The Veress needle is one of the most fundamental instruments in laparoscopic surgery. It is used to establish pneumoperitoneum, which is the introduction of carbon dioxide (CO₂) gas into the peritoneal cavity to create working space for the laparoscope and surgical instruments. Since its introduction in 1938 by Hungarian internist Dr. János Veres, the Veress needle has become a standard tool in minimally invasive surgery. Understanding its design, working principle, insertion techniques, and safety considerations is crucial for every laparoscopic surgeon.

Design and Structure of Veress Needle

The Veress needle is a spring-loaded device with a blunt inner stylet that retracts inside a sharp outer cannula.

Key features include:

Outer cannula: A hollow, beveled needle with a sharp tip that penetrates the abdominal wall.

Inner stylet (blunt trocar): Spring-loaded and protrudes once the peritoneum is entered, protecting underlying organs.

Side hole (lateral opening): Located near the tip, it allows gas insufflation into the peritoneal cavity.

Hub and stopcock: At the proximal end, the hub connects to the CO₂ insufflator, and the stopcock controls gas flow.

The standard length of the Veress needle is 12–15 cm, though longer versions (up to 20 cm) are available for obese patients.

Principle of Operation

The working principle is based on safety by design. As the needle pierces tissue layers, the sharp cannula leads the way. Once the peritoneum is penetrated, the spring-loaded blunt stylet instantly advances forward, covering the sharp tip. This prevents damage to intra-abdominal organs.

Technique of Veress Needle Insertion

Correct placement of the Veress needle is essential to avoid complications. The technique involves the following steps:

Patient Preparation

The patient is placed in a supine position under general anesthesia.

The bladder is emptied, and the stomach is decompressed with a nasogastric tube if necessary.

Insertion Site

Common site: Infraumbilical region, through the linea alba, as it is the thinnest abdominal wall location.

Alternative sites: Palmer’s point (left subcostal region), especially in obese patients or in cases with prior abdominal surgery where adhesions may exist.

Insertion Steps

Make a small skin incision at the chosen site.

Hold the Veress needle like a dart and advance it at a 45° angle in thin patients or perpendicular in obese patients.

A “double-click” sensation is often felt as the needle traverses the fascia and peritoneum.

Confirm entry into the peritoneal cavity with safety tests.

Confirmation of Proper Placement

Several techniques help confirm correct intraperitoneal placement:

Aspiration Test: Aspirate with a syringe; if blood, bowel contents, or urine are obtained, the needle is misplaced.

Saline Drop Test: A drop of saline is placed at the hub; if it flows freely into the cavity, placement is correct.

Initial Insufflation Pressure: Low initial intra-abdominal pressure (<10 mmHg) indicates proper placement.

Hanging Drop Test: Similar to saline drop test, relies on negative intra-abdominal pressure.

Establishing Pneumoperitoneum

Once correct placement is confirmed, CO₂ is insufflated using an electronic insufflator. The goal is to create an intra-abdominal pressure of 12–15 mmHg in adults. This insufflation lifts the abdominal wall away from underlying viscera, providing a clear working space for trocar insertion and visualization.

Safety Considerations

Although widely used, Veress needle insertion carries certain risks. Complications may arise if the needle enters a hollow viscus or blood vessel. Therefore:

Correct angle and site selection are critical.

Alternative entry points (Palmer’s point, Jain point) should be considered in patients with prior surgeries.

The surgeon must be familiar with open (Hasson) technique in high-risk patients.

Complications of Veress Needle

While rare, potential complications include:

Vascular injury – puncture of major vessels causing bleeding.

Visceral injury – bowel or bladder perforation.

Subcutaneous emphysema – gas leakage into soft tissues.

Preperitoneal insufflation – improper placement leading to failed pneumoperitoneum.

Most complications are preventable with correct technique and experience.

Alternatives to Veress Needle

Some surgeons prefer the open (Hasson) technique, where a small incision is made, and the trocar is placed under direct vision. Newer technologies, such as optical trocars, also provide direct visualization during entry, further reducing risks. Despite these alternatives, the Veress needle remains the most commonly used method worldwide.

Conclusion

The Veress needle is an indispensable tool in laparoscopic surgery, allowing safe and efficient creation of pneumoperitoneum. Its spring-loaded design minimizes the risk of organ injury, while its simple mechanism makes it reliable and cost-effective. For safe use, surgeons must master insertion techniques, recognize the signs of correct placement, and be aware of possible complications.

At advanced training centers like World Laparoscopy Hospital, laparoscopic surgeons receive hands-on instruction under the guidance of experts such as Dr. R. K. Mishra, ensuring proficiency in Veress needle insertion as a critical skill in minimally invasive surgery.