Establishment of pneumoperitoneum through the left ninth intercostal space

A simple technique for pneumoperitoneum needle insertion in patients presumed to have anterior abdominal wall adhesions from previous surgery, when abdominal obesity prevented successful umbilical insufflation, is described. The left ninth intercostal space (the lowest interspace above a fixed rib attached to the sternum) was chosen as this area is easily accessible, rarely has adhesions, and is void of major intra-abdominal organs. There were no complications from using this entry site. Three of 50 insertions failed to obtain free flow insufflation. The technique is simple and adds safety to laparoscopy in patients at risk for anterior abdominal wall adhesions, and entry-site flexibility when umbilical insufflation fails.