Laparoscopic surgery has become the standard approach for many abdominal and pelvic procedures due to its minimally invasive nature, reduced postoperative pain, and faster recovery. However, establishing safe and effective access to the abdominal cavity is the first and most critical step in laparoscopic surgery.

The Veress needle technique is one of the most widely used methods for creating a pneumoperitoneum, providing surgeons with a safe and controlled way to introduce carbon dioxide (CO₂) into the peritoneal cavity. Proper understanding of the technique, anatomy, and safety precautions is essential to minimize complications such as vascular injury, bowel perforation, or subcutaneous emphysema.

Principles of Veress Needle Technique

The Veress needle, developed by János Veress in 1938, was originally designed for inducing pneumothorax but later adapted for laparoscopy. It is a spring-loaded needle with a blunt inner stylet that automatically retracts when the needle tip encounters resistance, thereby reducing the risk of injury to intra-abdominal organs.

The main principle of the Veress needle technique is to create a controlled pneumoperitoneum before inserting the first trocar for laparoscopic instruments. This establishes working space in the abdominal cavity for safe visualization and manipulation.

Indications

The Veress needle technique is suitable for:

Diagnostic laparoscopy

Elective laparoscopic procedures such as cholecystectomy, appendectomy, or hernia repair

Gynecological laparoscopic surgeries including hysterectomy, ovarian cystectomy, and endometriosis treatment

However, it is contraindicated in patients with:

Extensive intra-abdominal adhesions (e.g., post-surgery or peritonitis)

Large ventral hernia

Distorted abdominal anatomy due to previous surgeries or masses

In such cases, open (Hasson) technique is preferred.

Technique of Laparoscopic Access Using Veress Needle
Patient Positioning

The patient is placed in the supine position with arms tucked or abducted depending on the procedure.

Slight Trendelenburg or reverse Trendelenburg tilt may be used to facilitate organ displacement.

Proper positioning ensures ease of entry and minimizes risk of injury.

Preparation and Site Selection

The umbilicus is the most common entry point due to a thin abdominal wall and minimal vascularity.

The entry site is cleaned and draped under sterile conditions.

A small skin incision (2–3 mm) is made to facilitate needle insertion.

Veress Needle Insertion

The Veress needle is held like a dart, perpendicular to the abdominal wall.

After tenting the abdominal wall, the needle is advanced with gentle pressure.

The spring-loaded inner stylet retracts as it penetrates the peritoneum, protecting intra-abdominal organs.

Proper placement is confirmed using the following tests:

Aspiration Test: No blood or bowel contents should be aspirated.

Saline Drop Test: A drop of saline should be sucked into the needle if correctly placed.

Hanging Drop Test: Saline placed at the hub of the needle should be pulled inwards when intra-abdominal pressure is negative.

Insufflation of Carbon Dioxide

Once proper placement is confirmed, CO₂ is introduced at 2–4 L/min until an intra-abdominal pressure of 12–15 mmHg is reached.

Adequate pneumoperitoneum elevates the abdominal wall away from underlying structures, providing a safe working space.

Trocar Insertion

After achieving pneumoperitoneum, the primary trocar is introduced at the same site under controlled conditions.

Laparoscopic visualization is then established, allowing safe insertion of additional ports as required.

Safety Considerations

Always check for prior abdominal surgeries and consider adhesions.

Avoid excessive force during needle insertion.

Confirm correct placement with tests before insufflation.

Monitor intra-abdominal pressure and patient vitals continuously.

In case of resistance or abnormal findings, do not force the needle—convert to open technique if necessary.

Complications, though rare, may include: vascular injury, bowel perforation, subcutaneous emphysema, or failed pneumoperitoneum. Proper training and adherence to protocol minimize risks.

Advantages of Veress Needle Technique

Minimally invasive with a small entry point

Rapid establishment of pneumoperitoneum

Widely accepted and standardized in laparoscopic procedures

Reduces risk of organ injury compared to blind trocar insertion without pneumoperitoneum

Conclusion

The Veress needle technique is a cornerstone of laparoscopic surgery, providing a safe and efficient method to establish pneumoperitoneum. Mastery of this technique requires understanding abdominal anatomy, proper patient positioning, needle handling, and safety checks.

When performed correctly, it allows surgeons to initiate minimally invasive procedures with reduced complications and improved patient outcomes. Expertise in the Veress needle technique is essential for both novice and experienced laparoscopic surgeons, forming the foundation for safe and successful laparoscopic surgery.