Laparoscopic Trocar Placement


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Laparoscopic Trocar Placement

  1. 1. LAPAROSCOPIC TROCAR PLACEMENT George Ferzli, MD, FACS Professor of Surgery, SUNY-HSC Brooklyn, New York
  2. 2. Proper trocar placement is an essential step in the laparoscopic approach to abdominal operations.
  3. 3. IDEA: There is a target organ… and a semicircle of trocars.
  4. 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. 5. TROCAR PLACEMENT Working against the camera and ‘blind spots’ “ Dueling swords” phenomenon (scissoring effect) Avoid…
  6. 6. QUESTION <ul><li>Is the idea of placing trocars in a </li></ul><ul><li>semicircle around a target applicable </li></ul><ul><li>to all intra-abdominal procedures? </li></ul>
  7. 7. TROCAR PLACEMENT BY QUADRANT Thoracic triangle Pelvic triangle 1 2 3 4
  8. 8. TROCAR PLACEMENT BY QUADRANT Each quadrant must be addressed from frontal as well as lateral positions. y z x
  9. 9. RIGHT UPPER QUADRANT <ul><li>Cholecystectomy </li></ul><ul><li>Right liver wedge resection </li></ul><ul><li>CBD exploration </li></ul><ul><li>Choledochoduodenostomy </li></ul><ul><li>Choledojejeunostomy </li></ul><ul><li>Pancreatic head resection </li></ul><ul><li>Right colon hepatic flexure </li></ul><ul><li>resection </li></ul>D C B A
  10. 10. Hepatic Flexure Colon Resection A B C Mesocolon is the target organ “ Tenting” the mesocolon indicates where the mesenteric arteries are located for transsection. Dissecting a small window reveals the underlying structures to be avoided.
  11. 11. HEPATIC FLEXURE COLON RESECTION <ul><li>The ileum is more mobile than the </li></ul><ul><li>transverse colon, which can still be </li></ul><ul><li>delivered adequately at this level. </li></ul>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. 12. RETROPERITONEAL RT. UPPER QUADRANT <ul><li>Right kidney resection </li></ul><ul><li>Right adrenal resection </li></ul><ul><li>Right retroperitoneal tumor </li></ul>
  13. 13. RT. KIDNEY RESECTION <ul><li>Subxiphoid port (D) - liver retraction </li></ul><ul><li>Trocar A - parallel to vena cava </li></ul><ul><li>(perpendicular approach to rt. renal </li></ul><ul><li>vessels and rt. adrenal vein – </li></ul><ul><li>additional trocar may be placed </li></ul><ul><li>more laterally and posterior to </li></ul><ul><li>trocar A if needed.) </li></ul>B C D A E
  14. 14. UPPER MIDLINE (thoracic triangle) <ul><li>Nissen fundoplication </li></ul><ul><li>Paraesophageal hernia </li></ul><ul><li>Esophageal myotomy </li></ul><ul><li>Highly selective vagotomy </li></ul><ul><li>Left lobe liver resection </li></ul><ul><li>Proximal gastrectomy </li></ul><ul><li>Esophagojejeunostomy </li></ul><ul><li>Gastroplasty/gastrostomy </li></ul><ul><li>Roux en Y gastric bypass </li></ul><ul><li>(RYGB) </li></ul><ul><li>Lap band </li></ul>C D E B A
  15. 15. <ul><li>Trocars - placed high, close to </li></ul><ul><li>the costal margin. </li></ul><ul><li>Trocar A - liver retraction. </li></ul><ul><li>Trocar D - can be enlarged to </li></ul><ul><li>allow for placement of a port. </li></ul><ul><li>Trocar C - placed left of the </li></ul><ul><li>midline for correct view of </li></ul><ul><li>Angle of Hiss. </li></ul>LAP-BAND C D E B A
  16. 16. <ul><li>Trocars C and E - introduced GIA </li></ul><ul><li>from right or left upper quadrants </li></ul>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. 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. 18. LEFT UPPER QUADRANT D E C B A <ul><li>Distal pancreatomy </li></ul><ul><li>Proximal gastrectomy </li></ul><ul><li>Colon resection </li></ul><ul><li>Splenic flexure </li></ul><ul><li>Splenectomy </li></ul>
  19. 19. DISTAL PANCREATECTOMY D E C B A <ul><li>GIA is introduced through “D” </li></ul>
  20. 20. RETROPERITONEAL LEFT UPPER QUADRANT <ul><li>Trocar C – placed parallel to the aorta and </li></ul><ul><li>perpendicular to renal hilar and splenic vessels </li></ul><ul><li>Trocar D – optional </li></ul><ul><li>Trocar placement – close to costal margin </li></ul><ul><li>Camera not placed in the umbilicus unless </li></ul><ul><li>dealing with massive splenomegaly (in lateral </li></ul><ul><li>position, the bowel falls in front of the camera </li></ul><ul><li>view). </li></ul><ul><li>Splenectomy </li></ul><ul><li>Left nephrectomy </li></ul><ul><li>Adrenalectomy </li></ul><ul><li>Left ureterolysis </li></ul><ul><li>Solid tumor of left </li></ul><ul><li>retroperitoneal area </li></ul>A B C D
  22. 22. LEFT LOWER QUADRANT A B C <ul><li>Sigmoid colon resection </li></ul><ul><li>Left colon </li></ul>
  23. 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. 24. SIGMOID COLON RESECTION <ul><li>Trocar A (12 mm) – right lower </li></ul><ul><li>quadrant suprapubic area </li></ul><ul><li>allows placement of GIA for </li></ul><ul><li>proximal and distal division of </li></ul><ul><li>the sigmoid colon (site later </li></ul><ul><li>enlarged for specimen retrieval </li></ul><ul><li>and placement of anvil). </li></ul>A B C
  25. 25. NOTE: <ul><li>If proximal divided end of colon can reach </li></ul><ul><li>through the skin there has been sufficient </li></ul><ul><li>dissection of splenic flexure providing a </li></ul><ul><li>tension-free anastomosis. </li></ul>
  26. 26. RIGHT LOWER QUADRANT <ul><li>Alternatively, an appendectomy can be </li></ul><ul><li>performed through a trocar in the umbilicus </li></ul><ul><li>and two trocars in the suprapubic area medial </li></ul><ul><li>to the epigastric vessels for a superb cosmetic </li></ul><ul><li>result (if an extended right hemicolectomy is to </li></ul><ul><li>be performed, the hepatic flexure positioning is </li></ul><ul><li>preferred.) </li></ul><ul><li>Right colon </li></ul><ul><li>Appendix </li></ul><ul><li>Meckel's diverticulum </li></ul>
  27. 27. PELVIC TRIANGLE <ul><li>Trocars – added as needed along semicircular </li></ul><ul><li>line. i.e., during a prostatectomy, another </li></ul><ul><li>trocar is added between A and B. </li></ul><ul><li>Another trocar may be added between B and </li></ul><ul><li>C allowing the surgeon and assistant surgeon </li></ul><ul><li>on the opposite side to each use both hands. </li></ul><ul><li>In laparoscopic APR, trocar C is placed at the </li></ul><ul><li>future colostomy site to avoid an additional </li></ul><ul><li>incision. </li></ul><ul><li>Abdominal perineal resection (APR) </li></ul><ul><li>Rectal prolapse </li></ul><ul><li>Prostatectomy </li></ul><ul><li>Pelvic node dissection </li></ul><ul><li>Spine surgery </li></ul><ul><li>Bladder procedures (diverticulum, </li></ul><ul><li>resection and neck suspension) </li></ul><ul><li>Inguinal hernia repair </li></ul>A B C
  28. 28. MIDLINE ABDOMINAL OPERATIONS <ul><li>Ventral hernia repair </li></ul><ul><li>Incisional hernia repair </li></ul><ul><li>Umbilical hernia repair </li></ul>
  29. 29. VENTRAL HERNIA REPAIR <ul><li>Additional trocars may be added in </li></ul><ul><li>a mirror image to facilitate mesh </li></ul><ul><li>placement. Trocars are placed far </li></ul><ul><li>from hernia defect to allow a large </li></ul><ul><li>piece of mesh to be secured </li></ul><ul><li>properly - away from edges of </li></ul><ul><li>defect. </li></ul>Surgeon operates from either side of table.
  30. 30. QUESTION <ul><li>Is it applicable to combined procedures? </li></ul>
  31. 31. COMBINED PROCEDURES <ul><li>Transverse colectomy </li></ul><ul><li>Total gastrectomy </li></ul><ul><li>Duodenal switch </li></ul>E D C B A
  33. 33. LAP. COLON SURGERY/ TOTAL COLECTOMY <ul><li>Five trocars could be placed (lt. view), but preferable to use the &quot;tristar&quot; trocar </li></ul><ul><li>placement (rt. view) for sequential approach to mesocolon vessels, starting from </li></ul><ul><li>right to left side in a &quot;question mark&quot; dissection. Once the mesocolon is </li></ul><ul><li>dissected free, the colon will be freed from its attachments. </li></ul>Alternate trocar placement
  34. 34. QUESTION <ul><li>Are there any exceptions? </li></ul>
  35. 35. EXTRAPERITONEAL APPROACHES (vertical) <ul><li>Straight line trocar placement </li></ul><ul><li>generally used. </li></ul><ul><li>Inguinal hernia repair uses three </li></ul><ul><li>trocars placed on the midline. </li></ul><ul><li>Inguinal hernia repair </li></ul><ul><li>Pelvic lymph node dissection </li></ul><ul><li>Bladder neck suspension </li></ul>
  37. 37. EXTRAPERITONEAL APPROACHES (horizontal) <ul><li>Adrenal access uses trocars placed </li></ul><ul><li>along a horizontal line as needed. </li></ul><ul><li>Nephrectomy </li></ul><ul><li>Adrenalectomy </li></ul><ul><li>Aortic procedures </li></ul><ul><li>Inf. mesenteric artery ligation </li></ul><ul><li>Lumbar sympathectomy </li></ul><ul><li>Ureterolysis </li></ul><ul><li>Retroperitoneal tumor resection </li></ul>
  39. 40. CONCLUSIONS Proper 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.