Port Positioning And Setup

Port placement is critical for efficient performance of all procedures and in children this is perhaps even more critical as there is less room for maneuvering. Port positions depend upon the procedure and the anatomy of the patient. Location should be in proportion to the size of the patient rather than determined by any arbitrary set distances between ports.

While each type of surgery requires a distinctive port setup, the general principle of a symmetrical array of working ports around the camera-operative site line should be adhered to as much as possible. For example, port placement for transperitoneal pyelo-plasty would involve an umbilical port for the camera and working ports in the midline between xyphoid and umbilicus and in the ipsilateral lower quadrant in the mid-clavicular line (Fig. 1). This offers a symmetric alignment toward the ureteropelvic junction to permit the most efficient working arrangement. In the smaller spaces in children, the effect of one port that is asymmetric may be significant and very troublesome in the performance of the procedure. When the operative field is wide, as it might be for a total ureterectomy, some compromise is needed. In those cases, one would give preference to the orientation for the most difficult aspect of the procedure. In the case of total nephroureterectomy, the exposure and access to the renal hilum is the most important part of the procedure, so the port alignment should favor that area, rather than the distal ureter, which may often be mobilized up to an accessible position. Occasionally a fourth port may be needed to complete the operation.

The arrangement of patient, surgeon, and surgical team follows similar principles as with adult surgery, although the small patient size offers some potential advantages.

While laparoscopy is well tolerated by most children and infants, there is the potential for respiratory compromise due to the elevated intra-abdominal pressures.

Port placement is critical for efficient performance of all procedures. In children this is perhaps even more critical as there is less room for maneuvering. Port positions depend upon the procedure and the anatomy of the patient. Location should be in proportion to the size of the patient rather than determined by any arbitrary set distances between ports.

The arrangement of patient, surgeon, and surgical team follows similar prin ciples as with adult surgery, although the small patient size offers some potential advantages.

FIGURE 1 ■ Port placement for transperitoneal laparoscopic pyeloplasty. The camera port is in the umbilicus while the working ports are in the midline between the umbilicus and xyphoid and in the midclavicular line in the ipsilateral lower quadrant.

For upper abdominal procedures, as with the kidney, it may be preferable in the small child to position the surgeon at the feet of the child, reaching over the legs and pelvis to be in comfortable line with the upper abdomen. This arrangement is shown in Figure 2. In larger children, the lower legs may be flexed to permit a similar arrangement. For still larger patients, the surgeon is best positioned at the opposite side, aiming toward the ipsilateral shoulder (Fig. 3).

When the surgical field is the pelvis, the surgeon may be best positioned at the head of the patient (Fig. 4) to be in line with the endoscope and operative area. There is a significant advantage to be gained when working in a linear arrangement, both for orientation, equal efficiency of both working ports and comfort. Surgeon discomfort will detract from surgical efficiency and its emphasis is not to make life easier for the surgeon, but for the patient (5).

FIGURE 1 ■ Port placement for transperitoneal laparoscopic pyeloplasty. The camera port is in the umbilicus while the working ports are in the midline between the umbilicus and xyphoid and in the midclavicular line in the ipsilateral lower quadrant.

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