Standardized Placement of PortsPresentation Transcript
STANDARDIZED PLACEMENT OF PORTS George Ferzli, MD, FACS Abe Fingerhut, MD, FACS Greece 2005
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
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 it’s lumen
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.
TROCAR PLACEMENT Working against the camera and ‘blind spots’ “ Dueling swords” phenomenon (scissoring effect) Avoid…
TROCAR PLACEMENT BY QUADRANT Each quadrant must be addressed from frontal as well as lateral positions. y z x
RIGHT UPPER QUADRANT
Right liver wedge resection
Pancreatic head resection
Right colon hepatic flexure
D C B A
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.
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
RETROPERITONEAL RT. UPPER QUADRANT B C D A E
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 E may be placed
more laterally and posterior to
trocar A if needed.)
B C D A E
UPPER MIDLINE (thoracic triangle)
Highly selective vagotomy
Left lobe liver resection
Roux en Y gastric bypass
C D E B 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 of
Angle of His.
LAP-BAND C D E B 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 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
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
LEFT UPPER QUADRANT D E C B A
DISTAL PANCREATECTOMY D E C B A
GIA is introduced through “D”
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
Solid tumor of left
A B C D
LEFT LOWER QUADRANT A B C
Sigmoid colon resection
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 B C
If proximal divided end of colon can reach through
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.)
PELVIC TRIANGLE A B C
Abdominal perineal resection
(APR) - trocar C is placed at the future
colostomy site to avoid an additional
Pelvic node dissection
Bladder procedures (diverticulum,
resection and neck suspension)
Inguinal hernia repair
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.
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
Surgeon operates from either side of table.
Is it applicable to combined procedures?
E D C B A
TRANSVERSE COLECTOMY E D C B A
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.
• 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