Chapter 12
Port Insertions
The surgeon initiates the operation by placing the required ports in their respective positions. To reiterate, the primary port accommodates a 10 mm 30° laparoscope. Its site of placement depends on the uterine size. If the uterus is normal size (except in cases with prior laparotomy scars), then the umbilicus can be used as the insertion point. When the uterus is larger, however, the insertion site must be above the umbilicus in the midline. For example, if the uterus is 10–16 weeks in size, one can go two fingers breadth above the umbilicus. If the uterine height corresponds to more than 16 weeks, it is advisable to insert the primary port four fingers above the umbilicus. The same site is used whenever there are abdominal scars from prior surgery. The senior author has never encountered midline bowel adhesion above the umbilicus in patients who have undergone gynecological laparotomies for benign conditions. In the event of multiple previous surgical laparotomies, on the other hand, it is advisable to consider the open laparoscopic approach.
The two secondary ports are placed on the patient’s right side. The first is two fingers medial to the anterior superior iliac spine in the spino-umbilical line. This point is lateral to the level of the inferior epigastric vessels in the vicinity of the oblique muscle and is relatively thin. The site of insertion is indented with the finger and visualized internally with the laparoscope. Then, the 5.5 mm trocar is introduced perpendicular to the abdominal wall until it is about to penetrate the peritoneum. At this juncture, the direction of the trocar insertion is changed so that it lies horizontal under the abdominal wall as it enters the abdominal cavity under direct vision. Care should be taken to retract the uterus away from the insertion site using the manipulator. Use of this port plan guarantees that the tips of both ancillary instruments will converge at the operative site. In contrast, if this port plan is not used, the tips of the instruments will be parallel, thus making the operation more cumbersome and less ergonomic.
The second accessory port is placed more medial to the first by 10–15 cm in the midclavicular line. Insertion is also under direct vision using principles previously described. The senior author advises not to insert the second ancillary port at the same level as the first because of the unphysiological situation that would occur whereby both hands would not work in an ergonomic and comfortable manner when the surgeon is half turned to look at the monitor screen. This would not be the case if the surgeon were standing in a position where he or she could look straight ahead at a screen in the same manner that a pilot looks down the runway.
After insertion of the primary port, the telescope is inserted and the surgeon lifts the abdomen to confirm the correct position of the trocar and check for adhesions in the immediate vicinity of the tip of the cannula. Insufflation of the abdomen then should commence. The usual insufflation pressure is set at 12–14 mmHg with a flow rate of 8–12 liters/minute. It is axiomatic that the surgeon must not only inspect the abdominal cavity in the area of pathology, but also manipulate the laparoscope so that the entire upper abdomen including the stomach, liver and diaphragm are inspected. Additionally, at this time it may be useful to visualize both ureters and their course from the area of the pelvic brim to the level of the uterosacral ligaments.
The laparoscope is in place and as a first step the uterus is pushed out of the pelvis in a cephalad direction so that the fundus and adnexae are easily visible. Attention is given to the uterine size and mobility (up and down, side to side, and axial rotatory mobility), as well as access to the lateral aspects of the uterus and the pouch of Douglas.