LAPAROSCOPIC TROCAR PLACEMENT

George Ferzli, MD, FACSProfessor of Surgery, SUNY-HSC

Brooklyn, New York

Proper trocar placement is an essential step in the laparoscopic approach to abdominal operations.

IDEA:

There is a

target organ…

and a semicircle

of trocars.

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 thesemicircular line.

TROCAR PLACEMENT

Working against the cameraand ‘blind spots’

“Dueling swords” phenomenon (scissoring effect)

Avoid…Avoid…

QUESTION

Is the idea of placing trocars in a

semicircle around a target applicable

to all intra-abdominal procedures?

TROCAR PLACEMENT BY QUADRANT

Thoracic triangle

Pelvic triangle

1 2

34

TROCAR PLACEMENT BY QUADRANT

Each quadrant must be addressed from frontal as well as lateral positions.

yz

x

• Cholecystectomy • Right liver wedge resection• CBD exploration• Choledochoduodenostomy• Choledojejeunostomy• Pancreatic head resection• Right colon hepatic flexure resection

RIGHT UPPER QUADRANT

D

CB

A

Hepatic Flexure Colon Resection

AB

CMesocolon is the target organ

“Tenting” the mesocolon indicates where the mesentericarteries are located for transsection.

Dissecting a small windowreveals the underlying structures to be avoided.

HEPATIC FLEXURE COLON RESECTION

ABTension-free anastomosis

The ileum is more mobile than the transverse colon, which can still be delivered adequately at this level.

Trocar C is used for GIA divisionof distal ileum and midtransverse colon (site is enlarged to retrieve specimen and for extracorporeal anastomosis).

C

RETROPERITONEAL RT. UPPER QUADRANT

• Right kidney resection• Right adrenal resection• Right retroperitoneal tumor

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 may be placed more laterally and posterior to trocar A if needed.)

B

C

D

AE

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 DEB

A

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 ofAngle of Hiss.

LAP-BAND

C DEB

A

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 andleft upper quadrant trocars for better triangulation.

C

B

A

D E

F

Trocar A - liver retractionTrocars B and C - surgeon uses both handsTrocars E and F -assistant uses both hands

NOTE:

Placement of sutures employs right upper quadrant trocars;

…however, tying knots usesboth right and left upper

quadrant trocars for bettertriangulation.

CD E

B

A

C

E

B

B

F

LEFT UPPER QUADRANT

DEC

B

A

• Distal pancreatomy• Proximal gastrectomy• Colon resection• Splenic flexure• Splenectomy

DISTALPANCREATECTOMY

DEC

B

A

• GIA is introduced through “D”

• Splenectomy• Left nephrectomy• Adrenalectomy• Left ureterolysis• Solid tumor of left retroperitoneal area

RETROPERITONEAL LEFT UPPER QUADRANT

A

BC D

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 LOWER QUADRANT

A

B

C

• Sigmoid colon resection• Left colon

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.

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

BC

NOTE: If proximal divided end of colon can reachthrough the skin there has been sufficient dissection of splenic flexure providing a tension-free anastomosis.

RIGHT LOWER QUADRANT

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.)

• Right colon• Appendix• Meckel's diverticulum

PELVIC TRIANGLE

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 surgeonon the opposite side to each use both hands.In laparoscopic APR, trocar C is placed at the future colostomy site to avoid an additional incision.

• Abdominal perineal resection (APR)• Rectal prolapse• Prostatectomy• Pelvic node dissection• Spine surgery• Bladder procedures (diverticulum, resection and neck suspension)• Inguinal hernia repair

AB

C

MIDLINE ABDOMINAL OPERATIONS

• Ventral hernia repair• Incisional hernia repair• Umbilical hernia repair

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.

QUESTION

Is it applicable to combined procedures?

COMBINEDPROCEDURES

• Transverse colectomy• Total gastrectomy• Duodenal switch

E

DCB

A

TRANSVERSECOLECTOMY

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 the mesocolon is dissected free, the colon will be freed from its attachments.

Alternate trocar placement

QUESTION

Are there any exceptions?

EXTRAPERITONEAL APPROACHES (vertical)

Straight line trocar placement generally used.

Inguinal hernia repair uses threetrocars placed on the midline.

• Inguinal hernia repair• Pelvic lymph node dissection• Bladder neck suspension

BLADDER NECK SUSPENSION

EXTRAPERITONEAL APPROACHES (horizontal)

Adrenal access uses trocars placedalong a horizontal line as needed.

• Nephrectomy• Adrenalectomy• Aortic procedures• Inf. mesenteric artery ligation• Lumbar sympathectomy• Ureterolysis• Retroperitoneal tumor resection

LAPAROSCOPIC SIGMOIDECTOMY

CONCLUSIONSProper trocar placement is essential. 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

The standardized method such as the one proposed can be a guide for the less experienced and the highly experienced surgeon alike.

As with any predetermined algorithm, there are exceptions. Situations will arise requiring modifications.