1) Standardized trocar placement in a semicircular pattern around the target organ can optimize ergonomics, decrease fatigue, and increase safety during laparoscopic surgery. 2) Trocar placement follows specific quadrants and positions depending on the procedure, such as in the upper right quadrant for cholecystectomy or lower left for sigmoid resection. 3) While standardized trocar positioning is applicable to most intra-abdominal procedures, some exceptions like inguinal hernia repairs or extraperitoneal approaches may require straight-line rather than semicircular placement.

1. STANDARDIZED PLACEMENT OF PORTS George Ferzli, MD, FACS Abe Fingerhut, MD, FACS Greece 2005

2. 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

3. 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

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. TROCAR PLACEMENT Working against the camera and ‘blind spots’ “ Dueling swords” phenomenon (scissoring effect) Avoid…

7. TROCAR PLACEMENT BY QUADRANT Thoracic triangle Pelvic triangle 1 2 3 4

8. TROCAR PLACEMENT BY QUADRANT Each quadrant must be addressed from frontal as well as lateral positions. y z x

10. 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. 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

21. SPLENECTOMY

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.

29. 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.

34. TRANSVERSE COLECTOMY E D C B A

38. INGUINAL HERNIA REPAIR

40. AORTIC PROCEDURES: lumbar artery clip

41. LAPAROSCOPIC SIGMOID RESECTION (lateral decubiti position)

42. Lateral Supine

43. • 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