Page 29 - WJOLS

WJOLS

Is there an Ideal Port Position for Laparoscopic Urological Procedures?

Another approach through the retroperitoneal space is in techniques and manoeuvres unique to single site surgeries
obtained through a 15 to 20 mm incision just below the tip are employed. 12
of the 12th rib and the secondary ports are then placed along During laparoendoscopic single site (LESS) nephrec­
the inferior border of the costal margin using digital palpation tomy, a periumbilical incision is made to the rectus fascia.
through the balloon dilated incision site. After digital place­ The peritoneum is entered with an extra­long trocar. After
ment of all the secondary ports, the primary balloon­tip port pneumoperitoneum, another trocar, is placed 1 to 1.5 cm
is inserted. The posterior secondary 12 mm port is placed at caudal and at the 4 o’clock position to the extra­long trocar,
the lateral border of the paraspinal muscle along the inferior eventually functioning as the camera port. A 12 mm port
border of the 12th rib. An anterior port is placed near the is inserted 1.5 cm caudal to the second trocar, resulting in
anterior axillary line, just below the inferior tip of the 11th triangular configuration. A fourth 12 mm standard length
rib. An additional 5 mm port may be placed, on the midaxi­ trocar is placed 1 cm cephalad to the umbilical protuber­
llary line at or above the level of the superior iliac crest, and ance, through which liver or splenic retraction and control
used for retraction and suction. Often a 12 mm port is placed of the renal upper pole and adrenal gland is achieved. 13
at Petit’s triangle just above the midportion of the iliac crest
and a fingerbreadth superior to the iliac crest. 8 Natural Orifice Transluminal
Endoscopic nephrectomy
Hand-assisted Laparoscopic nephrectomy
Natural orifice transluminal endoscopic surgery (NOTES),
The hand­assisted device for right renal surgery could be with the objective of incision free abdominal surgery
located at and just below the umbilicus on the midline. through natural orifices (mouth, vagina and rectum) has
Alter natively, on the right side, the hand port may be placed been described. Although, there were reports on successful
as a Gibson incision in the right lower quadrant. A port is completion of six laparoscopic transvaginal nephrectomies
placed on the midclavicular line just above the superior using conventional instruments in a porcine model, there
iliac crest; the laparoscope is positioned at this port site. were note of limitations of the laparoscopic instruments

A 12 mm port is placed two fingerbreadths below the costal making the procedure cumbersome and time consuming.
margin on the midclavicular line, to accommodate the Endo­ Clayman et al reported their experience with single port
GIA stapling device. A 5 mm port is placed on the midline NOTES transvaginal nephrectomy and encountered similar
in the epigastric region for placement of an instrument to difficulty until a purpose built multi lumen operating instru­
retract the liver superiorly and medially. 8 ments were made available. 14
Conversely, on the left the incision for the hand­assisted Hybrid NOTES in which two natural orifices are used
laparoscopic (HAL) device is located on the midline, at and for approaches has also been described and tried for neph­
above the umbilicus on the midclavicular line just above rectomies. Transvaginal NOTES hybrid combined with
the superior iliac crest, a 10 mm port placed for positioning either transgastric or transvesical nephrectomy, transvesical­
of the 10 mm, 30º laparoscope. The laparoscope may then transgastric have all been described. 15
be used for visualization of the HAL device incision. An
additional 12 mm working port is placed on the midclavi­ Laparoscopic Pyeloplasty
cular line 2 fingerbreadths below the costal margin. Retraction Standard port placement described as ports placed in the
of the kidney laterally may be facilitated by an instrument upper and lower quadrant midclavicular lines and the
placed through a 5 mm port in the midaxillary line, midway camera port placed near the umbilicus. An assistant port is
between the costal margin and superior iliac crest. 8 placed in the suprapubic midline. 16
Another approach with a primary port at 2.5 cm to the
Laparoendoscopic Single Site nephrectomy right of umbilicus, a 5 mm port midway between the primary
Since the advent of laparoscopy, urologists have tried port and right costal margin and, on right midclavicular line,
to minimize scars and improve cosmesis, leading to the and another 5 mm port midway between the anterosuperior
progression to laparoendoscopic single site urological iliac spine and the umbilicus was used while the patient
procedure. Access is usually gain through the umbilicus, was placed in the 45 left lateral position. Fourth flank port
but others include transabdominal or retroperitoneal flank is placed for retraction. 17
approach, a suprapubic or mini­Pfannenstiel approach or
Gibson incisions. 12 LESS Pyeloplasty
Either a specialized port or cluster conventional port The patient is positioned in a modified flank fashion, and
can be used to obtain access. Conventional laparoscopic a 2.5 cm incision is made within the umbilical dimple to
techniques are generally followed, although modifications conceal the scar. After insufflation of the abdomen, three
World Journal of Laparoscopic Surgery, May-August 2014;7(2):74-87 75