Trocar placement for laparoscopic abdominal procedures: a simple standardized method.

Abstract

Minimal access approaches have been described for nearly all surgical procedures performed in the abdomen, with many manuals published and techniques described for a wide array of procedures accomplished laparoscopically. In contrast very few authors have investigated trocar placement in relation to optimal ergonomics and related technical considerations. Difficulties resulting from anatomical conditions, local pathology, adhesions, and patient habitus have been reported but rarely has any publication emphasized the role of poorly placed trocars. Correct trocar placement provides direct access to target organs, optimal vision of the operative field with a minimal loss of time and effort and a decrease in mental and muscular fatigue, and enhances recognition of structures and pathologic conditions. Less time is lost because of instruments competing for space (“working opposite” or “against” the camera, and “scissoring” or the “dueling swords” phenomenon). There is also less necessity for trocar relocation, not only cutting down operative time and costs, but considerably reducing complications and reducing the number of conversions from operative difficulties. Finally, correct placement of trocars should facilitate adequate and full vision of the operative field, making immediate recognition of mishaps possible as they occur and allowing immediate correction with a minimum of morbidity. This report is intended to provide the reader with recommendations for safe, adapted, worker-friendly laparoscopic access to the abdominal cavity through a standardized methodology of trocar placement, which is based on the location of the target organ, the procedure envisioned, and on patient and surgeon habitus. TECHNIQUE The anterior and lateral abdominal wall is here divided into four quadrants corresponding to the classical divisions, plus two triangles: thoracic, cephalad and pelvic, caudad (Fig. 1A). For each quadrant a schematic diagram depicts the placement of trocars along a semicircular line centered on the projection of the target organ, a line 16 to 18 cm long (the distance on the average surgeon’s hand, fingers spread apart, from the base of the palm to the tip of the medius [third finger]) (Fig. 1B). Landmarks on the anterior and lateral aspect of the abdomen assist the surgeon in determining the center of the semicircular arc in each of the six above-mentioned divisions. Advancing or retracting trocar placement along one of the axes or radii depends on the following: patient habitus (thickness of the abdominal wall); whether a 0-, 25-, 30-, or 45-degree scope is being used (the greater the angle of the optical end, the closer the scoping trocar should be inserted to the target organ); and surgeon preference. It is also obvious that the greater the thickness of the abdominal wall, the more the trocar should be inclined in the direction of the target organ to avoid excessive torque. The endoscope, which can be 3 mm, 5 mm, 7 mm, or 10 mm in diameter, can be moved from one trocar to another as needed and will always stay pointed at the target. Trocar size should be adapted to instrument and endoscope diameters as required. In the thoracic and pelvic triangles additional trocars can be placed in the subxyphoid and suprapubic areas. It must be remembered that in the thoracic triangle the abdominal esophagus and cardiac region are high, and because of the interposition of the left lobe of the liver the triangle is slightly deviated to the left. In combined operations such as the duodenal switch, nephroureterectomy, colectomy, and others, additional monitors may be needed. In left upper quadrant operations it must also be remembered that the ligament of Treitz projects at the intersection of two lines: one running from the xyphoid to the left anterosuperior iliac spine, and the other going from the umbilicus to the left shoulder. No competing interests declared.