Evaluation of Outcomes of Supraumbilical Versus Infraumbilical Primary Port Placement for Laparoscopic Access among Comorbid Patients in A Tertiary Care Hospital of Bangladesh
Executive Summary
This briefing document analyzes a prospective randomized controlled trial involving 70 comorbid patients at a tertiary care hospital in Bangladesh. The study compared the efficacy and safety of supraumbilical versus infraumbilical primary port placement for laparoscopic access.
The analysis concludes that infraumbilical primary port placement is the superior approach for this high-risk population. Key findings include significantly faster pneumoperitoneum establishment (3.6 minutes vs. 4.2 minutes), a higher first-attempt success rate (91.4% vs. 74.3%), and superior visualization quality. While both techniques maintained comparable safety profiles regarding major complications, the infraumbilical approach demonstrated a numerically lower incidence of access-related complications, port site infections, and herniations, alongside significantly better cosmetic outcomes.
Study Overview and Methodology
The study addressed the ongoing debate regarding optimal primary port placement, specifically within the context of comorbid patients—individuals with diabetes, hypertension, obesity, or previous abdominal surgeries—who present unique surgical challenges such as altered anatomy and increased risk of adhesions.
Trial Parameters
Design: Prospective randomized controlled trial.
Setting: Department of Surgery, Dinajpur Medical College, Bangladesh (January 2023 – June 2024).
Participants: 70 adult patients (ASA II-III) with at least one significant comorbidity.
Allocation:
Group A (Supraumbilical): 35 patients; 12-mm trocar inserted 1-2 cm above the umbilical rim at a 45-degree angle.
Group B (Infraumbilical): 35 patients; 12-mm trocar inserted 1-2 cm below the umbilical rim perpendicularly or at a slight caudal angle.
Patient Profile
The groups were well-matched with no significant differences in age, gender, or BMI. The comorbidity burden was high, with 88.6% of Group A and 82.9% of Group B presenting with multiple comorbidities.
Analysis of Primary Technical Outcomes
The infraumbilical approach demonstrated clear technical advantages across all primary metrics.
1. Efficiency of Access
Time to Pneumoperitoneum: The infraumbilical group achieved access significantly faster (3.6 ± 1.4 minutes) compared to the supraumbilical group (4.2 ± 1.8 minutes; p=0.038).
Success Rates: Group B achieved a 91.4% first-attempt success rate, whereas Group A succeeded on the first attempt only 74.3% of the time (p=0.045).
2. Ease of Insertion
Trocar insertion was rated as "Very Easy" for 54.3% of patients in the infraumbilical group, compared to only 34.3% in the supraumbilical group (p=0.032). Subgroup analysis revealed that obese patients (BMI >30) experienced a greater difference in insertion difficulty, favoring the infraumbilical approach.
Secondary and Surgical Performance Outcomes
Visualization Quality
The infraumbilical site provided superior internal visualization, categorized as "Excellent" in 74.3% of cases, compared to 51.4% in the supraumbilical group (p=0.041). This advantage is particularly noted for upper abdominal procedures.
Operative and Recovery Metrics
No statistically significant differences were observed in:
Total Operative Time: 62.3 minutes (Infra) vs. 68.4 minutes (Supra).
Postoperative Pain: Measured via Visual Analog Scale (VAS) at 6, 12, and 24 hours; both groups followed a similar downward trend in pain levels.
Hospital Stay: Median stay was 2 days for both groups.
Patient Satisfaction: Scores were comparable (8.6 for Group B vs. 8.1 for Group A).
Safety and Long-term Complications
While major vascular or bowel injuries occurred in neither group, technical complications and delayed outcomes favored the infraumbilical approach.
Access-Related Complications
The supraumbilical group experienced a numerically higher rate of total complications (22.9%) compared to the infraumbilical group (8.6%). These included minor vascular injuries, omental injuries, and subcutaneous emphysema.
Delayed Outcomes
Delayed measures assessed the long-term implications of port site selection:
The cosmetic advantage for infraumbilical access was statistically significant (p=0.048).
Conclusions and Clinical Implications
The study highlights that for comorbid patients—who are prone to impaired healing and technical surgical challenges—the choice of primary port site is critical.
Anatomical Advantage: The infraumbilical region typically has reduced fascial thickness and provides a more direct perpendicular insertion angle, which minimizes the risk of vessel injury and facilitates easier penetration in obese patients.
Standardization: The findings support adopting infraumbilical placement as the standard approach in tertiary care settings, especially in resource-constrained environments where optimizing surgical efficiency and minimizing postoperative complications are paramount.
Summary Recommendation: Infraumbilical port placement offers faster establishment of pneumoperitoneum, higher success rates, better visualization, and superior cosmetic results without compromising patient safety.
