Abdominal anatomy in the context of port placement and trocars

Abstract

Although the anatomy of the human being has not changed, technical developments in operating materials and methods demand a simultaneous development in operative management. Developments in electronic and optical technologies permit many gynecological operations to be performed laparoscopically. One fundamental distinction between any other operating method and laparoscopy is the hurdle that the initial entry, whether with a needle, cannula, or trocar, is mostly performed blind. However, there is a risk that blind entry may result in vascular or organ damage. One of the difficulties associated with entry complications is that any damage may not be immediately recognized, leading to major abdominal reparative surgery, and at worst, a temporary colostomy. Therefore, the technical and operative quality of laparoscopic surgery begins with port placement and trocars. Visual access systems are available but are not yet widely used. The aim of this review was to introduce the different port placement and trocar systems as well as their correct and professional usage in correlation with the abdominal functional anatomy.

Keywords: Gynecological endoscopy; complication prevention; entry technique; functional gynecological anatomy; pneumoperitoneum; port placement.

Figure 1

a–d. Typical palpation point in the subumbilical region. The fingertip is pointing to the promontorium. Subumbilical incision and local palpation demonstrate the short distance from the skin to the spine (a), diaphanoscopy illuminates the region of insertion of the ancillary trocars while demarcating the superficial epigastric artery and the circumflex iliac superficial artery (b–d)

Figure 2

a–c. Point of insertion from the outside (two thumbs medial of the anterior superior spine), at a 90° angle to the surface with penetration of all abdominal wall layers (a), trocar insertion site lateral to the plica umbilicalis lateralis (b), overview after insertion of the laparoscope and three ancillary trocars (c), graphical illustration of (a) and (b)

Figure 3

a–c. Overview of the abdominal wall from the interior (a), the plica umbilicalis mediana contains the obliterated urachus, the plica umbilicalis medialis contains the obliterated umbilical artery, and the plica umbilicalis lateralis contains the inferior epigastric vessels. Palpation with the index finger from the outside under laparoscopic view (b), entry with a sharp trocar strictly lateral to the inferior epigastric vessels (c–d)

Figure 4

a–c. Diaphanoscopy illuminates the region of insertion of the ancillary trocars while demarcating the superficial epigastric artery and the circumflex iliac superficial artery (a), vision is dependent of the thickness of the abdominal wall. Point of insertion from the outside (two thumbs medial of the anterior superior spine), at a 90° angle to the surface with penetration of all abdominal wall layers. Direct entry of the ancillary trocars can avoid severe bleeding in the subcutaneous tissue (b), single-use trocar is situated strictly lateral to the plica umbilical lateralis and strictly lateral of the inferior epigastric vessels (c)

Figure 5

a–d. Depiction of the alternative entry site. For the large uterus, particularly at or above the level of the umbilicus, the Lee-Huang point is recommended for video laparoscopy (a), Palmer’s Point, it is situated in the midclavicular line approximately 3 cm below the costal margin (b–d)

Figure 6

a–d. Entry under view in a case of previous peritonitis after repeated laparotomy, including the left epigastric area (a–d) Endopath^TM, or EndotipTM are disposable and reusable entry ports to enter under view (c–d)

Figure 7

a–d. Omega-shape umbilical incision (a), single-site port introduction with the “folded” port-clamping technique using an atraumatic clamp (b), single-port cluster (c), pneumoperitoneum induction after the umbilical placement of the single-site port and positioning of the 12-mm lubricated trocar for the 30-degree scope (d)

Figure 8

a–c. Veress needle and insufflation pressure (a), lifting of the abdominal wall, insertion angle is 45° (b), entry of the Veress needle through the abdominal wall (c1), the sharp tip penetrates the skin and fascia (c2), after piercing the peritoneum, the blunt tip springs forward due to the release of resistance and thereby avoids organ (bowel) damage (c3)

Figure 9

a-ı. Hohl manipulator (Storz) (a), Dionisi uterine manipulator (Storz) (b), Mangeshikar uterine manipulator (Storz) (c), RfQ uterine manipulator (d), Clermont-Ferrand uterine manipulator (Storz) (e), Braun uterine manipulator (f), Koninckx uterine manipulator (Storz) (g), Tintara uterine manipulator (Storz) (h), Donnez uterine manipulator (Storz) (ı)