Port Placement

Tagged laparoscopy, port placement, Training; Comments 2 ; Posted 12 years ago

A while ago we produced a teaching video that is used by Lina, the company that markets the McCartney tube for laparoscopic hysterectomy. The video is actually a great step-by-step guide how to set the operation up and how to do it. Step by step. No secrets, no myths. Just straight forward as it is.

Car, a gynaecologists who saw the video had a couple of questions about port placement. He was wondering whether the port on the right, lower abdominal side is difficult o operate for small surgeons. He was concerned that leaning over from the left tot he right myight be a strenuous task for small people. 

To recap: There are a total of four ports. The camera bearing port is in the umbilicus. For me this is almost always a 5 mm port. If that is not available a 10 mm scope is good as well. In that case, I just bury it in the deepest point of the umbilicus to get the best possible cosmetic result.

There are an additional three helper ports, and they definitely should be 5 mm (or less). On the left there is one port lateral to the inferior epigastric vessels; there are two additional ports on the right hand side. One is at the level of the umbilicus and the other one is on the paramedian right, just above the pubic symphysis.

My gynae oncology fellow Archie is a petite 152 cm small female. I passed on Carl’s question to her: "How do you cope with a paramedian port on the right side?" She said she “adapted”.  She uses a stool to stand on, so that she gets high up, which makes sense. However, after operating on big and very big women she feels exhausted. Well, don’t we all?

Then Archie and I talked about the operating table and why it is critical to chose the right bed and the role the fulcrum plays in a surgeon’s life. I blogged about this issue previously. In brief, as the surgeon you want to be on top. If you are only at level with the patient you need to reach above and over the patient and your arms might not be as long; this is when people like Carl or me get exhausted.

To get on top you need to stand on a high stool, you can lower the operating table and/or you can avoid lifting the patient’s pelvis when the anaesthetist will give you “head down”. Sliding the operating table to bring the patient's pelvis under the table’s fulcrum will help massively.

I do also watch other people operate. Standing on the patient’s left hand side, some surgeons use two ports on the left and are thus able to relax their shoulders. They let the work on the right hand side do by their assistant. I am sure it is very convenient and good on the main surgeon’s body. However, it would not be the right thing for me. I want to be in control as much and as often as I can and I would have difficulties leaving half the operation to my surgical assistant.

These are the tricks that I know. If you know some more, I am keen to learn, as always.