The Four-Clamp Technique for primary laparoscopic access in morbidly obese patients: a retrospective cohort study

This retrospective, single-centre cohort study evaluated the Four-Clamp Technique for primary laparoscopic access in 45 morbidly obese women (body mass index ≥40 kg/m2) undergoing gynaecological procedures at a tertiary centre between January 2015 and August 2025. The technique utilised four symmetrically positioned towel clamps to allow omnidirectional traction to achieve stable abdominal wall elevation before direct trocar insertion. First-attempt success was achieved in 39 (86.7%) of patients, with overall success in 42 (93.3%) women. No major vascular or visceral injuries occurred. Ten (22.2%) minor complications occurred: trocar-site or clamp-site bleeding (4, 8.9%), minor omental injury (3, 6.6%), subcutaneous emphysema (2, 4.4%), and extraperitoneal insufflation (1, 2.2%). Mean time to intraperitoneal access was 74±18 seconds. Target intra-abdominal pressure was maintained at 12-14 mmHg. The Four-Clamp Technique may represent a feasible and reproducible method for primary laparoscopic access in morbidly obese patients in this single-centre cohort; however, prospective comparative studies are warranted to confirm these preliminary findings.