83 Angelo Territo & Alberto Breda Uro‐Oncology Division and Kidney Transplant Units, Fundació Puigvert, Autonoma University of Barcelona, Barcelona, Spain Pure laparoscopy and robotic surgery are minimally invasive approaches to access the abdominal cavity for diagnostic or therapeutic purposes, using dedicated instruments. At present, the transperitoneal approach has become widespread and more popular than the retroperitoneal approach due to the familiar intraperitoneal anatomy and the larger available working space. Any transperitoneal laparoscopic or robotic procedure starts with the establishment of a pneumoperitoneum, followed by trocar placement. The choosing of the optimal site on the abdominal wall is the first step in transperitoneal access. In general, the initial site is used to introduce the video‐laparoscope. The number, size, and arrangement of the other trocars depend on the type of procedure, patient’s body habitus and surgeon’s experience. Furthermore, in choosing the entry site it is mandatory to consider previous surgical scars and anatomic anomalies, in order to avoid the risk of injuries. In this chapter, we describe the current “state of the art” regarding pure laparoscopic and robotic transperitoneal access and trocar placement in the most common urological procedures. Advantages, limits, and complications related to transperitoneal access and trocar placement will also be described. Knowledge of the abdominal wall is fundamental to any open or laparoscopic/robotic procedure. The abdominal skin is backed by Camper’s fascia, a loose layer of fatty tissue varying in thickness depending on the patient’s nutritional status. In this layer superficial circumflex iliac, external pudendal, and superficial inferior epigastric vessels branch from the femoral vessels. The abdominal wall is composed of five paired muscles: two vertical muscles (rectus abdominis and pyramidalis), and three layered, flat muscles (external abdominal oblique, internal abdominal oblique, and transversus abdominis). These muscles and their fascial attachments form a protective layer that supports the anterolateral abdominal wall (Figure 83.1) [1]. Superior epigastric artery and vein (direct continuations of the internal thoracic vessels) provide blood supply to the superior half of these muscles. The inferior epigastric artery and vein, which arise from the external iliac vessels, approximately 1 cm below the inguinal ligament, supply the inferior portion of the rectus muscles and run superiorly until the anastomosis with the superior epigastric vessels. Furthermore, lower intercostal vessels provide additional vascularization [1] (Figure 83.1). Underneath the muscle layers, the transversalis fascia and the anterior layer of the peritoneum are found before entering the intraperitoneal space (Figure 83.1). Figure 83.1 Anterolateral abdominal wall. Source: From Fundaciò Puigvert, Spain. The transperitoneal approach requires the establishment of a successful pneumoperitoneum. The first step is to optimize entry technique in order to avoid injuries in the abdominal cavity [2]. Three techniques are described: the Veress needle technique, open (Hasson) technique, and direct optical access. The choice of the best method of transperitoneal access is still debated in terms of safety, and there is insufficient evidence to recommend one entry technique over another, although the open access and the direct visual trocar entry appear to have lower minor complications and faster access when compared to the Veress needle entry [3–5]. A common approach to enter the abdominal cavity and create the pneumoperitoneum is by using a Veress needle. This needle is composed of an inner blunt‐tipped obturator and an outer sharp‐tipped sheath. This design protects the intra‐abdominal structures thanks to the advancement of the inner sheath after the outer sheath encounters an area of decreased resistance (peritoneal cavity). Commonly, access with a Veress needle is obtained in the periumbilical area, and far from previous surgical scars (Figure 83.2a). The needle is inserted, tenting the abdominal wall upward (Figure 83.2a). The rationale for lifting the abdominal wall is to increase the abdominal wall tension against which to push the Veress needle and to increase the distance between the bowel and the major retroperitoneal vessels. The Veress needle is held between the thumb and index finger. In the majority of cases, two clicks can be heard, which correspond to the two areas of maximum resistance encountered as the needle passes through the two abdominal wall fascia layers: muscle fascia and peritoneum. Correct placement of the needle into the peritoneal cavity must be quickly verified with the drop test, which consist of injecting 3–5 ml of saline into the Veress needle. In case of correct intraperitoneal placement, the saline is sucked inside the needle due to the negative intraperitoneal pressure. It is also important to aspirate the saline back to verify that no blood, bowel contents, or urine are present. If the first entry attempt fails, a second attempt is performed before choosing an alternative entry site. Figure 83.2 (a) The Veress needle access in periumbilical area, tenting the abdominal wall upward. (b) Initial trocar placement one fingerbreadth inferior to the costal margin, using a visual trocar system with a 5 mm camera and 0° lens (the lens is immediately changed to a 30° one in order to place working trocars and perform the procedure). (c) Second trocar placement at a 90° angle to the abdominal wall and pushed inside until the tip of the trocar can be seen with the laparoscope. Source: From Fundaciò Puigvert, Spain. An initial gas pressure below 9 mmHg reflects the correct intraperitoneal Veress needle placement [6]. It is important to avoid any movements of the needle after its placement in the abdominal cavity. When the Veress needle is correctly positioned, the insufflation of CO2 gas can start. The initial intra‐abdominal insufflation pressure is normally set at 12–15 mmHg, with 3–6 liters of CO2 per minute. Once adequate intraperitoneal pressure is achieved, the first trocar can be placed (Figure 83.2b). Video‐endoscopic inspection is performed immediately after to verify the intraperitoneal trocar placement and to check for potential intraperitoneal injuries. The open entry technique was first described by Hasson in 1974 [7] and provides direct access to the peritoneal cavity. A mini‐laparotomy (1.5–2 cm) at the umbilical area or pararectal line is usually performed. The fascia is exposed with narrow retractors and incised. The peritoneum is identified by sharp dissection of the muscles, tented up, and incised under vision. At this point, the peritoneal cavity adjacent to the incision should be explored with a finger to ensure absence of adhesions. The Hasson trocar is placed immediately after and pneumoperitoneum is initiated. This port consists of a blunt trocar, a cannula with an adjustable conical sleeve, and suture‐holding arms for fixation. The direct optical access is an alternative to the Veress needle. Optical trocar access is considered by many the safest entry method and is associated with a low incidence of intraoperative complications [8]. Nevertheless, in the obese population a randomized controlled trial showed that the Veress needle insertion technique is safer than direct trocar insertion using a nonoptical bladed trocar [9]. A 5 or 10 mm laparoscope is placed directly into the visual trocar sheath. The trocar is then pushed with a twisting motion stepwise into the peritoneal cavity, visualizing each abdominal wall layer during the trocar movement. Under the continuous gentle rotation of the optic trocar, the sequential layers of subcutaneous fat, anterior rectus sheath, pre‐peritoneal fat, and peritoneum are visualized [10]. Once inside, the CO2 is connected and pneumoperitoneum is obtained. The camera and working trocar arrangements depend on the type of surgical procedure and the surgeon’s individual preference or experience. Commonly, triangulation is considered a basic principle of laparoscopic port placement, and for this reason the trocar arrangement is described as using a four‐point diamond configuration, in which the operative site is enclosed within the diamond, with the camera placed between two working trocars [11]. For upper tract transperitoneal surgery, the camera is often placed in the periumbilical area with the other trocars positioned according to the exact procedure, the location of the disease, and the body habitus of the patient [12]. For renal and adrenal laparoscopic surgery performed in obese patients, port placement is further modified by shifting it laterally. Once the aiming point has been located, second trocars are placed at a 90° angle to the abdominal wall and pushed inside until the tip of the trocar can be visualized with the laparoscope, in order to avoid intraperitoneal injuries (Figure 83.2c). Laparoscopic transperitoneal reconstructive surgery in which laparoscopic suturing is needed still represents a challenge, mostly due to spatial limitation, fixed trocar positions, and restricted instrument movements. In order to optimize laparoscopic suturing, Frede et al. [13] found that an isosceles triangle trocar arrangement is needed, and the angle between laparoscopic instruments should be adjusted to between 25° and 45°. Even if this positioning is intuitive and replicates human anatomy with an arm on either side of the point of view, this arrangement often fails to be ergonomic, due to interactions between the assistant holding the camera and the surgeon. In order to reduce this arm conflict between the surgeon and camera holder, and obtain a better ergonomic working position for both, Harper et al. [14] were the first to describe a linear port configuration suitable for all urological transperitoneal laparoscopic renal and adrenal surgery. After creating the pneumoperitoneum with a Veress needle, the first and uppermost port is placed one fingerbreadth below the costal margin, using a visual trocar. The camera is introduced through this trocar. The middle (second trocar) and inferior trocars (third trocar) are placed approximately four fingerbreadths apart. The lowest inferior trocar is approximately at the level of the umbilicus, rarely lower. A fourth port is often placed off the tip of the 11th or 12th rib and used for retraction (Figure 83.3). Figure 83.3 Linear port configuration for left side upper tract surgery using three 5 mm trocars along left pararectal line and a fourth 5 mm port placed off the tip of the 11th or 12th rib for retraction. C, camera; W1 and W2, working ports; R, retractor). Source: From Fundaciò Puigvert, Spain. For right‐sided cases, the first trocar is placed two fingerbreadths lower than the left side (because of the liver) and a trocar for liver retraction is also placed in the midline, right below the xiphoid sternum. Considering this trocar arrangement, both working ports are to one side of the camera and the surgeon’s point of view remains intuitive. Furthermore, the authors [14] described the use of a 30° lens that is usually oriented in line with the surgeon’s angle of view. Linear port placement along the pararectal line is well suited also in cases of performing sutures (pyeloplasties and partial nephrectomy renorrhaphy), positioning the camera temporarily through the middle trocar. This generates a helpful separation of the laparoscopic instruments, making suturing and knot tying quicker and easier [14]. The choice of trocar size depends on the instruments needed for the procedure. Generally, in laparoscopic surgery, trocars from 3 to 12 mm can be used. When larger instruments such as entrapment devices or endoscopic ultrasound probes are needed [14], larger trocars are available as big as 15 mm. Trocar length is usually the standard 10 cm, although longer trocars (15 cm) are available for obese patients. Recently, in a multicenter prospective study, Breda et al. [15] evaluated the role of mini‐laparoscopy, using 3 mm instruments and a laparoscope, in renal and adrenal surgery. The same mini‐laparoscopic approach was also proposed in live donor nephrectomy as an attractive alternative to the standard laparoscopy [16]. The authors found that the operative time was possibly longer than that in a standard laparoscopy, but clinical and safety outcomes were not compromised. Furthermore, mini‐laparoscopy provided excellent pain control and cosmetic results by minimizing the incision site [15]. As far as the type of trocar to use is concerned, many are available, including bladed, bladeless/blunt, and radially dilating trocars. According to the literature, bladeless/blunt and radially dilating trocars are preferred to the bladed ones due to a lower incidence of bleeding, hernia, and pain. Furthermore, by using radially dilating devices, fascial closure can be avoided [17–20]. Finally, laparoendoscopic single‐site (LESS) surgery was introduced in urology in order to decrease morbidity and improve recovery times and cosmetic results [21]. The umbilicus is the most frequently used access site, with a 4–5 cm periumbilical incision. There are multiple LESS devices available, the majority of which include a multichannel port [22]. Trocar‐related complications such as trocar site bleeding, herniation, infection, and postoperative pain may be related to the type and size of trocars [17]. Abdominal wall vessel injury (usually the epigastric vessels) can be managed with direct coagulation through a second trocar placement. If direct coagulation fails, a Carter–Thomason closure device may provide a figure‐of‐eight absorbable suture in order to control the bleeding. The risk of hernia occurrence in the entry site increases with the trocar size used, although fascial closure is performed [23]. The data reported by Kadar et al. showed an increasing port site hernia rate of 3.1% using 12 mm trocars compared with 5/10 mm ports. The same authors also recommended closure of the fascia after laparoscopic procedures using larger than 5 mm trocars [24]. The majority of these hernias occurred within the first two weeks, with a range between a few hours and 1 year [25] and the most frequent site of occurrence is the umbilical scar [23]. Shalhav et al. [26] found that by using blunt trocars rather than sharp trocars the risk of hernia formation could be limited due to the mechanism of insertion. A blunt trocar penetrates the abdominal wall layers by splitting fibers, allowing a nontraumatic separation of the tissues and a spontaneous muscle reapproximation after trocar removal. Although infrequent, port site infection is one of the most bothersome complications in laparoscopic and robotic surgery, increasing patient morbidity. Infections are more common at the umbilical port [27]. In this site, the infection may be related to the specimen extraction technique. For this reason, Sasmal et al. underlined the importance of irrigating and cleaning the port site before closure and removing the specimen in an endobag [27]
Transperitoneal Access and Trocar Placement
Introduction and general considerations
Anterior abdominal anatomy
Access to peritoneal cavity and creation of pneumoperitoneum
Closed entry technique
Open entry technique
Direct optical access
Principles of trocar placement
Choice of the trocar and laparoendoscopic single‐site surgery
Complications related to trocar placement and transperitoneal access
Trocar‐related complications
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