Where should ascitic drains be placed? Revisiting anatomical landmarks for paracentesis

We welcome the recent publication of the BSG/BASL guidelines on the management of ascites in cirrhosis which will serve as a framework for patient management across the world.1 Following clinician feedback on Twitter,2 we wish to respectfully highlight concerns regarding their guidance on landmarks for therapeutic paracentesis. Our first concern relates to the description of the landmarks. The authors recommend this to be ‘at least 8 cm (laterally) from the midline and 5 cm above the symphysis (pubis)’.1 This was predicated on three studies (two laparoscopic; one cadaveric) on the anatomical course of the inferior epigastric artery.3–5 While this approach avoids puncturing the vessel, there remains a risk of injury to underlying solid organs which can result in haemorrhage or perforation. Of note, these studies may not be generalisable to patients with distortion of …