British Journal of Obstetrics zyxwvuts and Gynaecology zyxwvuts September 2000, Vol107, pp. zyxwvutsr 1179-1184 zyxwvutsrq CORRESPONDENCE Open laparoscopy: the way forward (Received 15 December 1999) zyxwvutsr Sic In their interesting editorial Pickersgill et al. (Vol 106, November 1999)’make a plea to abandon the Veress needle. The Veress needle technique of creating a pneumoperitoneum has three blind spots: blind insertion of the Veress needle, blind introduction of carbon dioxide and blind insertion of the sharp trocar and cannula. Most complications of laparoscopy are caused by the Veress needle and by the trocd. Direct access effectively avoids the three blind spots and should make laparoscopy safer. SinceJanuary 1998 we have used an open technique for all diagnos tic and operative laparoscopies using a disposable ORIGIN port (PEI, Falcon Way, Belfast). The change was introduced in imitation of the general surgeons who had never been comfortable with a Veress nee- dle. A postal questionnaire was mailed to consultantgynaecologists and specialist registrars in Northern Ireland. Replies were received from 47 of the 53 consultants and 22 other grades. Sixty-eightuse aVeress nee- dle and one inserts the trocar directly through the abdominal wall. In case of failure of the primary technique only one respondent selected direct or open access as an alternative method. Seventeen continue to use the Rocket i n s d a t o r rather than a more modern machine and seven use a maximum insufflation pressure of 20 mmHg. It will be a major task to persuade practising gynaecologists to alter a technique that they have used successfully for many years and that was endorsed by the confidentialenquiry of the Royal College of Obstetricians and Gynaecologists in 1978?. However 21 years later we believe it is important that gynaecologists in training and those with any special interest in laparoscopy should move away from the Veress needle and adopt direct access. Richard H. B. de Courcy-Wheeler zyxwvutsr & Nasser Shehata Daisy Hill Hospital, Newry, Northern Ireland References 1 Pickersgill A, Made RJ, Falconer GF, Attwood S. Open laparoscopy: the way forward. Br JObstet Gynaecoll999; 106: 1116-1119. 2 Witz M, Lehmann JM. Major vascular injury during laparoscopy. Br J Surg 1997; zyxwvutsrqp 84: 800. 3 Chamberlain G, Warren Brown J. Gynaecological laparoscopy. The Report of the Working Party of the Confidential Enquiq into Gynae- cological Laparoscopy.London: RCOG Press, 1978. (Received 4 January 2000) zyxwvutsrq Sic We read with interest the commentaries on open laparoscopy by Pick- ersgill et al. (Vol 106, November 1999)’ who recommend it as a safe and superior method of creating a pneumoperitoneum, and recom- mend that we abandon the blind insertion of any instrument into the abdominal cavity. If we agree that entering the abdominal cavity is a dangerous pro- cedure, whatever the laparoscopic procedure, and that it is responsi- ble for a third of the severe complications arising from laparoscopic surgery*,we cannot agree with his (and many other authors’)analysis of the article by Bonjer et al., referred to by Pickersgill’. This author based his preference for open laparoscopy by comparing 489,335 closed laparoscopies performed by various operators with 12,444 open laparoscopies performed by a few well-trained operators. Who can deny that this comparison is unfair? The low prevalence of major complications of laparoscopy implies that ascertainment of the preferred method, open or closed, is difficult, and there is no evidence that the open method is superior. In fact the opposite may be true: 8.4% of laparoscopies in France are performed by the open procedure, but this accounts for 14% of intestinal injuries and two major vessel injuries (including one death) (SociCtC d’Endoscopie GynCcologique; unpublished data). Different methods of laparoscopic abdominal entry need more thorough evaluation before abandoning the standard technique of closed laparoscopy3. Fabrice Pierre Department of Obstetrics and Gynaecology and Reproductive Medicine, CHU-La Militrie, Poitiers Cedex, France Henri Marret Department of Obstetrics and Gynaecology, Fetal Medicine and Humn Reproduction. CHU-Bretonneau.Tours, France Charles Chapron Department of Gynaecological Surgery, University Hospital Baudelocque, Pans, France References 1 Pickersgill A, Made RJ, Falconer GF, A t t w d S. Open laparoscopy: the way foward. BrJObstetGynuecoll999 106: 1116-1119. 2 Chapron C, Querleu D, Bruhat MA et al. Surgical complications of diagnostic and operative gynaecological laparoscopy: a series of 29,966 cases. Human Reprod 1998; 13: 867-872. 3 Pierre F, Chapron C, Querleu D et al. Entry phase in operative gynae- cological laparoscopy: Recommends. Eur J Gynecol Obstet Reprod Biol2ooO,29 in press. AUTHOR’S &PLY Sic We would like to thank Pierre et al. for their interesting comments on our article. They are correct in stating that, at present, it is impossible to conclude which method of developing a pneumoperi- toneum is the safest. In order to reach this conclusion massive ran- domised controlled trials involving hundreds of thousands of women would be necessary to demonstrate only small reductions in complication rates’. The point out from unpublished data that 8.43% of French laparo- scopies are “open” and responsible for 14% of intestinal injuries and two vascular injuries. Unfortunately they do not provide us with fur- ther details of this data. It could well be the case that surgeons unfa- miliar with the open method are selecting this for high risk patients likely to suffer complications. We are somewhat surprised by their mention of a fatality from a major vessel injury as it is widely accepted that a correctly performed open laparoscopy should eliminate the risk of vascular damage. We acknowledge that bowel perforations could still occur with the open method but are certain they are more likely to be recognised, resulting in less morbidity and mortality than those associated with the closed method. Their letter perhaps best illustrates an advantage of the French, in that they keep a register of laparoscopic complications, something that we would urge generally. We would also like to thank de Courcy-Wheeler and Shehata for their support of our thoughts and echo their call for all gynaecologists to learn the technique of open laparoscopy. We would recommend that as the very minimum, if previous surgery suggests that closed laparoscopic entry is more hazardous, then an alternative entry 0 RCOG 2000 British Journal of Obstetrics and Gynaecology 1179