Trocar and Hand Port Configuration

We have used the following hand incision and trocar configurations successfully in over 500 cases with little modification. Numerous factors must be considered when determining the optimal positioning of trocars and the hand incision. These factors include

The surgeon's wrist should have free range of motion and the fingertips should comfortably reach the renal hilum (the most important part of the dissection).

If emergent conversion is required, an incision should be made in a location that will allow most efficient and safe management of the situation at hand. Trying to manage a complication or difficult case through an extended hand incision if it will not offer optimal exposure is not recommended.

the specific operation being performed, the patient's anatomy, the surgeon's experience and the surgeon's hand and forearm size.

At the start of the case the table is rolled so that the patient is in a near supine position. The midline should always be marked, which aids in trocar placement as well as provides a quick and accurate guide if emergent laparotomy is necessary. Placement of the hand incision is made with the patient in this position as this allows for easier access to the peritoneal cavity and ensures better cosmetic results, especially in obese patients.

The length of the hand incision in centimeters is usually equal to the surgeon's glove size. Once the incision is made and the peritoneal cavity is entered, test the size and length of the incision for comfort. If the incision is too small, parasthesias and cramping of the surgeon's hand can result, which will make the operation more difficult. Too large of an incision may result in the hand device coming dislodged and loss of the pneumoperitoneum.

The renal hilum is approximately 8-12 cm cephalad to the umbilicus, but this distance can vary widely based on patient body habitus and vascular anatomy. Examine the patient's computed tomography scan and calculate this distance by counting the number of tomographic images between the renal hilum and the umbilicus. If the distance is greater than 12 cm, the surgeon has short arms, the patient is obese, or the girth of the abdominal cavity is larger than normal consider moving the hand incision cephalad and/or lateral, which allows improved access to the renal hilum.

The hand incision should be far enough from the operative target to allow insertion of the entire hand and wrist into the peritoneal cavity.

The surgeon's wrist should have free range of motion and the fingertips should comfortably reach the renal hilum (the most important part of the dissection).

If the hand incision is placed too close to the kidney, the hand will not be able to be completely inserted into the abdominal cavity, loosing maneuverability of the wrist and fingers. The hand will act more as a retractor and less optimally as a dissector.

Attempt to place the hand incision as low as possible on the abdominal cavity, as this will result in decreased postoperative discomfort and respiratory compromise. Additionally, always try to avoid cutting muscle fibers, as this will reduce postoperative morbidity and reduce the risk of incisional hernias. We use a low midline or peri-umbilical hand incision for a left nephrectomy and a muscle splitting right lower quadrant incision for a right nephrectomy.

For a right-sided nephrectomy (Fig. 5), the hand incision is placed in the right lower quadrant lateral to the rectus muscle, just below the level of the umbilicus. The skin is incised in line with the external oblique fascial fibers and the abdominal wall musculature is split. In a small percentage of right-sided cases, the incision is made in line with the internal oblique fibers and shifted more cephalad. This alteration gives the surgeon the option to extend the incision cephalad and medially, creating a low lateral subcostal incision if the case cannot be completed laparoscopically.

If emergent conversion is required, an incision should be made in a location that will allow most efficient and safe management of the situation at hand. Trying to manage a complication or difficult case through an extended hand incision if it will not offer optimal exposure is not recommended.

After insertion of the hand-assist device, the working instrument port is placed just below or above the umbilicus and the camera port is placed in the supraumbilical midline approximately 8 cm cephalad to the working trocar. The camera and working instruments may be switched at any time to facilitate the dissection. A third port is placed in the right mid-clavicular line at the costal margin that allows placement of a liver retractor. Placement of this port more medially will result in the liver retractor leaning against the gallbladder, potentially causing injury.

For a left nephrectomy (Fig. 6), the hand port is placed midline in the infraumbil-ical or periumbilical region. The camera port is placed in the anterior axillary line at the level of the umbilicus while the working instrument port is placed in the midclavicular line, just below the level of the umbilicus. For very large upper pole tumors, an additional superior midclavicular working port may be used for the most cephalad part of the dissection. Adequate mobilization of the spleen obviates the need for a splenic retraction port.

In morbidly obese patients or patients with very rotund and protuberant abdominal walls, the hand and trocar template is shifted lateral and cephalad. In a left-sided nephrectomy, the hand incision is placed lateral to the rectus muscle belly and the two trocar sites are moved approximately equidistance lateral to their standard locations. In a right-sided nephrectomy, the hand-access incision and trocar sites can

Lateral attachments of the kidney to the body sidewall should be preserved, as these attachments are used for counter traction, which aids in the medial dissection of the renal hilum.

be moved lateral any distance, as the hand-access incision is already lateral to the rectus muscle belly.

In almost all cases, we start out by making the hand incision and inserting the hand-access device and working trocar prior to establishing a pneumoperitoneum. In cases where there is a high index of suspicion for significant adhesions, the hand incision allows direct visualization of the abdominal cavity and open surgical lysis of adhesions. Lysis of extensive intra-abdominal adhesions through the hand incision can save a significant amount of time as compared to using a purely laparo-scopic technique.

Another option is to initially establish the pneumoperitoneum using a Hasson trocar or Veress needle and inspect the peritoneal cavity using the laparoscope. This allows the surgeon to identify adhesions and appreciate variations of anatomy that may alter the positioning of the hand-assist device and/or trocars. We stopped using this technique after our first 100 cases, as we found that the placement of our hand incision and trocar placement was rarely, if ever, modified.

Once the pneumoperitoneum is established, it is maintained at a pressure of 12-15 mmHg as per standard laparoscopy.

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