Abdominal and Pelvic Wall

The anterior abdominal wall is the first barrier to be crossed for surgical access, and the mastery of this anatomy is fundamental to reduce risks. Puncture accidents account for over 50% of complications in laparoscopy (1), and may cause delays, sequelae or change in the procedure. The preferred positioning for the main trocar is the umbilical scar, where there is complete fusion of the skin with the peritoneum and with a shorter distance to be covered by the trocar. The distance from the umbilical scar to the great vessels may vary according to the BMI and the patient’s positioning, important criteria for the adoption of the most appropriate technique. The lateral punctures should take into account the path of the vessels that compose the superficial and deep irrigation networks, especially the inferior epigastric artery, a branch of the external iliac artery and the main blood supply of the anterior wall. This vessel ascends medially to the internal inguinal canal, travels below the transverse fascia, composing the lateral peritoneal fold, towards the umbilical scar. As it crosses the lateral border of the rectus abdominis muscle, at the arcuate line, it is susceptible to injury during insertion of the lateral trocars. At this site there may also be nerve injury, especially to the iliohypogastric and ilioinguinal nerves, which pass medially to the anterosuperior iliac crest.