TROCAR / PORT PLACEMENT FOR THE PROCEDURE: GENERAL STRATEGIES

George Ferzli, MD, FACS

Chicago 2006

Correct trocar placement should provide direct access to the target organs, an optimal view of the operative field and minimize mental and muscular fatigue.

Working against the camera and ‘blind spots’

“Dueling swords” phenomenon (scissoring effect)

Avoid competing for the same space:

No obstacle between trocar entry and target

To avoid iatrogenic injuries.

Avoid the epigastric vessels

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

(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 nerveIlioinguinal nerve

(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

Avoid areas of prior surgery

Be aware of bladder location for suprapubic trocar

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 thesemicircular line.

QUESTION

Is the idea of placing trocars in a

semicircle around a target applicable

to all intra-abdominal procedures?

TROCAR PLACEMENT BY QUADRANT

Thoracic triangle

Pelvic triangle

1 2

34

TROCAR PLACEMENT BY QUADRANT

Each quadrant must be addressed from frontal as well as lateral positions.

yz

x

• Cholecystectomy • Right liver wedge resection• CBD exploration• Choledochoduodenostomy• Choledojejeunostomy• Pancreatic head resection• Right colon hepatic flexure resection

RIGHT UPPER QUADRANT

D

CB

A

HEPATIC FLEXURE COLON RESECTION

AB

C

Mesocolon is the target organ.

“Tenting” the mesocolon indicates where the mesentericvessels are located for transection.

Dissecting a small windowreveals the underlying structures to be avoided.

HEPATIC FLEXURE COLON RESECTION

ABTension-free anastomosis

The ileum is more mobile than the transverse colon, which can still be delivered adequately at this level.

Trocar C is used for GIA divisionof distal ileum and midtransverse colon (site is enlarged to retrieve specimen and for extracorporeal anastomosis).

C

RETROPERITONEAL RT. UPPER QUADRANT

B

C

D

AE

• 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

AE

UPPER MIDLINE (thoracic triangle)

• Nissen fundoplication• Paraesophageal hernia• Esophageal myotomy• Highly selective vagotomy• Left lobe liver resection• Proximal gastrectomy• Esophagojejeunostomy• Gastroplasty/gastrostomy• Sleeve gastrectomy• Roux en Y gastric bypass (RYGB)• Lap band

C DEB

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 ofAngle of His.

LAP-BAND

C DEB

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

FTrocar A - liver retractionTrocars B and C - surgeon uses both handsTrocars E and F - assistant uses both hands

Roux en Y Gastric Bypass (RYGB)

Visualization of the location of the Ligament of Treitz(intersection of two projecting lines).

NOTE:

Placement of sutures employs right upperquadrant trocars;

…however, tying knots uses both right and left upper quadrant trocars

for better triangulation.

CD E

B

A

C

E

B

B

F

LEFT UPPER QUADRANT

DEC

B

A

• Distal pancreatomy• Proximal gastrectomy• Colon resection• Splenic flexure• Splenectomy

DISTAL PANCREATECTOMY

DEC

B

A

• Trocars “A” and “B” divide gastrocolic ligament• GIA is introduced through “D”

• Splenectomy• Left nephrectomy• Adrenalectomy• Left ureterolysis• Solid tumor of left retroperitoneal area

RETROPERITONEAL LEFT UPPER QUADRANT

A

BC D

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

view).

SPLENECTOMY

LEFT LOWER QUADRANT

A

B

C

• Sigmoid colon resection• Left colon

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

BC

NOTE: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

• Right colon• Appendix• Meckel's diverticulum

APPENDECTOMYAlternatively, an appendectomy can be performed through a trocar in the umbilicus and two trocars in the suprapubic area medial to the epigastric vesselsfor a superb cosmetic result (if an extended right hemicolectomy is to be performed, the hepatic flexure positioning is preferred.)

PELVIC TRIANGLE

AB

C

• Abdominal perineal resection (APR) - trocar C is placed at the future colostomy site to avoid an additional incision.• Rectal prolapse• Prostatectomy• Pelvic node dissection• Spine surgery• Bladder procedures (diverticulum, resection and neck suspension)• Inguinal hernia repair

PROSTATECTOMY

AB

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 surgeonon 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 defect.

Surgeon operates from either side of table.

QUESTION

Is it applicable to combined procedures?

COMBINEDPROCEDURES

• Transverse colectomy• Total gastrectomy• Duodenal switch

E

DCB

A

TRANSVERSECOLECTOMY

E

DC

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 entiremesocolon is completed, the colon will be released from its lateral attachments.

Alternate trocar placement

QUESTION

Are there any exceptions?

EXTRAPERITONEAL APPROACHES (vertical)

Straight line trocar placement generally used.

• Inguinal hernia repair• Pelvic lymph node dissection• Bladder neck suspension

INGUINAL HERNIA REPAIR

BLADDER NECK SUSPENSION

EXTRAPERITONEAL APPROACHES (horizontal)

• Nephrectomy• Adrenalectomy• Aortic procedures• Inf. mesenteric artery ligation• Lumbar sympathectomy• Ureterolysis• Retroperitoneal tumor resection

AORTIC PROCEDURES:lumbar artery clip

LAPAROSCOPIC SIGMOID RESECTION(lateral decubiti position)

LateralSupine

• The standardized method of port placement is applicableto 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