1. STANDARDIZED PLACEMENT OF PORTS George Ferzli, MD, FACS Abe Fingerhut, MD, FACS Greece 2005

2. Proper trocar placement is an essential step in the laparoscopic approach to abdominal operations. It can: Mininize instrument and scope interference Optimize ergonomics Decrease mental and muscular fatigue Cut down loss of time and effort Markedly increase safety and Insure good surgical practice

3. tro-car - [Fr., troisis , three + carre, side] noun a sharp-pointed surgical instrument fitted with a cannula and used especially to insert the cannula into a body cavity cannula - [L., dim of canna, reed] noun a tube that is inserted into a cavity by means of a trocar filling its lumen

4. Trocar distance from the target organ depends upon the size of the patient. Individual trocars can be moved closer to the target along an axis line. Additional trocars can be added along the semicircular line.

5. TROCAR PLACEMENT Working against the camera and blind spots Dueling swords phenomenon (scissoring effect) Avoid

6. QUESTION

• Is the idea of placing trocars in a

• semicircle around a target applicable

• to all intra-abdominal procedures?

7. TROCAR PLACEMENT BY QUADRANT Thoracic triangle Pelvic triangle 1 2 3 4

8. TROCAR PLACEMENT BY QUADRANT Each quadrant must be addressed from frontal as well as lateral positions. y z x

9. RIGHT UPPER QUADRANT

• Cholecystectomy

• Right liver wedge resection

• CBD exploration

• Choledochoduodenostomy

• Choledojejeunostomy

• Pancreatic head resection

• Right colon hepatic flexure

• resection

D C B A

10. Hepatic Flexure Colon Resection A B C Mesocolon is the target organ. Tenting the mesocolon indicates where the mesenteric vessels are located for transection. Dissecting a small window reveals the underlying structures to be avoided.

11. HEPATIC FLEXURE COLON RESECTION

• The ileum is more mobile than the

• transverse colon, which can still be

• delivered adequately at this level.

A B Tension-free anastomosis Trocar C is used for GIA division of distal ileum and midtransverse colon (site is enlarged to retrieve specimen and for extracorporeal anastomosis). C

12. RETROPERITONEAL RT. UPPER QUADRANT B C D A E

• Right kidney resection

• Right adrenal resection

• Right retroperitoneal tumor

13. RT. KIDNEY RESECTION

• Subxiphoid port (D) - liver retraction

• Trocar A - parallel to vena cava

• (perpendicular approach to rt. renal

• vessels and rt. adrenal vein

• additional trocar E may be placed

• more laterally and posterior to

• trocar A if needed.)

B C D A E

14. UPPER MIDLINE (thoracic triangle)

• Nissen fundoplication

• Paraesophageal hernia

• Esophageal myotomy

• Highly selective vagotomy

• Left lobe liver resection

• Proximal gastrectomy

• Esophagojejeunostomy

• Gastroplasty/gastrostomy

• Roux en Y gastric bypass

• (RYGB)

• Lap band

C D E B A

15.

• Trocars - placed high, close to

• the costal margin.

• Trocar A - liver retraction.

• Trocar D - can be enlarged to

• allow for placement of a port.

• Trocar C - placed left of the

• midline for correct view of

• Angle of His.

LAP-BAND C D E B A

16.

• Trocars C and E - introduced GIA from

• right or left upper quadrants

Roux en Y Gastric Bypass (RYGB) Placement of sutures - right upper quadrant trocars; Tying knots: from both right and left upper quadrant trocars for better triangulation. C B A D E F Trocar A - liver retraction Trocars B and C - surgeon uses both hands Trocars E and F - assistant uses both hands

17. NOTE: Placement of sutures employs right upper quadrant trocars; however, tying knots uses both right and left upper quadrant trocars for better triangulation. C D E B A C E B B F

18. LEFT UPPER QUADRANT D E C B A

• Distal pancreatomy

• Proximal gastrectomy

• Colon resection

• Splenic flexure

• Splenectomy

19. DISTAL PANCREATECTOMY D E C B A

• GIA is introduced through D

20. RETROPERITONEAL LEFT UPPER QUADRANT

• Trocar C placed parallel to the aorta and

• perpendicular to renal hilar and splenic vessels

• Trocar D optional

• Trocar placement close to costal margin

• Camera not placed in the umbilicus unless

• dealing with massive splenomegaly (in lateral

• position, the bowel falls in front of the camera

• view).

• Splenectomy

• Left nephrectomy

• Adrenalectomy

• Left ureterolysis

• Solid tumor of left

• retroperitoneal area

A B C D

21. SPLENECTOMY

22. LEFT LOWER QUADRANT A B C

• Sigmoid colon resection

• Left colon

23. SIGMOID COLON RESECTION A B C Camera placed in rt. upper quadrant, not umbilicus. Dissection begins with mesenteric vessels (IMA), the real targets, so camera should be placed distantly.

24. SIGMOID COLON RESECTION

• Trocar A (12 mm) right lower

• quadrant suprapubic area

• allows placement of GIA for

• proximal and distal division of

• the sigmoid colon (site later

• enlarged for specimen retrieval

• and placement of anvil).

A B C

25. NOTE:

• If proximal divided end of colon can reach through

• the skin there has been sufficient dissection of

• splenic flexure providing a tension-free anastomosis.

26. RIGHT LOWER QUADRANT

• Right colon

• Appendix

• Meckel's diverticulum

27. APPENDECTOMY

• Alternatively, an appendectomy can be

• performed through a trocar in the

• umbilicus and two trocars in the

• suprapubic area medial to the epigastric vessels

• for a superb cosmetic result (if an extended

• right hemicolectomy is to be performed, the

• hepatic flexure positioning is preferred.)

28. PELVIC TRIANGLE A B C

• Abdominal perineal resection

• (APR) - trocar C is placed at the future

• colostomy site to avoid an additional

• incision.

• Rectal prolapse

• Prostatectomy

• Pelvic node dissection

• Spine surgery

• Bladder procedures (diverticulum,

• resection and neck suspension)

• Inguinal hernia repair

29. PROSTATECTOMY A B C Trocars added as needed along semicircular line. i.e., during a prostatectomy, another trocar is added between A and B. Another trocar may be added between B and C allowing the surgeon and assistant surgeon on the opposite side to each use both hands.

30. MIDLINE ABDOMINAL OPERATIONS

• Ventral hernia repair

• Incisional hernia repair

• Umbilical hernia repair

31. VENTRAL HERNIA REPAIR

• Additional trocars may be added in

• a mirror image to facilitate mesh

• placement. Trocars are placed far

• from hernia defect to allow a large

• piece of mesh to be secured

• properly - away from edges of

• defect.

Surgeon operates from either side of table.

32. QUESTION

• Is it applicable to combined procedures?

33. COMBINED PROCEDURES

• Transverse colectomy

• Total gastrectomy

• Duodenal switch

E D C B A

34. TRANSVERSE COLECTOMY E D C B A

35. LAP. COLON SURGERY/ TOTAL COLECTOMY

• Five trocars could be placed (lt. view), but preferable to use the "tristar" trocar

• placement (rt. view) for sequential approach to mesocolon vessels, starting from

• right to left side in a "question mark" dissection. Once division of the entire mesocolon is

• completed, the colon will be released from its lateral attachments.

Alternate trocar placement

36. QUESTION

• Are there any exceptions?

37. EXTRAPERITONEAL APPROACHES (vertical)

• Straight line trocar placement

• generally used.

• Inguinal hernia repair

• Pelvic lymph node dissection

• Bladder neck suspension

38. INGUINAL HERNIA REPAIR

39. EXTRAPERITONEAL APPROACHES (horizontal)

• Nephrectomy

• Adrenalectomy

• Aortic procedures

• Inf. mesenteric artery

• ligation

• Lumbar sympathectomy

• Ureterolysis

• Retroperitoneal tumor

• resection

40. AORTIC PROCEDURES: lumbar artery clip

41. LAPAROSCOPIC SIGMOID RESECTION (lateral decubiti position)

42. Lateral Supine

43. The standardized method of port placement is applicable to most intra-abdominal procedures. It can be a guide for both the surgical resident-in-training as well as the highly experienced surgeon. As with any proposed algorithm, there are exceptions. Situations may arise requiring modifications. CONCLUSIONS