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peritoneum; otherwise the patient will
have a reduced SPO2 level post-op.
• In obese patients, incentive spirometry
pre-op and post-op helps to reduce atelectasis of the lung and maintain good
saturation levels for faster recovery.
• Post-operatively, one should consider
injection of Clexane 0.6 (LMWH)
because laparoscopy and Trendelenburg
(head low) lithotomy position may
induce DVT.
• One should ambulate patient as soon as
possible post-op to avoid problems of
DVT.
• Good local anaesthetic (LA) inltration
of port sites before inserting ports avoids
unnecessary tachycardia and
hypertension.
• Good LA inltration of port sites at the
end of surgery ensures a pain-free
41
patient.
• Any subcutaneous emphysema that may
occur will recover spontaneously.
• LA instillation is done just below the
diaphragm to reduce post-op shoulder
pain.
• Post-op, give oxygen at 3L/min for a
couple of hours to wash out all CO2.
Also, put patient in propped up
position.
• Full GA with endotracheal intubation
and good muscle relaxation to be used
instead of LMA (in times of COVID).
• The pregnant woman should be managed as a full stomach patient.
CO2 pneumoperitoneum can lead to
foetal acidosis during laparoscopy surgery in a pregnant woman; hence,
mechanical ventilation should be
adjusted to maintain physiological
maternal alkalosis.
C. E. Nwachukwu et al.
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Laparoscopic Port Position,
https://t.me/med1917
Placement andClosure
FredrickAnolue andLateefAkinola
1 Port Position andPlacement
1.1 Introduction
Port is the keyhole passage in the abdominal wall
through which instruments are inserted to perform laparoscopy. The choice of port position is
important as it is necessary to position and place
instruments at such angles to the operative site
and to each other to resemble a natural relationship of the hands, eyes and target tissue during
open surgery.
Wrong port placement is one of the causes of
complications with increasing tendency to conversion to open surgery. It also causes stressful
minimal access surgery. Good port placement is
key to successful laparoscopic procedure and
helps avoid the technical issue of overlap of
instruments commonly referred to as swording
phenomenon.
Cannulas and their accompanying trocars are
used to create ports and sizes range from 3mm,
5mm, 10mm, 12mm and occasionally 15mm.
Ten-millimetre ports are usually used for passage
F. Anolue (*)
Department of Obstetrics and Gynaecology, Faculty
of Clinical Sciences, College of Medicine, Imo State
University, Owerri, Nigeria
L. Akinola
Medison Specialist Women’s Hospital and Fertility
Assyst, Lagos, Nigeria
Akinola of telescope, while 5-mm ports are used
for instrument insertion. Ports of 12mm or more
are used for tissue retrieval. Bigger ports can be
reduced to smaller ports intraoperatively with the
aid of reducers which are readily available.
Smaller ports can be dilated to bigger ones.
Bigger ports of 12mm or more has a risk of causing incisional hernia if not closed at the facial
level [1, 2].
Ports are usually described as primary or secondary. The primary port, also called optic port,
is rst established for purposes of inserting the
telescope. The secondary port, sometimes called
accessory or working port, is established for purposes of inserting instruments. There is renewed
interest in laparoendoscopic single-site surgery
(LESS) [2]. It aims to use one port as both primary and secondary ports.
1.2 Primary Port
It is the port where the telescope is rst inserted
for view of the peritoneum and its content. The
initial trochar insertion for creation of a primary
port is perhaps the most dangerous aspect of trochar use and minimally invasive surgery [3].
Over 50% of trochar-related injuries to the bowel
and vessels happen during the creation of a primary port [4]. Ninety-ve percent of surgeons
and gynaecologists use the umbilicus [1]. It has
© The Editor(s) (if applicable) and The Author(s), under exclusive license to Springer Nature
Switzerland AG 2022
J. E. Okohue et al. (eds.), Gynaecological Endoscopic Surgery,
https://doi.org/10.1007/978-3-030-86768-3_9
97
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s
PRIMARY PORTS
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F. Anolue and L. Akinola
the advantage of being central to the abdomen as
well as being the thinnest part of the anterior
abdominal wall. Moreover, it can camouage
scars (Fig.1).
The exact choice of location within the umbilicus varies. Intraumbilical is said to be the thinnest portion than infra- or supraumbilical and is
therefore preferred with a vertical skin incision.
Once peritoneum is entered, there should be no
further advance of the sharp trocar which is
removed and replaced with a telescope.
Infection rates appear higher on the umbilical
port [5–7]. However, another opinion suggests
that infection rate is the same as for other ports
unless it is used for retrieval of infected material
[1]. Similarly, rates of incisional hernia are not
higher than as in other sites where a 10-mm cannula was used, but the hernia rate increases with
the use of an umbilical port for tissue retrieval
and when it is more than 10mm [1].
Alternative primary port sites are the Palmer’s
and Lee-Huang’s points [8, 9]. The alternate
points could become necessary in the following
situations: suspected periumbilical adhesions as
in previous surgery, umbilical hernia, three failed
attempts at insufation and pelvic/abdominal
tumours extending up to or near the umbilicus
[2]. Palmer’s point is in the left midclavicular line
approximately 3cm below the coastal margin [8].
Lee-Huang’s point lies centrally between the
xiphoid process and the umbilicus [9]. It is commonly called the mid-upper abdominal point.
Transuterine and trans-cul-de-sac routes have
been described but should not be used because of
the high risk of complication and infection [10].
1.3 Secondary Port
These are working ports for insertion of instruments and other manoeuvres in laparoscopic procedures. Proper location and placement of
secondary ports ensure that there are no injuries
to vessels and vestiges of the anterior abdominal
wall as well as the viscera. It also ensures that
target organs for surgery are approached tangentially and the angles between the working instruments and telescope are maintained at an
optimum value for maximal ergonomics. Proper
secondary port location also guarantees that the
Fig. 1 Sites for primary
ports
Xiphoid Proces
Palmers Point
Lee-Huangs Point
Umbilicus
Secondary Port
SECONDARY PORTS
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Fig. 2 Secondary port
placement
99
Umbilicus
Superficial Inferior Epigastric Vessel
Anterior Superior IIiac Spine
optimum length of instrument is inserted into the
abdomen to enable easy up, down and lateral
movements by the surgeon.
Opinions vary as to the proper location of secondary ports [1, 2]. In standard operations like
diagnostic laparoscopy/dye test and laparoscopicassisted vaginal hysterectomy, standard port sites
related to surface markings may be used. The
positioning of secondary ports also depends on
the target organ for surgery and the organ/tissue
pathology to be encountered. This may necessitate individualized port placement [1, 11].
Placement of secondary port should be under
direct vision after pneumoperitoneum. Point of
insertion is usually two ngerbreadths medial to
the anterior superior iliac spine (Fig. 2). The
insertion should be at 90 degrees to the skin and
till anterior abdominal wall thickness is transversed. Insertion should be lateral to the branches
of the supercial epigastric vessels which is easily picked out by transillumination especially in
thin persons [2]. This move should be preceded
by a mock entry by pressure from the index nger
pushing at the desired point on the anterior
abdominal wall. Once the tip of the trocar is
sighted, it should be oriented to a near horizontal
Fig. 3 Optimum manipulation angle of 60°
position towards a less delicate organ till passage
is completely created.
Mishra [1] and Yinusa et al. [11] have
described a set of guidelines for optimum port
position and placement to ensure a stress-free
surgery. In this guideline it is suggested that
placements that achieve a 60% manipulation
angle between working instruments (Fig.3) with
a half to two-thirds of the working instrument in
the abdomen ensure a stress-free surgery.
100
e
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F. Anolue and L. Akinola
Primary Port
Secondary Por t
Surgical Target
Fig. 4 Index nger sign
To achieve this, identify your target in whatever procedure is being contemplated and ensure
that the secondary port is at least 5cm to 7.5cm
lateral inferiorly from the optical port.
Furthermore, the following are suggested [1]:
(i) Dispose the index ngers of both hands in a
manner that the tips aim for the target while
the tips of the thumb unite at the primary
port. The location of the junction of the skin
crease of the index nger and thumb sign
posts the best location for the secondary port.
This makes the diagram for the ports come
out like a triangle with the apex (optic port)
slightly higher than the secondary ports
(Fig.4).
(ii) Draw two concentric circles of 18 cm and
24cm diameter over the surgical target. It is
advised that the secondary ports lie in
between the 18- and 24-cm circle. This
ensures that at least half to two-thirds of the
instruments lies within the abdomen for a
stress free surgery (Fig.5).
1.3.1 Removal ofCannula
After surgery the cannula should be removed
with caution by rst deating the abdomen and
inserting a blunt obturator into the cannula to
avoid sucking in bowels/omentum or having the
telescope in situ while withdrawing the cannula.
Incorrect port position and placement make a
surgeon struggle during his/her procedures and
solutions may include additional port placement,
Umbilicus
18cm
24cm
Ta rget for Procedur
Fig. 5 Concentric circles of 18 and 24cm
changing the instruments to a different port or
withdrawal of telescope and the use of an angled
telescope.
1.4 Single Port
Laparoendoscopic single-site surgery (LESS) is the
name adopted for approaches aiming to do laparoscopy through a single incision usually made over
the umbilicus [12]. It includes single- incision laparoscopic surgery (SILS). Single- incision laparo-
scopic surgery was rst used in the 1970s for tubal
ligation using Yoon’s ring and later hysterectomy
[13, 14]. It was later abandoned because of the well-
documented technical issues of swording. It has
recently found its way back to routine gynaecological procedures and in the area of robotic gynaecological surgeries [15, 16]. This is largely because of
improvements in technology specically miniaturization of equipment as well as creation of exible
optical and coagulation systems [15].
It has the advantage of being faster, reducing
morbidity especially pain, and is more cosmetically acceptable [2, 15–18]. The learning curve is
however steep especially for intracorporeal suturing [15].
The devices have different numbers and sizes
of ports for insertion of instruments. It is inserted
through 1.5– 2.5cm or more incisions made over
the umbilicus. Some of the well-known devices
are SILS Port (Covidien, Manseld, MA, USA)
Laparoscopic Port Position, Placement andClosure
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Fig. 6 SILS Port (Covidien, MA, USA)
101
Learning Points
• Umbilicus is the preferred position for pri-
mary (optic) port. Intraumbilical site is
recommended.
• Secondary (working) port position varies
widely depending on surgery.
• Optimum position of secondary port will be
ideally 5–7.5 cm from the optic port and
between 18 and 24cm (1/2–2/3) of the instru-
ment should be in the abdomen.
• Entry should be guided by laparoscopic vision
under pneumoperitoneum to avoid injury.
• Exit should be guided and hollow cannula
blocked by a blunt instrument or telescope to
avoid tissue being sucked in.
• Laparoendoscopic single-site surgery(LESS)
is increasingly being practiced but the learn-
ing curve is steep.
2 Laparoscopic Port Closure
Fig. 7 GelPOINT (Applied Medical Resources Corp.,
Rancho Santa Margarita, CA, USA)
(Fig. 6) and GelPort and GelPOINT Systems
(Applied Medical, Rancho Santa Margarita, CA,
USA) (Fig.7). The integration of single-incision
laparoscopic surgery and natural orice transluminal endoscopic surgery (NOTES) has been suggested as the catalyst for wider application of this
modality [16].
Laparoscopic procedures are increasingly
being used for diagnostic and therapeutic purposes. Laparoscopy is cosmetically acceptable
to patients and recovery is faster. Technology
is driving innovations in further ensuring its
safety and wide use in various pathologies.
Bladeless trochars with radially expanding
technology have been suggested to decrease
the incidence of postoperative trochar site hernia [19]. This occurs especially when laparoscopic entry ports are improperly sutured and
closed.
The entry points through which the primary
instrument, telescope and working instruments
are inserted into the abdomen are occasional
sites for ventral abdominal wall hernias and will
therefore require closure as prophylaxis against
laparoscopic port-hernia formation. The incidence of port hernia ranges from 0.02% to 5%
with an average of 1% [19, 20]. Hernias in all
ports have been reported but the ports most at
risk of causing hernias are 10–12mm ports and
above especially those in the midline [20, 21].
Ninety percent of hernias occur through 10-mm
cannula or more.
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F. Anolue and L. Akinola
2.1 Predisposing Factors toPort
Hernia
• Large port sizes especially greater than
10mm.
• Midline ports because of the thin fascia alba in
this location.
• Ports used for tissue retrieval.
• Increased number of ports as used in complex
laparoscopic surgeries.
• Pre-existing umbilical hernia.
• Comorbidities especially obesity, diabetes
mellitus and wound infection.
Nacef etal. [22] noted that the most incriminated risk factors are trocar size, obesity and
open laparoscopic entry. Age greater than
60 years, body mass index greater than 25 and
surgery lasting more than 90min increased the
risk of hernia in laparoscopic cholecystectomy
patients [23].
Clinically, port site hernias can be early or
delayed. Early presentation occurs within
2 weeks of the surgery with abdominal pain of
varying degrees with or without vomiting, protrusion over the site, fever and general malaise.
Visible cough impulse may be obvious. The
delayed variant may take months to present. A
high index of suspicion needs to be maintained in
a patient presenting with the above following a
previous surgery. The regular workup for surgery
should be done which should include blood
count, serum electrolyte, urea and creatinine,
abdominal X-rays and possible computerized
tomography scan. Treatment involves the repair
of the fascial defect. Laparoscopic or open surgical approach may be adopted. This largely
depends on the surgeon’s condence to further
deal with this laparoscopically and the consent
by the patient.
Findings at surgery may reveal segmental
bowel infarction (Richter’s hernia), full bowel
infarction or omental protrusion and incarceration in the fascial defect. Simple interrupted
suturing or mesh placement may be adopted.
Adhesions may be encountered and should be
divided. The postoperative period is usually
uneventful.
2.2 Safe Approaches toPort
Closure
The most prevalent opinion is to close ports of
10mm or more [20, 21, 24]. All approaches at port
closure must be simple and safe and aim at not
enlarging the skin wound for better cosmesis. An
important aim is to properly approximate the fascia
and the peritoneum. Reported cases of port hernia
after closure is probably from poor techniques.
There are two methods:
2.2.1 The Standard Open Closure
This is done as for any surgical wound without
laparoscopic aid. After laparoscopy, the abdomen is deated and the cannula is removed.
With the aid of a retractor, the opposite edges of
the fascia are picked up for a simple suture or a
gure-8 suture using Vicryl 1. Aziz [25]
described a simple, cheap and safe two-step
open laparoscopic port closure using two
‘S’-shaped retractors on port sizes greater than
8mm. This can be considerably easy in a thin
patient and in the midline where there is minimal adiposity and fascia is merged. In some
patients, efforts may be made to pick up the
edges of the fascia with long Kocher’s forceps
for maximum retraction. Others have passed a
foley catheter [20] balloon and used it to tract on
the wound to facilitate suturing. Standard open
closure may be difcult in obese patients necessitating enlargement of the skin incision for better access. Skin enlargement therefore becomes
a necessity for optimum results.
2.2.2 Laparoscopic Direct
Visualization
In this approach fascia and peritoneum disruption is closed under direct vision of the telescope with intact pneumoperitoneum. This
helps to avoid visceral injury. The port may be
in place or may be removed. Most often, the
port is left in place and only removed at the
point of knotting the suture. The principle is to
pass a suture using a suture passer, needle or
other devices. A suture passer is a needle that is
notched or grooved at the tip to allow loading
of the suture. There is usually an outer cover-
Laparoscopic Port Position, Placement andClosure
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103
ing of plastic or metal for the needle that allows
the suture secured and hidden for passage into
the peritoneum. Passage is usually allowed
through a spring-loaded mechanism or a
mechanical device with a jaw handle into the
peritoneum.
The tip of the needle is passed on one side of
the facial defect at an angle of 30°–45° under the
skin through the subcutaneous layer. Inside the
peritoneum one end of the suture is dropped or
picked up from the suture passer by a 5-mm
grasper passing through another port. The suture
passer is retrieved and again passed through the
other half of the fascial defect and the suture is
picked up and exteriorized for a subcutaneous
knot. The end may be reloaded once or more for a
gure-8 knot or continuous suturing. Cannulas are
available that have two openings on opposite sides
to aid easy passage of sutures. The VersaOne fascial closure system from Medtronic is a unique allin-one solution that serves as a trochar and a fascial
closure device. It is said to be safe and faster.
These devices have the additional use of con-
trolling port site bleeding during laparoscopy.
Suture passers include Grice (Fig. 8) and
Goretex (Fig.9) devices, while needles that can
Fig. 8 Grice suture passer
Fig. 9 Goretex suture passer
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Fig. 10 Port closure needles (Deschamps)
F. Anolue and L. Akinola
Learning Points
• Port site hernias can occur in ports of any size.
• Port sizes of 10mm or more should be closed
especially if in the midline.
• A simple safe inexpensive method, with surgeon’s competence in consideration, is
recommended.
• Standard open visualization and closure of the
facial defect and direct laparoscopic visualization of the facial defect are the two options.
• Standard open visualization and closure can
be done on thin patients especially on the midline ports.
• Direct laparoscopic visualization using one of
the many methods is recommended for accurate placement of suture. It also reduces visceral injury.
• Empty abdomen of pneumoperitoneum before
removing ports to avoid escaping CO2 drawing omentum or bowel into the port site.
• Port closure should be accomplished before
waking patient up to avoid coughing or gagging with attendant possibility of hernia.
• Increasing the size of skin suture may be a
worthwhile price to pay for obese patients
where adequate fascial closure is desirous.
Fig. 11 Port closure needles (Reverdin)
be used to pass sutures include Deschamps
(Fig.10) and Reverdin (Fig.11) needles.
Vein catheter, spinal cord needle and angiocath needle are cheap devices improvised for
insertion of sutures and effecting fascial closure.
Implantation of a bioabsorbable hernia plug
Hernin has been documented on the 10-mm
umbilical port [26]. Improvising with Veress needle has been practiced [27]. It is cheap as it
improvises with a Vicryl 1 suture. A comprehensive list of various port closure devices can be
found in a review of different port closure devices
by Majid and Mishra [20].
References
1. Mishra RK. Principle of laparoscopic port position.
In: Mishra RK, editor. Textbook of practical laparoscopic surgery. 1st ed. Jaypee publishers; 2008.
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2. Alkalout I, Mettler L, Maas N, Noe G-K, Elessawy
M. Abdominal anatomy in the context of port
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3. Mahajan NN, Gaikwad NL.Direct trocar insertion: a
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4. Vilos GA, Vilos AG, Abu-Rafea B, Horlet-Caines J,
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