Technical Variations Trocar Positioning

In the Montsouris technique, the authors from Paris prefer the insertion of Veress needle to achieve pneumoperitoneum before placement of the first two 10-mm trocars.

In contrast, in the Heilbronn and Creteil experiences, the authors prefer to place the first trocar (12 -mm) using an open Hasson technique at the infraumbilical location (6,21).

Position of the trocars is different in the Montsouris, Creteil, and Cleveland experience in spite of the same technique (7,20,22).

Montsouris Technique

After creating pneumoperitoneum with a Veress needle, a 10-mm trocar is inserted infraumbilically. The second 10-mm trocar is inserted at McBurney's point, to which the CO2 line is connected. A 5-mm trocar is placed superomedial to the second trocar on the right pararectal line at the level of umbilicus. A 5-mm trocar is inserted in the left iliac fossa midway between the anterior-superior iliac spine and umbilicus. Finally, a midline 5-mm trocar is placed between the umbilicus and the symphysis pubis.

Creteil Modification

The Creteil technique comprises a 12-mm trocar at the infraumbilical location (open Hasson technique); a second 12-mm trocar, near to the lateral margin of the rectus sheath and just below the umbilicus on the surgeon's side; a 10-mm trocar, lateral to the rectus and just below the umbilicus on the assistant's side; and two 5-mm trocars on each side at the level of the anterior-superior iliac spine, just lateral to the epigastric vessels.

Cleveland Modification

The Cleveland variation includes a 12-mm trocar at the infraumbilical location; 10-mm trocars (as port 2 and 3) are on either side of the midline, positioned lateral to the rectus muscle bilaterally and approximately two fingers breadths inferior to the level of the umbilicus; and 5-mm trocars (as port 4 and 5) on either side in the left iliac fossa midway between the anterosuperior iliac spine and umbilicus.

Heilbronn Technique

The Heilbronn technique includes a 12-mm trocar at the infraumbilical location (open Hasson technique); 10-mm trocars (as port 3 and 4) on either side of the midline, positioned lateral to the rectus muscle bilaterally and approximately two fingers breadths inferior to the level of the umbilicus; 5-mm trocars (as port 2 and 5) on the either side of the anterior axillar line at the level of umbilicus; and a sixth 5-mm port in the right lower abdomen following access to the Retzius' space by high transection of the urachus and both lateral umbilical ligaments are employed.

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