13.2. Spinal Access Surgery Port Placement Arrangements
Namir Katkhouda, M.D., F.A.C.S.
Sharan Manhas, M.D.
A. Port Placement
What follows are general guidelines; final selection of port sites is appro- priately guided by the patient’s anatomic variations. Thus, the surgeon should be forewarned that the port arrangements presented may need to be modified some- what to accommodate a given patient. (Figure 13.2.1)
1. A 5- or 10-mm port (depending on size of laparoscope used) is placed at or just below the umbilicus (for patients with average or large body habitus) via the Veress needle method or via placement of a Hasson-type port after open cutdown (for large body habitus below, for petite body above). This will be primarily used as the camera port.
2. Two additional 10-mm trocars are next inserted under direct vision at the level of the left and right iliac crest just lateral to the border of the rectus muscle. Care must be taken to avoid the epigastric vessels. These are the oper- ating ports for the laparoscopic surgeon. These trocars together with the camera port form a triangular configuration that minimizes “sword fighting” and helps avoid the “needle knitting” effect. (The availability of 5-mm clip appliers make it possible to use 5-mm ports instead of 10-mm ports at these locations.)
3. A 15- to 18-mm port is placed in the lower midline after the annulus has been laparoscopically exposed from side to side. This port is positioned in the lower midline superior to the bladder and is used for spinal instrumentation. It is often placed using fluoroscopic guidance to ensure a correct entry angle for working in the diseased disk space. Its location will be higher for L4–L5 than for L5–S1.
4. Occasionally, an additional 5-mm port may be needed in the left upper abdomen for the purpose of introducing an instrument to retract the small bowel with a fan retractor to provide better exposure of the spine.
5. For higher-level lumbar fusion, such as L3–L4 or rarely L4–L5, it may be desirable to place the camera port three fingers above the symphysis pubis and still maintain a triangular arrangement between this port and the lateral ports. This configuration allows the spinal instrumentation port to be inserted farther cephalad, even at the umbilicus, if necessary, and thus closer to the spinal target area.
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Figure 13.2.1.Port placement for spinal fusion.
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132 N Katkhouda and S Manhas
B. Brief Description of Exposure Procedure
1. The patient is placed in steep Trendelenburg position. The surgical team member’s locations about the table have been explained above. Dissection begins after sweeping the small bowel out of the pelvis. The sigmoid colon with its asso- ciated mesocolon is elevated and retracted to the left of the patient by the camera assistant. This exposes the sacral promontory. The sigmoid colon can be tacked in place by stapling the appendices epiploicae to the abdominal wall or by stapling the pericolic fat to the abdominal wall to hold the colon out of the way.
This step can be accomplished with a hernia stapler. Two to three staples are usually sufficient to provide adequate tension on the mesocolon.
2. The posterior peritoneum is incised longitudinally over the sacral promontory.
3. The ureters are identified and avoided. The right ureter courses over the right iliac vessels and can usually be identified via visible peristalsis whereas the left ureter lies deep to the sigmoid colon in the retroperitoneal space.
4. Monopolar electrocautery should be avoided during the dissection to avoid injuring the presacral parasympathetic plexus, which can result in retro- grade ejaculation.
5. Disk exposure is accomplished with a Kittner wand.
6. The middle sacral vessels are isolated, clipped, and divided.
7. The iliac artery and vein (left or right or both) are carefully dissected and retracted laterally with an endoscopic vascular retractor. The iliac vein rep- resents the most hazardous part of the operation and should be protected during the spinal portion of the operation with a dental pledget.
8. At the L4–L5 level the left iliac artery must be formally dissected and retracted with a vessel loop. The vessel loop can either be held by the grasper of the camera assistant or exteriorized through a separate small skin incision.
Next, the left iliac vein is exposed. The iliolumbar vein must be ligated to allow full mobilization of this vein. An alternative is to dissect the artery and vein as described before and then retract both vessels to the right medially in the event of a low bifurcation to expose L4–L5. To expose higher lumbar levels, the lumbar arteries and veins are exposed at the left side of the aorta and ligated. The big vessels are then retracted medially.
9. The dissection space should be large enough to allow the spinal surgeon to insert, through an 18-mm suprapubic port, the instruments needed to perform the spinal work.
10. Correct disk identification is accomplished by placing a Kirschner (K)-wire into the intervertebral space (intraoperatively or preoperatively from the back). The position of the K-wire is checked on anteroposterior and lateral fluo- roscopic views. This localization also helps optimize positioning of the supra- pubic working portal by ensuring that the docking trocar is perpendicular to the intervertebral disk space.
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