Medicine 2016;7:824‐7.
Köstü 2 2016 {published data only}
    1. Köstü B, Ercan Ö, Özer A, Bakacak M, Özdemir Ö, Avci F. Assessment of the safety of the supraumbilical compression technique in closed laparoscopic entry. Journal of Clinical and Analytical Medicine 2016;7:824‐7.
Köstü 3 2016 {published data only}
    1. Köstü B, Ercan Ö, Özer A, Bakacak M, Özdemir Ö, Avci F. Assessment of the safety of the supraumbilical compression technique in closed laparoscopic entry. Journal of Clinical and Analytical Medicine 2016;7:824‐7.
Lai 2011 {published data only}
    1. Lai ECH, Yang GPC, Tang CN, Yih PCL, Chan OCY, Li MKW. Prospective randomized comparative study of single incision laparoscopic cholecystectomy versus conventional four‐port laparoscopic cholecystectomy. American Journal of Surgery 2011;202:254‐8.
Lam 2000 {published data only}
    1. Lam TY, Lee SW, Frcs H, Kwok, P. Radially expanding trocar: a less painful alternative for laparoscopic surgery. Journal of Laparoendoscopic and Advanced Surgical Techniques 2000;10(5):269‐73.
Luna 2013 {published data only}
    1. Luna RA, Nogueira DB, Varela PS, Rodrigues Neto Ede O, Norton MJR, Ribeiro Ldo C, et al. A prospective randomized comparison of pain, inflammatory response, and short‐term outcomes between single port and laparoscopic cholecystectomy. Surgical Endoscopy 2013;27(4):1254‐9.
Mettler 2000 {published data only}
    1. Mettler L, Maher P. Investigation of the effectiveness of the radially‐expanding needle system, in contrast to the cutting trocar in enhancing patient recovery. Minimally Invasive Therapy and Allied Technologies 2000;9(6):397‐401.
Minervini 2008 {published data only}
    1. Minervini A, Davenport K, Pefanis G, Keeley FK Jr, Timoney AG. Prospective study comparing the bladeless optical access versus Hasson open trocar for the establishment of pneumoperitoneum in laparoscopic renal procedures. Archivo Italiano di Urologia e Andrologia 2008;80(3):95‐8.
Ostrzenski 1999 {published data only}
    1. Ostrzenski A. Randomized, prospective, single‐blind trial of a new parallel technique of Veress pneumoperitoneum needle insertion versus the conventional closed method. Fertility and Sterility 1999;71(3):578‐81.
Partelli 2016 {published data only}
    1. Partelli S, Barugola G, Sartori A, Crippa S, Falconi M, Ruffo G. Single‐incision laparoscopic cholecystectomy versus traditional laparoscopic cholecystectomy performed by a single surgeon: findings of a randomized trial. Surgery Today 2016;46:313‐8.
Peitgen 1997 {published data only}
    1. Peitgen K, Nimtz K, Hellinger A, Walz MK. Open access or Veress needle technique for laparoscopic surgery? [Offener Zugang oder Veress‐Nadel bei laparoskopischen Eingriffen?]. Chirurg 1997;68:910‐3.
Perez 2013 {published data only}
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Phillips 2012 {published data only}
    1. Phillips MS, Marks JM, Roberts K, Tacchino R, Onders R, DeNoto G, et al. Intermediate results of a prospective randomized controlled trial of traditional four‐port laparoscopic cholecystectomy versus single‐incision laparoscopic cholecystectomy. Surgical Endoscopy 2012;26:1296‐303.
Porta 2017 {published data only}
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Prieto‐Díaz‐Chávez 2006 {published data only}
    1. Prieto‐Díaz‐Chávez E, Medina‐Chávez JL, González‐Ojeda A, Anaya‐Prado R, Trujillo‐Hernández B, Vásquez C. Direct trocar insertion without pneumoperitoneum and the Veress needle in laparoscopic cholecystectomy: a comparative study. Acta Chirurgica Belgica 2006;106(5):541‐4.
Santala 1999 {published data only}
    1. Santala M, Jarvela I, Kauppila A. Transfundal insertion of a Veress needle in laparoscopy of obese subjects: a practical alternative. Human Reproduction 1999;14(9):2277‐8.
Schulze 1999 {published data only}
    1. Schulze S, Lyng KM, Bugge K, Perner A, Bendtsen A, Thorup J, et al. Cardiovascular and respiratory changes and convalescence in laparoscopic colonic surgery. Archives of Surgery 1999;134:1112‐8.
Tansatit 2006 {published data only}
    1. Tansatit T, Wisawasukmongchol W, Bunyavejchevin S. A randomized, prospective study comparing the use of the missile trocar and the pyramidal trocar for laparoscopy access. Journal of the Medical Association of Thailand 2006;89(7):941‐7.
Tinelli 2009 {published data only}
    1. Tinelli A, Malvasi A, Guido M, Istre O, Keckstein J, Mettler L. Initial laparoscopic access in postmenopausal women: a preliminary prospective study. Menopause: Journal of the North American Menopause Society 2009;16:966‐70.
Tinelli 2010 {published data only}
    1. TInelli A, Malvasi A, Istre O, Keckstein J, Stark M, Mettler L. Abdominal access in gynaecological laparoscopy: a comparison between direct optical and blind closed access by Veress needle. European Journal of Obstetrics, Gynecology, and Reproductive Biology 2010;148:191‐4.
Tinelli 2011 {published data only}
    1. Tinelli A, Malvasia A, Guido M, Tsin DA, Hudelist G, Stark M, et al. Laparoscopy entry in patients with previous abdominal and pelvic surgery. Surgical Innovation 2011;18(3):201‐5.
Tinelli 2013 {published data only}
    1. Tinelli A, Malvasi A, Mynbaev OA, Tsin DA, Davila F, Dominguez G, et al. Bladeless direct optical trocar insertion in laparoscopic procedures on the obese patient. Journal of the Society of Laparoendoscopic Surgeons 2013;17(4):521‐8.
Tsimoyiannis 2009 {published data only}
    1. Tsimoyiannis EC, Konstantinos TE, Pappas‐Gogos G, Farantos C. Different pain scores in single transumbilical incision laparoscopic cholecystectomy versus classic laparoscopic cholecystectomy: a randomized controlled trial. Surgical Endoscopy 2010;24:1842‐8.
Venkatesh 2007 {published data only}
    1. Venkatesh R, Sundaram CP, Figenshau RS, Yan Y, Andriole GL, Clayman RV, et al. Prospective randomized comparison of cutting and dilating disposable trocars for access during laparoscopic renal surgery. Journal of the Society of Laparoendoscopic Surgeons 2007;11:198‐203.
Vilallonga 2012 {published data only}
    1. Vilallonga R, Barbaros U, Sümer A, Demirel T, Fort JM, González O, et al. Single‐port transumbilical laparoscopic cholecystectomy: a prospective randomised comparison of clinical results of 140 cases. Journal of Minimal Access Surgery 2012;8(3):74‐8.
Villalobos 2014 {published data only}
    1. Villalobos Mori R, Escoll Rufino J, Herrerías González F, Mias Carballal MC, Escartin Arias A, Olsina Kissler JJ. Prospective, randomized comparative study between single‐port laparoscopic appendectomy and conventional laparoscopic appendectomy. Cirugia Espanola 2014;92(7):472‐7.
Vilos 2015 {published data only}
    1. Vilos AG, Vilos GA, Abu Rafea B, Oraif A, Abduljabar H. Randomized comparison of Veress needle intraperitoneal placement (VIP) at caudally displaced umbilicus versus left upper quadrant (LUQ) during laparoscopic entry. Journal of Minimally Invasive Gynecology 2015;22(6 Suppl):S104.
Yim 2001 {published data only}
    1. Yim SF, Yuen PM. Randomized double‐masked comparison of radially expanding access device and conventional cutting tip trocar in laparoscopy. Obstetrics and Gynecology 2001;97(3):435‐8.
Youssef 2015 {published data only}
    1. Youssef T, Abdalla E. Single incision transumbilical laparoscopic varicocelectomy versus the conventional laparoscopic technique: a randomized clinical study. International Journal of Surgery 2015;18:178‐83.
Zakerah 2010 {published data only}
    1. Zakherah MS. Direct trocar versus veress needle entry for laparoscopy: a randomized clinical trial. Gynecologic and Obstetric Investigation 2010;69(4):260‐3.
Zaman 2015 {published data only}
    1. Zaman M, Singal S, Singal R, Shah A, Sandhu KS, Singh B, et al. Comparison of open and closed entry techniques for creation of pneumoperitoneum in laparoscopic surgery in terms of time consumption, entry‐related complications and failure of technique. World Journal of Laparoscopic Surgery 2015;8:69‐71.
References to studies excluded from this review Alekberzade 2015 {published data only}
    1. Alekberzade A, Lypnitskiy E, Sundukov I, Badalov J. Early postoperative results of single‐incision laparoscopic cholecystectomy versus four‐port laparoscopic cholecystectomy. 80th Annual Scientific Meeting of the American College of Gastroenterology; 2015; Honolulu (HI) United States. 2015; Vol. 110.
Artis 2014 {published data only}
    1. Artis T, Kucuk C, Akay A, Zararsiz G, Sozuer E. Prospective randomized study comparing single incision vs. standard laparoscopic cholecystectomy. Surgical Endoscopy and Other Interventional Techniques 2014;28:S47.
Cardin 2011 {published data only}
    1. Cardin JL, Johanet H. Intraoperative events and their outcome: data from 4007 laparoscopic interventions by the French "Club Coelio". Journal of Visceral Surgery 2011;148(4):299‐310.
Chakravartty 2014 {published data only}
    1. Chakravartty S, Murgatroyd B, Singh U, Sarma D, Sharafudeen S, Dasan J. Laparoscopic vs single incision gastric band insertion: a double blind randomised control trial. Conference: 19th World Congress of the International Federation for the Surgery of Obesity and Metabolic Disorders, IFSO 2014 Montreal, QC Canada. 2014:1176.
Dabbagh 2015 {published data only}
    1. Dabbagh N, Soroosh A, Khorgami Z, Shojaeifard A, Jafari M, Abdehgah AG, et al. Single‐incision laparoscopic cholecystectomy versus mini‐laparoscopic cholecystectomy: a randomized clinical trial study. Journal of Research in Medical Sciences 2015;20(12):1153‐9.
Dunne 2011 {published data only}
    1. Dunne N, Booth MI, Dehn TC. Establishing pneumoperitoneum: Verres or Hasson? The debate continues. Annals of The Royal College of Surgeons of England 2011;93(1):22‐4.
Fagotti 2010 {published data only}
    1. Fagotti A, Fanfani F, Rossitto C, Marocco F, Gallotta V, Romano F, et al. Laparoendoscopic single‐site surgery for the treatment of benign adnexal disease: a prospective trial. Diagnostic and Therapeutic Endoscopy 2010 Feb 8 [Epub ahead of print].
Garg 2012 {published data only}
    1. Garg P, Thakur JD, Singh I, Nain N, Mittal G, Gupta V. A prospective controlled trial comparing single‐incision and conventional laparoscopic cholecystectomy: caution before damage control. Surgical Laparoscopy, Endoscopy and Percutaneous Techniques 2012;22(3):220‐5.
Han 2012 {published data only}
    1. Han C, Ding Z, Fan J, Sun J, Qian Y. Comparison of the stress response in patients undergoing gynecological laparoscopic surgery using carbon dioxide pneumoperitoneum or abdominal wall‐lifting methods. Journal of Laparoendoscopic and Advanced Surgical Techniques. Part A 2012;22(4):330‐5.
Joshipura 2009 {published data only}
    1. Joshipura VP, Haribhakti SP, Patel NR, Naik RP, Soni HN, Patel B, et al. A prospective randomized, controlled study comparing low pressure versus high pressure pneumoperitoneum during laparoscopic cholecystectomy. Surgical Laparoscopy, Endoscopy and Percutaneous Techniques 2009;19(3):234‐40.
Kim 2009 {published data only}
    1. Kim SS, Kim SH, Mun SP. Should subcostal and lateral trocars be used in laparoscopic cholecystectomy? A randomized, prospective study. Journal of Laparoendoscopic and Advanced Surgical Techniques 2009;19:6.
Lu 2012 {published data only}
    1. Lu C‐C, Lin S‐E, Chung K‐C, Rau K‐M. Comparison of clinical outcome of single‐incision laparoscopic surgery using a simplified access system with conventional laparoscopic surgery for malignant colorectal disease. Colorectal Disease 2012;14(4):171‐6.
Rizwi 2014 {published data only}
    1. Rizwi F, Saleem M, Abid KJ. Outcome of single incision laparoscopic cholecystectomy (SILC) versus conventional four port laparoscopic cholecystectomy for cholelithiasis: a randomized control trial. Pakistan Journal of Medical and Health Sciences 2014;8(1):243‐6.
Sandhu 2009 {published data only}
    1. Sandhu T, Yamada S, Ariyakachn V, Chakrabandhu T, Chongrukust W, Ko‐iam W. Low‐pressure pneumoperitoneum versus standard pneumoperitoneum in laparoscopic cholecystectomy, a prospective randomized clinical trial. Surgical Endoscopy 2009;23:1044‐7.
Sangrasi 2011 {published data only}
    1. Sangrasi AK, Shaikh AR, Muneer A. Open versus close pneumoperitoneum: a pursuit for safer technique. Pakistan Journal of Medical Sciences 2011;27(3):523‐7.
Shayani‐Nasab 2013 {published data only}
    1. Shayani‐Nasab H, Amir‐Zagar MA, Mousavi‐Bahar SH, Kashkouli AI, Ghorban‐Poor M, Farimani M, et al. Complications of entry using direct trocar and/or veress needle compared with modified open approach entry in laparoscopy: six‐year experience. Urology Journal 2013;10(2):861‐5.
Singh 2014 {published data only}
    1. Singh D, Jaiswal V, Sonkar AA, Kumar S, Singh S. Randomized control trial of conventional laparoscopic versus single incision laparoscopic cholecystectomy. 11th World Congress of the International Hepato‐Pancreato‐Biliary Association Seoul South Korea 2014;16:115.
Taye 2016 {published data only}
    1. Taye M, Fazal S, Pegu D, Saikia D. Open versus closed laparoscopy: yet an unresolved controversy. Journal of Clinical and Diagnostic Research 2016;10(2):QC04‐QC07.
Warle 2013 {published data only}
    1. Warle MC, Berkers AW, Langenhuijson JF, Jagt MF, Dooper PM, Kloke HJ, et al. Low‐pressure pneumoperitoneum during laparoscopic donor nephrectomy to optimize live donors' comfort. Clinical Transplantation 2013;27(4):478‐83.
Watanabe 2016 {published data only}
    1. Watanabe J, Ota M, Fujii S, Suwa H, Ishibe A, Endo I. Randomized clinical trial of single‐incision versus multiport laparoscopic colectomy. British Journal of Surgery 2016;103(10):1276‐81.
Zhao 2015 {published data only}
    1. Zhao M, Zhao J, Hua K, Zhu Z, Hu C. Single‐incision multiport laparoscopy versus multichannel‐tipped single port laparoscopy in gynecologic surgery: outcomes and benefits. International Journal of Clinical and Experimental Medicine 2015;8(9):14992‐8.
References to studies awaiting assessment Köstü 2016a {published data only}
    1. Köstü B, Kıran G, Ercan Ö, Özer A, Bakacak M. A comparison of skin elevation and fascial elevation in veress needle closed entry method. Journal of the Turkish German Gynecology Association. Conference: 11th Turkish German Gynecology Congress. Istanbul, 2016; Vol. Suppl 1:S137.
Prabakar 2015 {published data only}
    1. Prabakar C. A randomized clinical trial comparing two different methods of trocar placement in gynecologic laparoscopy. Obstetrics and Gynecology. Conference: 63rd Annual Clinical and Scientific Meeting of the American College of Obstetricians and Gynecologists San Francisco, CA United States. 2015:45S‐46S.
References to ongoing studies NCT00731107 {unpublished data only}
    1. Manley T, Tan J. XCEL Bladeless Trocar Versus Veress Needle: A Randomised Controlled Trial Comparing These Two Entry Techniques in Gynaecological Laparoscopic Surgery. (first received 8 August 2008).
NCT02804529 {unpublished data only}
    1. Meng F, Wang C. A Comparison of Three Different Entry Points to Establish the Pneumoperitoneum. (first received 17 June 2016).
NCT03306238 {unpublished data only}
    1. Thomas AZ. LAParoscopic Entry Technique in REnal Surgery (LAPRES). (first received 11 October 2017).
Additional references Ahmad 2007
    1. Ahmad G, Duffy JMN, Watson AJS. Laparoscopic entry techniques and complications. International Journal of Gynaecology and Obstetrics 2007;99:1.
Alkatout 2017
    1. Alkatout I. Complications of laparoscopy in connection with entry techniques. Journal of Gynecologic Surgery 2017;33:81‐91.
Antoniou 2013
    1. Antoniou SA, Antoniou GA, Koch OO, Pointner R, Granderath FA. Blunt versus bladed trocars in laparoscopic surgery: a systematic review and meta‐analysis of randomized trials. Surgical Endoscopy 2013;27:2312‐20.
Antoniou 2014
    1. Antoniou SA, Koch OO, Antoniou GA, Lasithiotakis K, Chalkiadakis GE, Pointner R, et al. Meta‐analysis of randomized trials on single‐incision laparoscopic versus conventional laparoscopic appendectomy. American Journal of Surgery 2014;207(4):613‐22.
Bhoyrul 2001
    1. Bhoyrul S, Vierra MA, Nezhat CR, Krummel TM, Way LW. Trocar injuries in laparoscopic surgery. Journal of the American College of Surgeons 2001;192:677‐83.
Bijen 2009
    1. Bijen CB, Vermeulen KM, Mourits MJ, Bock GH. Costs and effects of abdominal versus laparoscopic hysterectomy: systematic review of controlled trials. PLoS ONE 2009;4(10):7340.
Cuss 2014
    1. Cuss A, Bhatt M, Abbott J. Coming to terms with the fact that the evidence for laparoscopic entry Is as good as it gets. Journal of Minimally Invasive Gynaecology 2014;22(3):3332‐41.
Deeks 2011
    1. Deeks JJ, Higgins JPT, Altman DG (editors). Chapter 9: Analysing data and undertaking meta‐analyses. In: Higgins JPT, Green S (editors). Cochrane Handbook for Systematic Reviews of Interventions Version 5.1.0 (updated March 2011). The Cochrane Collaboration, 2011. Available from www.cochrane‐.
Fader 2010
    1. Fader AN. Laparoendoscopic single‐site surgery in gynaecology. Current Opinions in Obstetrics and Gynaecology 2010;22:331‐8.
Fuller 2005
    1. Fuller J, Ashar BS, Carey‐Corrado J. Trocar‐associated injuries and fatalities: an analysis of 1399 reports to the FDA. Journal of Minimally Invasive Gynaecology 2005;12(4):302‐7.
GRADEproGDT 2015 [Computer program]
    1. McMaster University (developed by Evidence Prime, Inc.). GRADEproGDT: GRADEpro Guideline Development Tool []. Version 01/06/2015. Hamilton (ON): McMaster University (developed by Evidence Prime, Inc.), 2015.
Hasson 1971
    1. Hasson HM. A modified instrument and method for laparoscopy. American Journal of Obstetrics and Gynaecology 1971;110(6):886‐7.
Higgins 2011a
    1. Higgins JPT, Green S (editors). Cochrane Handbook for Systematic Reviews of Interventions Version 5.1.0 (updated March 2011). The Cochrane Collaboration, 2011. Available from www.cochrane‐.
Higgins 2011b
    1. Higgins JPT, Deeks JJ, Altman DG (editors). Chapter 16: Special topics in statistics. In: Higgins JPT, Green S (editors). Cochrane Handbook for Systematic Reviews of Interventions Version 5.1.0 (updated March 2011). The Cochrane Collaboration, 2011. Available from www.cochrane‐.
Jansen 1997
    1. Jansen FW, Kapiteyn K, Trimbos‐Kemper T, Hermans J, Trimbos JB. Complications of laparoscopy: a prospective multicentre observational study. British Journal of Obstetrics and Gynaecology 1997;104(5):595‐600.
Jansen 2004
    1. Jansen FW, Kolkman W, Bakkum EA, Kroon CD, Trimbos‐ Kemper TC, Trimbos JB. Complications of laparoscopy: an enquiry about closed versus open entry technique. American Journal of Obstetrics and Gynecology 2004;190(3):634‐8.
Krishnakumar 2009
    1. Krishnakumar S, Tambe P. Entry complications in laparoscopic surgery. Journal of Gynaecological Endoscopy and Surgery 2009;1(1):4‐11.
Lalchandani 2005
    1. Lalchandani S, Philips K. Laparoscopic entry techniques ‐ a survey of practices of consultant gynaecologists. Gynaecological Surgery 2005;2(4):245‐9.
Lefebvre 2011
    1. Lefebvre C, Manheimer E, Glanville J. Chapter 6: Searching for studies. In: Higgins JPT, Green S (editors). Cochrane Handbook for Systematic Reviews of Interventions Version 5.1.0 (updated March 2011). The Cochrane Collaboration, 2011. Available from www.cochrane‐.
Liliana 2011
    1. Liliana M, Alessandro P, Giada C, Luca M. Single‐port access laparoscopic hysterectomy: a new dimension of minimally invasive surgery. Journal of Gynecological Endoscopy and Surgery 2011;2(1):11‐7.
Magrina 2002
    1. Magrina JF. Complications of laparoscopic surgery. Clinical Obstetrics and Gynaecology 2002;45(2):469‐80.
Merlin 2003
    1. Merlin TL, Hiller JE, Maddern GJ, Jamieson GG, Brown AR, Kolbe A. Systematic review of the safety and effectiveness of methods used to establish pneumoperitoneum in laparoscopic surgery. British Journal of Surgery 2003;90:668‐79.
Mettler 1997
    1. Mettler L, Ibrahim M, Vu Quang V, Jonat W. Clinical experience with an optical access trocar in gynecological laparoscopy‐pelviscopy. Journal of the Society of Laparoendoscopic Surgeons 1997;1:315‐8.
Middlesbrough Consensus 1999
    1. Middlesbrough Consensus. A consensus document concerning laparoscopic entry techniques. Gynaecological Endoscopy 1999;8(6):403‐6.
Moher 2009
    1. Moher D, Liberati A, Tetzlaff J, Altman DG, PRISMA Group. Preferred reporting items for systematic reviews and meta‐analyses: the PRISMA statement. BMJ 2009;339:2535.
Molloy 2002
    1. Molloy D, Kaloo PD, Cooper M, Nguyen TV. Laparoscopic entry: a literature review and analysis of techniques and complications of primary port entry. Australian and New Zealand Journal of Obstetrics and Gynaecology 2002;42(3):246‐55.
RCOG 2008
    1. Royal College of Obstetricians and Gynaecologists. Preventing entry‐related gynaecological laparoscopic injuries (Green‐top Guideline No. 49). , 2008 (accessed 23 December 2014).
RevMan 2014 [Computer program]
    1. The Nordic Cochrane Centre, The Cochrane Collaboration. Review Manager (RevMan). Version 5.3. Copenhagen: The Nordic Cochrane Centre, The Cochrane Collaboration, 2014.
Song 2013
    1. Song T, Kim ML, Jung YW, Yoon BS, Joo WD, Seong SJ. Laparoendoscopic single‐site versus conventional laparoscopic gynaecologic surgery: a meta‐analysis of randomized controlled trials. American Journal of Obstetrics and Gynaecology 2013;209(4):317.
Swank 2012
    1. Swank HA. Systematic review of trocar‐site hernia. British Journal of Surgery 2012;99(3):315‐23.
Tarnay 1999
    1. Tarnay CM, Glass KB, Munro MG. Entry force and intra‐abdominal pressure associated with six laparoscopic trocar‐cannula systems: a randomized comparison.. Obstetrics and Gynecology 1999;94:83‐8.
Vilos 2007
    1. Vilos GA, Ternamian A, Dempster J, Laberge PY. Laparoscopic entry: a review of techniques, technologies and complications. Journal of Obstetrics and Gynaecology Canada 2007;29(5):433‐65.
References to other published versions of this review Ahmad 2007a
    1. Ahmad G, Duffy JMN, Phillips K, Watson A. Laparoscopic Entry Techniques. Cochrane Database of Systematic Reviews 2007, Issue 3. [DOI: 10.1002/14651858.CD006583]
Ahmad 2008
    1. Ahmad G, Duffy JMN, Phillips K, Watson A. Laparoscopic entry techniques. Cochrane Database of Systematic Reviews 2008, Issue 2. [DOI: 10.1002/14651858.CD006583]
Ahmad 2012
    1. Ahmad G, O'Flynn H, Duffy JMN, Phillips K, Watson A. Laparoscopic entry techniques. Cochrane Database of Systematic Reviews 2012, Issue 2. [DOI: 10.1002/14651858.CD006583]
Ahmad 2015
    1. Ahmad G, Gent D, Henderson D, O'Flynn H, Phillips K, Watson A. Laparoscopic entry techniques. Cochrane Database of Systematic Reviews 2015, Issue 8. [DOI: 10.1002/14651858.CD006583.pub4]

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