LAUSR

photographed corresponds to the diagram but appears too superior and lateral to be considered safe without ultrasound guidance, as this carries a risk of splenic injury and bowel perforation. Patient safety must always be prioritised. Ultrasound guidance mitigates the risks of paracentesisrelated complications, but its availability is limited in resourcepoor settings and in some UK hospitals. Training in bedside ultrasound is also variable. Moreover, with the COVID-19 pandemic, transporting ultrasound machines between patients and across sites risks transmission. Thus, it remains important to teach paracentesis landmarks in a clear and safe manner without sole reliance on ultrasound. Conventional teaching places emphasis on the following landmarks for paracentesis: (i) in relation to the anterior superior iliac spine (ASIS): 5 cm superiorly and medially; (ii) left or right lower quadrants: 2–3 cm lateral to the inferior rectus sheath border, (iii) midline approach within the linea alba: 2 cm below the umbilicus (this is unconventional in the UK). However, the use of absolute measurements is suboptimal as abdominal dimensions inevitably vary (eg, in children, morbid obesity or distortion due to chronic ascites). As such, a relative approach for landmarks would seem more appropriate. We propose several alterations to the authors’ landmarks for paracentesis (figure 1). We advocate the use of McBurney’s point as a rough surface landmark, guided by abdominal percussion, with the patient in supine position. This is located onethird of the distance between the right ASIS and the umbilicus, and is traditionally used to localise appendicitis. The contralateral (left) McBurney’s point is favoured, as the abdominal wall here is thinner, with deeper ascitic pool and lower theoretical risk of perforation as the sigmoid colon is more mobile than the fixed caecum. Care should be taken to avoid far lateral sites, engorged veins or previous scars. The landmarks can be shifted slightly laterally to account for scarring from regular paracentesis. We believe this approach to be safer and more anatomically correct in the absence of ultrasound guidance, and encourage a revision to Figure 4. However, this caveat should by no means detract from the commendable efforts by the authors in formulating these guidelines.