Jain point a viable option in contraindications of palmers point

1. JAIN POINT: A VIABLE OPTION IN CONTRA-
INDICATIONS OF PALMER’S POINT: A TEN YEARS
STUDY
DR.NUTAN JAIN
INDIA

2. OBJECTIVE
• To introduce a non umbilical entry port …jain point
• To introduce and illustrate jain point as a safe laparoscopic entry port in
previous surgery cases
• To discuss the rationale of its usage
• Analyze its safety in contra indications of palmer’s point.
Jain N, Sareen S, Kanawa S, Jain V, Gupta S, Mann S (2016) Jain point: a new safe portal for laparoscopic entry in previous surgery cases. J Hum Reprod Sci
9:9–17

3. PALMER’S POINT WAS THE FAVORED
SITE FOR HALF A CENTURY
• Palmer's point is described as the area in the left upper quadrant 3 cm below the costal margin and in
the midclavicular line.
• 1n 1974 he described Palmer's Point. This entry is utilized when midline adhesions are suspected.
• Two bony landmarks, the midclavicular line and the subcostal margin
Palmer R (1974) Safety in laparoscopy. J Reprod Med 13:1–5
Surface anatomy of Palmer’s point

4. LIMITATIONS OF PALMER’S POINT
• Improper nasogastric tube placement leading to
bloated stomach.
• Splenomegaly /Portal hypertension
• Suspected upper abdominal adhesions.
• In Gastro pancreatic masses.
• Previous Gastric surgery.
• Incisions in upper abdomen
• Big masses coming higher above palmer's point
Jain N, Jain V (2020) Limitations and contraindications of Palmer’s point. In: Jain N (ed) Non-umbilical laparoscopic entry ports, 1st edn. Jaypee Brothers
Medical Publishers, New Delhi, pp 76–84
Bloated stomach
Splenomegaly
Big mass
Big Long Vertical Scar

5. DILEMMA OF SURGEONS HOW TO
ENTER IN CONTRAINDICATIONS OF
PALMER’S POINT
Was a staggering concern in the minds of all
endoscopists among
all sub specialties of laparoscopy

6. EXISTING ENTRY PORTS
All other researches thought of moving in upper abdomen to make the primary port
Palmer’s Point
Lee Huang Point
9th Intercostal space
Were designed to avoid adhesions around umbilicus

7. WE DID NOT TREAD THE BEATEN PATH

8. WE THOUGHT DIFFERENTLY
THOUGHT OF BRINGING THE PRIMARY BLIND PORT AT MID ABDOMEN

9. WE INTRODUCED JAIN POINT

10. WHAT IS JAIN POINT ?
• Jain point lies in the mid abdomen, left paraumbilical region, in a straight line drawn vertically upward from
a point 2.5 cm medial to anterior superior iliac spine; thus lying 10 to 13 cm lateral to the umbilicus.
• Basic aim is to avoid –V V A B Vessel, Viscera, Adhesion and Bowel.
Jain N, Jain V, Chandi A, et al. Jain point: an alternate laparoscopic non-umbilical first blind entry port to avoid vessel, viscera, adhesions and bowel
(VVAB). Updates in Surgery. 2021 Jun. DOI: 10.1007/s13304-021-01099-z.
Video

11. CONCEPT OF THE JAIN POINT
x
U Jain point
Palmer’s point
SITTING OUTSIDE THE SURGICAL FIELD
MIMICS THE POSITION OF
A REFEREE ON A TENNIS COURT

12. RATIONALE OF JAIN POINT IN
PREVIOUS SURGERY CASES
• Jain point lies at level of umbilicus at L4 level
• On the left side spleen, stomach and kidney are located at level
of T10-T12 vertebrae
• Sigmoid colon adheres to the pelvic brim ….hence there is a large
nascent area from L1 up to pelvic brim where there are no
viscera
• This area has been consistently seen to be free of bowel
adhesions.
Jain point free
Multiple bowel loops

13. ADHESION AT PALMER’S POINT
LARGE VERTICAL SCAR
Finger pointing the palmer's point

14. JAIN POINT ENTRY IN CHEVRON
INCISION
Video

15. BECOMES THE MAIN WORKING PORT
• After initial entry does not become redundant becomes the main working port
• Distance from umbilicus is 10 to 13 cms
• The distance of lower port from the Jain point is around 10–12cm
• Good ergonomic working
• Becomes the main operating ipsilateral port
Sharp HT (2019) Overview of gynecologic laparoscopic surgery and non-umbilical entry sites. In: Falcone T (ed), UpToDate.

16. NEW ENTRANT VERSUS THE TRUSTED
CHAMPION
Palmer’s Point Jain Point
Two bony land marks to follow – mid clavicular
line in the unsterile area and subcostal margin
Single prominent bony land- mark. ASIS in the
sterile surgical field
High up so cannot be used further in surgery
….becomes redundant.
Becomes the main ergonomic working port in due
course of surgery.
Contraindications in previous scars coming up in
upper quadrant
Can be used in all upper and mid abdominal scars as well as
scars on the lower abdomen
Contra-indications
• Bloated stomach
• Hepatosplenomegaly
• Large gastro-pancreatic and big pelvic masses
coming high up in upper quadrant
Upper abdomen scars
No contraindications
More versatile

17. Total cases
8059
Total previous surgery cases
2345
Previous Laparoscopy
1116
Previous Laparotomy
1229

18. Previous Laparotomy (1229)
Prev. 6
Surgery (3)
Prev. 5 Surgery (4)
Prev. 4 Surgery (23)
Prev. 3 Surgery (98)
Prev. 2 Surgery (344)
Prev. 1 Surgery (757)

19. Previous Laparoscopy (1116)
Prev. 4
Surgery (1)
Prev. 3 Surgery (6)
Prev. 2 Surgery (64)
Prev. 1 Surgery (1045)

20. RESULT
• There was one Bowel Injury and no other major complication of Vessel, Viscera,
Adhesion and Bowel.
• Minor complications like under or overshoot of veress in initial learning curve ,which
is short , of about 8-10 cases.
• There were no reported incidence of bleeding at the port site.
• In the 10 years study period, there were no cases of port site hernia.

21. CONCLUSIONS
• Jain Point appears to be a viable, first blind port in
cases of previous surgeries and also, those with
contraindications of Palmer’s point.
• It then continues as the main ergonomic working
port all through the surgery.
• Easy entry technique, short learning curve, low
complication rate makes it a suitable option.

22. THANK YOU

23. Published Articles

24. Published Articles