The umbilicus is the usual site of initial entry. An infraumbilical “smile” or supraumbilical “frown” incision made in a natural skin crease is virtually invisible when healed (Fig. 42.1A). If conversion to open laparotomy is a strong possibility, a vertically oriented circumumbilical incision gives equally good access and is easily incorporated into a vertical midline incision.

Visualize the probable site of the pathology within the abdomen and consider the location of the umbilicus relative to this site. The level of the umbilicus varies considerably from individual to individual—do not hesitate to make the entry site slightly above or below the umbilicus if necessary. If the umbilicus is low on the abdomen and the target site is in the upper abdomen, an incision above the umbilicus may be necessary. Conversely, an incision below the umbilicus may provide the best visualization for laparoscopic cholecystectomy in a small patient. If all other things are equal, it is a bit easier to enter the abdomen through a smile incision because this avoids the falciform ligament. Make the incision a millimeter or two longer than the diameter of the trocar you plan to use. Deepen the incision through skin and subcutaneous tissue until the fascia at the base of the umbilicus is encountered. If the patient is obese, place a Kocher clamp on the underside of the umbilicus and pull up. Because skin is adherent to fascia at the umbilicus, this will elevate the fascia. Place Kocher clamps side by side on the fascia. Hold one in your nondominant hand and have your first assistant hold the other.

Test the Veress needle and confirm that the tip retracts easily (Fig. 42.1B). Introduce the Veress needle with steady controlled pressure, attentive to the popping sensations as it passes through the fascia and then the peritoneum (Fig. 42.1C). When the Veress needle is properly positioned, the tip should move freely from side to side as the hub is gently moved back and forth.