In this video, we will disscuss that Minimal Access Surgery (MAS), also known as minimally invasive surgery, has revolutionized the field of surgical intervention by offering patients smaller incisions, quicker recovery times, and reduced post-operative discomfort. A cornerstone of successful MAS is the optimal placement of surgical ports. The correct port position directly influences the ease of the procedure, surgical ergonomics, instrument triangulation, visualization, and ultimately, the patient’s outcome.

Understanding Port Positioning
 
Port positioning refers to the strategic placement of trocar entry points on the patient’s body to facilitate the introduction of laparoscopic or robotic instruments and the camera. Each surgical procedure has its unique anatomical and functional requirements, and therefore, port placement must be individualized.
 
Proper port placement ensures:
- Adequate instrument reach and range of motion
- Minimal external clashing between instruments
- Optimal internal triangulation
- Surgeon comfort and ergonomic efficiency
- Safe entry and reduced risk of injury to internal structures

Fundamental Principles of Port Placement
 
1. Anatomical Landmarks
Understanding surface and internal anatomy is vital. Port placement should respect anatomical planes, avoid critical structures like major vessels or nerves, and ensure access to the operative field.
 
2. Target Geometry
This involves aligning instruments and the camera in such a way that they converge on the target organ, forming a triangle — the ideal setup for triangulation. This enhances depth perception and manipulation.
 
3. Ergonomics and Instrument Handling
The surgeon’s comfort is critical. Poor port positioning can lead to awkward angles, fatigue, and decreased precision. The working ports should allow natural hand movements with minimal external conflicts.
 
4. Camera Positioning
The camera port usually sits between the working ports and is placed at an appropriate distance to provide a panoramic view of the operative field.

Port Positioning in Common MAS Procedures
 
1. Laparoscopic Cholecystectomy
- Typically requires four ports.
- Umbilical port for camera.
- Epigastric port for dissector or cautery.
- Two lateral ports for retraction and assistance.
- Ensure proper distance between ports to avoid crowding and enable triangulation.
 
2. Laparoscopic Appendectomy
- Usually performed with three ports.
- Camera in the umbilicus.
- Working ports in the left lower quadrant and suprapubic region.
- Variations exist depending on the surgeon’s preference and patient anatomy.
 
3. Laparoscopic Hernia Repair (TAPP/TEP)
- Port placement in the midline and laterally, tailored to expose the inguinal region.
- TEP requires precise dissection and placement to maintain the preperitoneal space.
 
4. Laparoscopic Colorectal Surgery
- Requires thoughtful planning due to the large operative field.
- Camera port often in the umbilicus.
- Working ports tailored to the lesion location — right, left, or sigmoid colon.
 
5. Robotic Surgery (e.g., Robotic Prostatectomy)
- Port configuration must account for robotic arm articulation.
- Spacing between ports (typically 8–10 cm) to prevent external arm collision.
- Docking angle and patient positioning are critical.

Tips for Optimal Port Placement
 
- Pre-operative Planning: Use imaging studies (CT/MRI) to understand organ size, position, and pathology. Plan port positions accordingly.
- Use of Templates: Some procedures benefit from templated port sites based on standard guidelines.
- Body Habitus: In obese patients, ports may need to be placed higher or further lateral to maintain angles and reach.
- Adjust for Instrument Type: Use low-profile ports and angled instruments as needed.
- Practice and Simulation: Dry lab or virtual simulation training can improve spatial awareness and planning.
 
Common Pitfalls and How to Avoid Them
 
- Too close ports: Causes clashing and poor triangulation.
- Too far apart: Leads to overextension and limited maneuverability.
- Improper camera angle: Reduces field of view and spatial perception.
- Ignoring patient factors: Obesity, prior surgeries, or hernias should guide customized placement.
 
Conclusion
 
Optimal port positioning in minimal access surgery is both an art and a science. It demands a comprehensive understanding of anatomy, procedural requirements, surgical ergonomics, and individual patient factors. With experience and meticulous planning, surgeons can master port placement, enhancing both their performance and patient outcomes.
 
Whether you are a surgical trainee or an experienced practitioner looking to refine your technique, revisiting the principles of port positioning can elevate your surgical practice. Remember: the success of MAS begins before the first incision — with the blueprint of port positioning.

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