“Linear” port configuration for upper urinary tract laparoscopy
The traditional flank position port placement or diamond-shaped configuration (Fig. 57.2) which consist in placing the camera port at the umbilicus or pararectal up to the umbilicus, and the second and third ports right and left to the camera, respectively, allows a better triangulation to facilitate handling of instruments and suturing. The major inconvenient of this approach is the poor ergonomics that forces the surgeon and the assistant to cross arms as the camera is between two working trocars. Also, this technique cannot be strictly standardized since the surgeon has to vary the trocar placement depending on the location of the targeted area for work and the body mass index of the patient .
Standard “diamond-shaped” port configuration for upper urinary tract laparoscopy
For the retroperitoneal access, we recommend an open approach, using a 2 cm transverse incision below the tip of 12th rib for the primary port. After a balloon dilator is inserted posterior to the Gerota’s fascia and anterior to the psoas muscle and the space is created a 10 to 12 mm trocar-balloon is inserted for the camera. After inspection of the retroperitoneal working space. A 5-mm trocar is placed posteriorly between the inferior border of 12th rib and the lateral border of erector spinae muscle. A second 10–12-mm trocar is placed anteriorly using digital guidance or under laparoscopic vision about three to four fingerbreadths, anterior to the primary port, along the anterior axillary line. In case a fourth working port is needed for the assistant, we place it lateral to the right hand of the primary surgeon (Fig. 57.3).
Port configuration for retroperitoneoscopy
Most of urological surgeries we perform in the pelvis need a transperitoneal approach. Only prostate can be removed using an extraperitoneal access. Nevertheless, the port placement is very similar either transperitoneal or extraperitoneal route.
We recommend a five-port technique to work comfortably, with the first being a 12 mm camera trocar, placed infra/peri/supra umbilical, depending on where is localized the main target of the surgery. Upper when we need to work proximally (ureter, lymphadenectomy) and lower when we need to work in the prostate and the urethra. The ports should be placed in a fan distribution with two lateral to the rectus abdominus muscles in a line 2 to 5 cm inferior to the infraumbilical port and two ports at least 3 cm medial to the anterior superior iliac spines (ASIS). The primary surgeon works from the patient’s left side through the left iliac and pararectus ports while the first assistant stands on the right and works through the corresponding right-sided ports. The camera operator stands on the right toward the patient’s head. Alternatively, the camera operator can be at the head of the operating table, creating more space for the surgeon and the assistant. All ports can be 5 mm, but we recommend a 10–11 mm on the left side in the dominant hand of the main surgeon. This size allows the use of hem-o-locks or other instruments which need wider ports as well as no problems to introduce and remove needles (Fig. 57.4). We would like to point out that, similar to what we do for kidney surgery, we prefer to work in parallel, to avoid crossing arms among the surgeons. For suturing or when access to the right site of the pelvis is difficult from the left side, main surgeon can use momentarily the pararectal port of the assistant, not being necessary a suprapubic trocar in the midline, as described bu some authors in initial series [1, 5]. In some patients with narrow pelvis is not possible to keep the distance among ports, so they need to be placed closer. In this tricky scenario it is very important to remember to gain space between trocars from the same surgeon, but never reduce the space between the camera port and the pararectal ports in order to avoid clashing.
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