RESUMEN
Establishing pneumoperitoneum using the classic umbilical port in women who have had several previous surgeries is risky, life threatening, and a diabolic challenge for the surgeon. Open laparoscopy is one alternative, with a risk factor for bowel injury of 0.5%. Since 1992 we have preferred the transcostal approach. A stab incision is made between the ninth and tenth ribs in the left medioclavicular line and a disposable Veress needle is pushed into the coelomic cavity. Passing the needle only in this area of strongly attached peritoneum, the typical needle click is heard and its intraabdominal position is confirmed by an insufflation pressure below 5 mm Hg. After insufflation of 0.5 L, percussion in the right hypochondric quadrant ensures correct distribution of the gas. A contraindication for this port is a prior splenectomy. No complications occurred in our series of 64 patients.