Safe introduction of ancillary trocars

Abstract

The problem of laparoscopic entry is currently still unsolved, and despite the various techniques adopted by the surgical community, it has not yet been determined which is the correct access in all patients. Add to this the problem of safe ancillary port introduction; all surgeons must avoid vascular and visceral damage. The 2 most common problems with second port trocars are inferior and superior epigastric artery damage, and bowel loops and adhesions. Over the years, we have developed 2 steps that are very useful to avoid iatrogenic injuries to vessels and viscera. In this brief report, we explain the following 2 simple steps, called by the authors "yellow island" port entry and second trocar "tip entry guided" by a suction cannula. In our practice of more than 3400 conventional laparoscopies, with data from patients with different characteristics, surgeons who have introduced laparoscopic surgery into their daily practice might teach these steps to young fellows and trainees.

Figure 1.

The red rings indicate the yellow island on the right lateral side of the abdominal wall.

Figure 2.

Image shows the yellow island on the right, as an accumulation of adipose subperitoneal round tissue, at the lateral third of the line between the anterior superior iliac spine and umbilicus; on the left, a corresponding computerized anatomical internal abdominal wall is reproduced.

Figure 3.

Surgeon safely introduced the first ancillary trocar though the yellow island.

Figure 4.

Transillumination of the abdominal wall is still indicated by some schools as a maneuver likely to avoid IEA injury, but it is clearly detectable only in thin and white-skinned women.

Figure 5.

First operator must leak out of the tip position of the trocar, so that the tip of the second ancillary trocar is completely in the suction cannula, ie, safe “tip entry guide” by suction cannula.