Trocar Positioning

After a transverse infraumblical incision of 1-2 cm, a Veress needle is introduced into the peritoneal cavity and insufflation started after the safety maneuvers, without exceeding a pressure of 12mmHg. After establishing pneumoperitoneum, a 10-mm trocar is inserted into the umbilicus for passage of the laparoscope. Four other trocars are placed

TABLE5 ■ Laparoscopic Radical Prostatectomy with the Heilbronn Technique-Technical Steps of the Procedure

1.Trocar placement

2. Exposure of Retzius'space

3. Incision of endopelvic fascia and control of dorsal vein complex

4. Transection for urethra and nerve sparing (if required)

5. Incision of bladder neck

6. Division of cranial pedicles and dissection of seminal vesicles

7. Urethrovesical anastomosis

8. Retriving the specimen

A "W"-shaped arrangement of the trocars with insertion of the first trocar following infraumbilical Hasson technique.A sixth 5-mm port was inserted in the right lower abdomen after creating Retzius' space By high transection of the urachus and both lateral umbilical ligaments

Following incision of the endopelvic fascia, partial transection of puboprostatic ligaments and placement of back flow stitch, the dorsal vein complex is double-sutured with grasping of the needle at a 100-degree angle to the branches of the needle holder The urethra is incised at the level of apex, the periprostatic fascia is incised laterally, and the neurovascular bundles are exposed and dissected from the apical part of the prostate The circumferential attachments between the bladder and the prostate are incised using bipolar and endoscissor after pulling ventrally of the apex

Stepwise two or three lockable 10-mm polyurethane clips. After division of both vasa deferentia, finally the seminal vesicles are completely isolated and divided with clipping their vasculature Using the right-medial port IV (for the needle holder) and the left lateral port I (for endodissector) for an angle between the instruments (30-35 degrees).The anastomosis is performed by consecutive six interrupted suturing

After placing of drainage tube via port IV under vision and fixed to the skin, now the prostate is extracted within the organ bag via peri the umbilical incision (site of trocar I)

into peritoneal cavity: a 5-mm trocar in the left iliac fossa midway between the left anterior-superior iliac spine and umbilicus, a midline 5-mm trocar between the umbilicus and symphysis pubis, a 5-mm trocar at the level of umbilicus localized at the lateral margin of the right rectus abdominis muscle, and for introduction of the needles and the entrapment sac a second 10-mm trocar in the right iliac fossa at McBurney's point. According to Guillonneau and Vallencien's standardized technique, the Montsouris technique is performed in seven steps (Table 6).

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