The patient is placed supine on the operating room table. Other positions include modified low lithotomy position with the thighs at or slightly below the level of the hip to prevent interference with laparoscopic instrument mobility. Split leg positioners can also be utilized because these devices support the entire lower extremity, decreasing the chance of peroneal nerve injury and offer the surgeon access to stand between the legs should the need arise. The author’s preference is to place the patient in split leg position. A restraint device can be placed across the patient’s chest to help prevent slippage on the operating room table during manipulation of the table intraoperatively for positioning. The legs can be similarly secured if in split leg position. The left arm should be padded and tucked at the patient’s side. Pneumatic sequential compression devices are placed to reduce the risk of deep vein thrombosis. A bladder catheter is inserted to decompress the bladder intraoperatively. Orogastric decompression can be accomplished by the anesthesia team. The surgeon and assistant stand to the patient’s left and monitors are placed on the patient’s right side. One or more monitors can be used if available. The scrub technician stands to the patient’s right side (Fig. 6-1). Alternatively, the surgeon can stand between the patient’s legs with the assistant to the patient’s left side, while the scrub can remain on the patient’s right side.

Port placement and location of the hand-assist port vary based on patient anatomy, surgeon preference, and surgeon confidence in being able to complete the operation laparoscopically. Two options exist to initiate the operation—placement of a traditional laparoscopic port usually in the periumbilical location and then evaluation and placement of the hand-assist port or initial placement of the hand-assist port with subsequent laparoscopic port placement. The approach is often related to surgeon experience and certainty of the diagnosis.

Figure 6-2 demonstrates some of the more common ports and hand-assist device layouts. Parts A,B, and C demonstrate a 10- or 12-mm supraumbilical Hasson-type port with the hand-assist device in the right lower quadrant, vertical suprapubic location, and low transverse suprapubic location. An additional 5-mm port is placed in the left lower quadrant with the option to place an additional 5-mm
port in the midepigastrum if required to assist with dissection or retraction. Figure 6-2D illustrates the hand-assist device in the periumbilical location with two additional ports on the left side of the abdomen, one for the camera and one for a working port. The placement of the hand in the midline/periumbilical location allows the most surgical versatility, but the hand can obscure visualization. Current hand-assist devices allow easy insertion and removal of the hand into and out of the peritoneal cavity while maintaining pneumoperitoneum. The size of the incision required for the hand-assist device is typically the same as the glove size of the surgeon in centimeters. Once the location is chosen and the incision is made, the wound retractor/protector is placed and secured. The hand-assist port is then secured to the base. The use of surgical lubricant on the back of the surgeon’s gloved hand facilitates hand exchanges through the hand-assist port.