Alignment of the umbilical axis: an effective maneuver for laparoscopic entry in the obese patient

BACKGROUND: In obese patients, a panniculus may cause a caudal deviation in the vertical axis of the umbilicus and make laparoscopic entry difficult. TECHNIQUE: First, the presence or absence of caudal deviation of the umbilical axis is ascertained by measuring the distance between the external umbilical orifice and the anterior superior iliac spines along the length of the patient. Second, the caudally deviated umbilicus is displaced cranially by manual pressure on the panniculus so that the external umbilical orifice rests approximately 8 cm above the level of the anterior superior iliac spines. Third, open laparoscopy is performed through the base of the umbilicus by elevating it with clamps and incising skin, fascia, and peritoneum in a vertical axis. EXPERIENCE: In an 18-month period, 67 consecutive obese women (weight range 99-213 kg) underwent surgery by the authors for gynecologic conditions requiring primary intraperitoneal evaluation or treatment. All of these patients were scheduled for laparoscopy and underwent the assessment, alignment, and entry technique described above to commence the operations. Laparoscopic entry by this technique was successful and rapid in all 67 cases and was not complicated by preperitoneal insufflation, subcutaneous emphysema, visceral injury, vascular injury, penetration of an underlying skin fold, or postoperative wound complications. CONCLUSION: Umbilical axis assessment and alignment safely facilitates laparoscopy in obese patients.