The umbilical port insertion is usually performed using a modified Hasson approach. A vertical 1-cm subumbilical incision is made. This is deepened down to the linea alba, which is then grasped on each side of the midline using Kocher clamps. A scalpel (no. 15 blade) or cautery is used to open the fascia between the Kocher clamps and Kelly forceps are used to open the peritoneum bluntly. It is important to keep this opening small (<1 cm) to minimize air leaks. After confirming entry into the peritoneal cavity, a purse string of 0 polyglycolic acid is sutured around the subumbilical fascial defect (umbilical port site) and a Rommel tourniquet applied (Fig. 3.1). A 10-mm reusable port is inserted through this port site, allowing the abdomen to be insufflated with CO₂ to a pressure of 12 mmHg. The camera is inserted into the abdomen and an initial laparoscopy performed carefully evaluating the liver, small bowel, and peritoneal surfaces.

We selectively use a Visiport optical trocar in reoperative cases when access to the abdomen cannot be safely obtained through the umbilicus (Fig. 3.2). A 1-cm skin incision is made, and the laparoscope is inserted into the Visiport optical trocar. The Visiport trocar is slowly advanced in a twisting fashion, allowing direct visualization of all layers of the abdominal wall.

For hand-assisted and single-incision laparoscopic cases, the abdomen is entered through an open cutdown technique. A vertical incision is made from just below the
umbilicus extending 5 to 7 cm in length cephalad (Fig. 3.3). The ideal size of the hand port incision is 1 cm less than surgeon’s glove size. This is deepened down to the linea alba, which is then grasped on each side of the midline using Kocher clamps. Cautery is used to open the fascia between the Kocher clamps and Kelly forceps are used to open the peritoneum bluntly. Having confirmed entry into the peritoneal cavity, the hand port is inserted. A blunt port is placed in the center of the hand port
for insufflation. Through this site, the abdomen is filled with CO₂ to a pressure of 12 to 15 mmHg.