Background: Safe and efficient abdominal entry is an essential step in minimally invasive gynecologic surgery. Several entry techniques have been described, but no single approach has been universally established as superior. We describe a standardized transumbilical entry technique combining complete umbilical eversion with direct trocar insertion (DTI) for robotic-assisted gynecologic surgery.
Methods: A retrospective, single-center observational cohort study was conducted at the University Department of Gynecology, Nuremberg General Hospital, Germany, including patients who underwent robotic-assisted gynecologic surgery between January 2021 and December 2024. The technique was applied in all 401 patients included in the analysis. The umbilicus was completely everted, a median sagittal incision of approximately 1 cm was created, and an 8-mm optical trocar was directly introduced through the preformed opening along a vertical trajectory of approximately 90°. Entry time was measured by the surgical team using a stopwatch, from the beginning of the skin incision to complete insertion of the trocar into the abdominal cavity. A historical cohort of 200 patients undergoing conventional laparoscopy with Veress needle entry during the same period was used solely for descriptive comparison of entry time.
Results: The technique was successfully completed in all 401 patients, with no documented entry failures or need for conversion to an alternative access technique. Mean entry time was 45 seconds, with an observed range of 40–65 seconds. In the historical Veress cohort, entry time was 3 to < 4 minutes in 30% of patients, 4 to <5 minutes in 60%, and ≥5 minutes in 10%. No clinically relevant access-related complication was documented in the direct entry cohort. During the available postoperative follow-up, no umbilical wound infection, wound dehiscence, clinically relevant umbilical pain, or umbilical hernia related to the access site was documented. Long-term systematic surveillance for incisional or umbilical hernia was not performed.
Conclusion: Umbilical eversion combined with direct trocar insertion was feasible and reproducible within this experienced robotic gynecologic surgery team. The technique allowed rapid establishment of abdominal access and was applied in patients with varying BMI with or without previous abdominal surgery. However, the retrospective single-center design and the use of a historical comparator with different surgical indications limit conclusions regarding comparative safety or efficacy. Prospective comparative studies are warranted to further evaluate this approach.