1. LAPAROSCOPIC TROCAR PLACEMENT George Ferzli, MD, FACS Professor of Surgery, SUNY-HSC Brooklyn, New York

2. Proper trocar placement is an essential step in the laparoscopic approach to abdominal operations.

3. IDEA: There is a target organ… and a semicircle of trocars.

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 arteries are located for transsection. 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.

32. TRANSVERSE COLECTOMY

36. BLADDER NECK SUSPENSION

38. LAPAROSCOPIC SIGMOIDECTOMY

40. CONCLUSIONS Proper trocar placement is essential. 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 The standardized method such as the one proposed can be a guide for the less experienced and the highly experienced surgeon alike. As with any predetermined algorithm, there are exceptions. Situations will arise requiring modifications.