What is the best method of access?

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Open Fielding technique:

This technique developed by George Fielding in 1992 involves a small incision over the everted umbilicus (use a Littlewoods' and a No 11 blade) at a point where the skin and peritoneum are adjacent.  It is very easy.  The surgeon stands on the side of their dominant hand. 

This technique can be used in patients with abdominal incisions  provided there is no midline incision, portal hypertension and re-canalized umbilical vein or umbilical abnormalities such as urachal cyst, sinus or umbilical hernia present.

A suture is not required to prevent gas leakage because the umbilicus has been everted (so the angle of insertion of the laparoscopic port becomes oblique) and the incision required is relatively small.  However, one may be needed to stabilize the port.  An alternative is the Littlewood forceps. 

 Thorough skin preparation of the umbilicus is carried out and the everted umbilicus (with toothed Littlewood grasping forceps) is incised from the apex in a caudal direction. Occasional two small retractors are required to expose the cylindrical umbilical tube running from the undersurface of the umbilical skin down to the linea alba. This tube is then cut from its apex downwards towards its junction with the linea alba.  Further blunt dissection through this plane permits direct entry into the peritoneum.  Once the peritoneal cavity is breached the laparoscopic port (without trocar) can then be inserted directly and insufflation started.  A blunt internal trocar facilitates insertion of this port and an external grip that can be attached to the port assist to secure it in position.

A single suture is used to close the defect.

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