The aortic bifurcation, located where the abdominal aorta splits into the right and left common iliac arteries, is a vital anatomical landmark. Accurate knowledge of its position relative to the umbilicus is critical in laparoscopic surgeries, particularly those involving the lower abdomen and pelvis. Iatrogenic vascular injury remains a significant risk during initial trocar and Veress needle insertion. Previous anatomical studies report variability in bifurcation levels based on anthropometric factors, including sex, height, and BMI. This expanded study provides a detailed analysis of this relationship in a larger cohort of 1000 patients, offering further insight into safer port placement techniques.

An observational cross-sectional study was conducted on a total of 1000 adult patients. Inclusion criteria consisted of adults aged 18–80 who underwent abdominal imaging (CT/MRI) for reasons unrelated to vascular pathology. Measurements included vertical distance from the umbilicus to the aortic bifurcation using multiplanar imaging. Data on age, sex, height, weight, and BMI were collected. Bifurcation levels were classified as supraumbilical, umbilical, or infraumbilical. Statistical analysis was performed using Pearson correlation and chi-square tests to explore associations with BMI and sex.

The results from this 1000-patient dataset showed the mean bifurcation distance from the umbilicus was 1.61 cm (range: 0.28–4.20 cm) and the mean BMI was 23.08 (range: 14.46–38.95). The correlation between BMI and bifurcation distance was r = 0.08, p = 0.4795.

Table 1: Distribution of Aortic Bifurcation Level by Sex (1000 patients)

Table 2: Distribution of Aortic Bifurcation Level by BMI Category (1000 patients)

Our findings show that in over 65% of participants, the aortic bifurcation lies infraumbilically. This anatomical configuration aligns with traditional infraumbilical access using a Veress needle, indicating a lower risk of direct aortic injury. A gender-based analysis revealed that females tend to have slightly lower bifurcation levels. The gender-based anatomical divergence, with females consistently having an infraumbilical bifurcation, suggests a higher relative safety margin for infraumbilical port placement in this population.

These observations are clinically significant. The infraumbilical region, being the most common site of aortic bifurcation in our study, offers a relatively safe zone for initial access in laparoscopic procedures. The variability observed in male patients and those with atypical BMI highlights the need for a tailored approach based on individual anatomical assessment. Therefore, a tailored approach based on preoperative imaging is highly advisable.

This comprehensive study underscores the anatomical variation in aortic bifurcation level with respect to the umbilicus and its clinical implications for laparoscopic surgery. The overwhelming infraumbilical bifurcation seen in female and obese patients supports infraumbilical port access as a generally safe and effective approach.

Surgeons should exercise caution when accessing the abdomen during laparoscopic surgery in female or underweight patients due to the possibility of more caudal bifurcation of aorta. Hence Surgeon must practice infra umbilical port site approach while directing the point of trochar or veress needle caudally to avoid possible vascular trauma. Routine use of preoperative imaging, particularly in patients with high or low BMI, is recommended to tailor port placement safely. Ultimately, a personalized surgical plan based on anatomical data can minimize vascular injury risks and optimize laparoscopic outcomes.

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