Standardized Placement of Ports
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- 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
- Right liver wedge resection
- Pancreatic head resection
- Right colon hepatic flexure
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 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
B C D A E
- 14. UPPER MIDLINE (thoracic triangle)
- Highly selective vagotomy
- Left lobe liver resection
C D E B A
- 15.
- Trocars - placed high, close to
- 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
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
- 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 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
A B C D
- 21. SPLENECTOMY
- 22. LEFT LOWER QUADRANT A B C
- 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
- allows placement of GIA for
- proximal and distal division of
- the sigmoid colon (site later
- enlarged for specimen retrieval
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
- 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
- Bladder procedures (diverticulum,
- resection and neck suspension)
- 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
- 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
Surgeon operates from either side of table.
- 32. QUESTION
- Is it applicable to combined procedures?
- 33. COMBINED PROCEDURES
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
- Pelvic lymph node dissection
- 38. INGUINAL HERNIA REPAIR
- 39. EXTRAPERITONEAL APPROACHES (horizontal)
- 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