Trocar/Port Placement for the Procedure: General Strategies


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Trocar/Port Placement for the Procedure: General Strategies

  2. 2. Correct trocar placement should provide direct access to the target organs, an optimal view of the operative field and minimize mental and muscular fatigue.
  3. 3. Avoid competing for the same space: Working against the camera and ‘blind spots’ “ Dueling swords” phenomenon (scissoring effect)
  4. 4. No obstacle between trocar entry and target To avoid iatrogenic injuries.
  5. 5. Avoid the epigastric vessels Saber et al. Safety zones for anterior abdominal wall entry during laparoscopy. Ann Surg 2004; 239:182
  6. 6. (adapted from) Anatomy of ilioinguinal and iliohypogastric nerves in relation to trocar placement and low transverse incisions James L. Whiteside, MD, Matthew D. Barber, MD, MHS, Mark D. Walters, MD, and Tommaso Falcone, MD (Am J Obstet Gynecol 2003;189:1574-8.) Anatomic distribution of nerves across anterior abdominal wall Iliohypogastric nerve Ilioinguinal nerve
  7. 7. (adapted from) Anatomy of ilioinguinal and iliohypogastric nerves in relation to trocar placement and low transverse incisions James L. Whiteside, MD, Matthew D. Barber, MD, MHS, Mark D. Walters, MD, and Tommaso Falcone, MD (Am J Obstet Gynecol 2003;189:1574-8.) Iliohypogastric n. Ilioinguinal n. Incision line/trocar sites vs. nerve distribution Epigastric a. Trocar site Pfannenstiel incision
  8. 8. Avoid areas of prior surgery
  9. 9. Be aware of bladder location for suprapubic trocar
  10. 10. 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
  11. 11. 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.
  12. 12. 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>
  13. 13. TROCAR PLACEMENT BY QUADRANT Thoracic triangle Pelvic triangle 1 2 3 4
  14. 14. TROCAR PLACEMENT BY QUADRANT Each quadrant must be addressed from frontal as well as lateral positions. y z x
  15. 15. 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
  16. 16. 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.
  17. 17. 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
  18. 18. RETROPERITONEAL RT. UPPER QUADRANT B C D A E <ul><li>Right kidney resection </li></ul><ul><li>Right adrenal resection </li></ul><ul><li>Right retroperitoneal tumor </li></ul>
  19. 19. 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 E 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
  20. 20. 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>Sleeve gastrectomy </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
  21. 21. <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 His. </li></ul>LAP-BAND C D E B A
  22. 22. <ul><li>Trocars C and E - introduced GIA from </li></ul><ul><li>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
  23. 23. Roux en Y Gastric Bypass (RYGB) Visualization of the location of the Ligament of Treitz (intersection of two projecting lines).
  24. 24. 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
  25. 25. 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>
  26. 26. DISTAL PANCREATECTOMY D E C B A <ul><li>Trocars “A” and “B” divide gastrocolic ligament </li></ul><ul><li>GIA is introduced through “D” </li></ul>
  27. 27. 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
  29. 29. LEFT LOWER QUADRANT A B C <ul><li>Sigmoid colon resection </li></ul><ul><li>Left colon </li></ul>
  30. 30. 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.
  31. 31. 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
  32. 32. NOTE: <ul><li>If proximal divided end of colon can reach through </li></ul><ul><li>the skin there has been sufficient dissection of </li></ul><ul><li>splenic flexure providing a tension-free anastomosis. </li></ul>
  33. 33. RIGHT LOWER QUADRANT <ul><li>Right colon </li></ul><ul><li>Appendix </li></ul><ul><li>Meckel's diverticulum </li></ul>
  34. 34. APPENDECTOMY <ul><li>Alternatively, an appendectomy can be </li></ul><ul><li>performed through a trocar in the </li></ul><ul><li>umbilicus and two trocars in the </li></ul><ul><li>suprapubic area medial to the epigastric vessels </li></ul><ul><li>for a superb cosmetic result (if an extended </li></ul><ul><li>right hemicolectomy is to be performed, the </li></ul><ul><li>hepatic flexure positioning is preferred.) </li></ul>
  35. 35. PELVIC TRIANGLE A B C <ul><li>Abdominal perineal resection </li></ul><ul><li>(APR) - trocar C is placed at </li></ul><ul><li>the future colostomy site to </li></ul><ul><li>avoid an additional incision. </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>
  36. 36. 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.
  37. 37. MIDLINE ABDOMINAL OPERATIONS <ul><li>Ventral hernia repair </li></ul><ul><li>Incisional hernia repair </li></ul><ul><li>Umbilical hernia repair </li></ul>
  38. 38. VENTRAL HERNIA REPAIR <ul><li>Additional trocars may be added </li></ul><ul><li>in a mirror image to facilitate </li></ul><ul><li>mesh placement. </li></ul><ul><li>Trocars are placed far from </li></ul><ul><li>hernia defect to allow a large </li></ul><ul><li>piece of mesh to be secured </li></ul><ul><li>properly - away from edges </li></ul><ul><li>of defect. </li></ul>Surgeon operates from either side of table.
  39. 39. QUESTION <ul><li>Is it applicable to combined procedures? </li></ul>
  40. 40. 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
  42. 42. 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 division of the entire </li></ul><ul><li>mesocolon is completed, the colon will be released from its lateral attachments. </li></ul>Alternate trocar placement
  43. 43. QUESTION <ul><li>Are there any exceptions? </li></ul>
  44. 44. EXTRAPERITONEAL APPROACHES (vertical) <ul><li>Straight line trocar placement </li></ul><ul><li>generally used. </li></ul><ul><li>Inguinal hernia repair </li></ul><ul><li>Pelvic lymph node dissection </li></ul><ul><li>Bladder neck suspension </li></ul>
  47. 47. EXTRAPERITONEAL APPROACHES (horizontal) <ul><li>Nephrectomy </li></ul><ul><li>Adrenalectomy </li></ul><ul><li>Aortic procedures </li></ul><ul><li>Inf. mesenteric artery </li></ul><ul><li>ligation </li></ul><ul><li>Lumbar sympathectomy </li></ul><ul><li>Ureterolysis </li></ul><ul><li>Retroperitoneal tumor </li></ul><ul><li>resection </li></ul>
  48. 48. AORTIC PROCEDURES: lumbar artery clip
  49. 49. LAPAROSCOPIC SIGMOID RESECTION (lateral decubiti position)
  50. 50. Lateral Supine
  51. 51. • 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