The document discusses strategies for correct trocar placement during laparoscopic procedures. It provides guidelines for trocar positioning based on the target organ and surgical procedure. Proper trocar placement should provide direct access and an optimal view while avoiding injury. Placement may need to be modified depending on individual patient anatomy, prior surgery, or if combining multiple procedures. Exceptions include extraperitoneal approaches and some procedures done in non-supine positions.

1. TROCAR / PORT PLACEMENT FOR THE PROCEDURE: GENERAL STRATEGIES George Ferzli, MD, FACS Chicago 2006

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. Avoid competing for the same space: Working against the camera and ‘blind spots’ “ Dueling swords” phenomenon (scissoring effect)

4. No obstacle between trocar entry and target To avoid iatrogenic injuries.

5. Avoid the epigastric vessels Saber et al. Safety zones for anterior abdominal wall entry during laparoscopy. Ann Surg 2004; 239:182

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. (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. Avoid areas of prior surgery

9. Be aware of bladder location for suprapubic trocar

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. 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.

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

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

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.

23. Roux en Y Gastric Bypass (RYGB) Visualization of the location of the Ligament of Treitz (intersection of two projecting lines).

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

28. SPLENECTOMY

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.

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.

41. TRANSVERSE COLECTOMY E D C B A

45. INGUINAL HERNIA REPAIR

46. BLADDER NECK SUSPENSION

48. AORTIC PROCEDURES: lumbar artery clip

49. LAPAROSCOPIC SIGMOID RESECTION (lateral decubiti position)

50. Lateral Supine

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