Triangulation is one of the fundamental concepts of laparoscopic surgery, as it permits traction and counter traction on tissues to facilitate dissection along anatomical planes. A comfortable triangulation, with two ports kept many centimeters apart like in LDN, is not achieved with LESS DN. When you are dissecting head-on with hands held close to each other, the angle of triangulation is very acute. When the hands holding the instruments are not held close to each other, the instruments tend to cross each other. The instrument held by the right hand crosses over to the left and vice versa.

In LDN, the uretero-gonadal packet can be retracted away by an assistant with an instrument inserted through a lateral port, achieving gentle traction while dissecting the pedicle. Similarly, instruments can help in retracting other organs like the bowel, spleen, and liver to improve your vision on the area of dissection as and when required by placing appropriate extra ports. These assistant retraction ports can be placed in LESS DN but will further contribute to the clashing of hands and instruments.

The extracorporeal clashing of surgeon’s hands to a certain extent can be avoided by switching the instrument ports. The caudal hand instrument is shifted into the cranial port, and the cranial hand instrument is shifted to the caudal port. So the dominant instrument held by the right hand (by a right handed surgeon) is now held by the left hand. The retraction instrument is held by the right hand. The surgeon should develop skills to do few surgical steps with the nondominant hand. If the surgeon is uncomfortable in operating the dominant instrument with the left hand, he may cross the hands extracorporeally. By crossing hands, the dominant working instrument can continue to be operated by the dominant hand. Another option which is possible in some access device is to switch the orientation of the working ports from a craniocaudal arrangement to a medial-lateral configuration (Fig. 9.2).

Another way to prevent clashing of hands is to use instruments of different lengths. So one instrument can be of standard length, while the other instrument is of bariatric length. The hands will then be kept away from each other extracorporeally, by keeping them in different planes of movement (Fig. 9.3).

The cameraman should sit down to maximize the extracorporeal work space for the surgeon who is standing. It also helps if the cameraman holds the camera by its “tail,” rather than by the regular grip, so as to give more space to the surgeon (Fig. 9.4).

The clashing of working instruments with the laparoscope can occur frequently (Fig. 9.5). The clashing of instruments can be avoided by using thinner 5 mm laparoscopes instead of the standard 10 mm laparoscope.

A longer bariatric laparoscope will keep the cameraman’s hand holding the camera further away from the surgeon, thus giving the surgeon more space.

The regular light cable with its perpendicular entry into the laparoscope from the top invariably gets onto the way of the surgeon’s working instruments. Sometimes, these light cables may also get crushed and damaged. The Endo Eye (Olympus, Tokyo, Japan) was suited for this as it came with the “chip-on-tip” technology which meant that it has a streamlined profile with a single coaxial cable and this reduced the cluttering and clashing with the bulky camera head and light cable.

In LDN, the laparoscope is placed at a slightly lower plane of view as compared to the working instruments. In LESS DN, the laparoscope is best placed in such a way as to get a bird’s-eye view of the working instruments. The advantage being, the hand holding the laparoscope, is kept away below the surgeon’s hands. A deflectable tip 5 mm laparoscope with a coaxial light cable is ideal for performing LESS procedures [5]. But a deflectable tip laparoscope would require the cameraman to be well versed and knowledgeable in its movements (Fig. 9.6).

Articulating instrumentation allows for triangulation or at least the effect to occur intracorporeally despite the entry points being adjacent to one another through the same skin incision. Articulating instruments were originally developed to mimic the freedom of movement afforded by the robotic wrist of the da Vinci Surgical Robot (Intuitive Surgical, Sunnyvale, CA). Articulating graspers, Endo Shears (Autosuture, Norwalk, CT), and needle holders are available. Roticulating instruments (Covidien, Dublin, Ireland) have a 0–80° range of motion, allowing infinite freedom for tip adjustment. They have a spin lock mechanism that allows them to use it as a rigid instrument. Handheld Autonomy Laparo-Angle Instruments (Cambridge Endo, Framingham, MA) have been designed to simulate the surgeons hand in motion and, with its axial rotation knob and exclusive angle locking mechanism, provide a better control. One disadvantage is that using all these articulating instruments has a significant learning curve before one handles them dexterously. The major disadvantage with most of the available articulating instruments is a lack of strength to retract using these. The cutting instruments like the hook or the scissors are most useful among the articulating instruments. Another issue is that by necessity, ultrasonic shears can neither be bent nor articulating.

Prebent instruments also attempt to achieve triangulation intracorporeally and also attempt to keep the hands away extracorporeally. Prebent instruments cannot be passed through regular straight trocars. They can, however, be passed through some of the access devices like the GelPOINT™, TriPort™, and QuadPort™, which have a very low profile inside and outside the abdominal wall. The advantage of the prebent instruments is that they have a fair degree of strength and can be used for retraction.