10.2. Port Placement Arrangements for Gastroesophageal Reflux Disease Surgery
Jorge Cueto-Garcia, M.D.
José Antonio Vazquez-Frias, M.D.
A. Introduction
1. A total of four different port arrangements for gastroesophageal reflux disease (GERD) procedures are presented and briefly described in this chapter.
2. Positioning: As mentioned in the previous chapter, either the supine or the modified lithotomy position can be used for minimally invasive GERD procedures. The authors of this chapter recommend the modi- fied lithotomy position. The so-called European position allows the surgeon to stand between the legs and provides excellent frontal vision for antireflux procedures. This position can also be used for car- diomyothomy, vagotomies, placement of the adjustable gastric band, reoperations in the esophageal hiatus, etc.
3. OR table: As for other advanced laparoscopic procedures, it is impor- tant that the operating table permit the patient to be placed in steep Fowler’s position (reverse Trendelenburg) as well as to allow sharp lateral angulation (“airplaning”) to provide adequate exposure.
4. Establishment of pneumoperitoneum: Regardless of which specific port arrangement is used, the pneumoperitoneum can be established through one of the epigastric port sites with a Veress needle unless there has been previous open abdominal surgery, in which case the initial puncture is done in the left upper quadrant. The authors rec- ommend infiltration of the trocar sites with 2% lidocaine with epi- nephrine (2–3 mL) to decrease postoperative pain as well as to limit the metabolic response to trauma [1].
5. Although most other advanced laparoscopic procedures make use of a periumbilical port, this position is not often used in GERD operations because of the long distance between this site and the esophageal hiatus.
Most instruments cannot reach the latter easily through a port at the umbilicus. One exception to this is in the pediatric patient in whom the periumbilical area is usually used to insert a 5- or 10-mm trocar.
6. Intrarectus ports: Most of the port arrangements presented in this chapter call for the placement of one or several ports through the rectus muscle. For GERD procedures it is usually necessary to make use
within the rectus muscle in order to prevent an injury to the epigastric vessels.
B. Port Placement 1
1. It is advised that the patient be placed in the modified lithotomy posi- tion (see Figure 10.1.1) and that the surgeon stand between the patient’s legs.
2. The initial trocar (5 or 10 mm) is placed 4–5 cm above the umbilicus and 3–4 cm to the right of the midline (intra-rectus) in a patient with average build (middle body drawing of Figure 10.2.1). Subsequently, this port is used for instruments held in the left hand of the surgeon.
3. A 5- or 10-mm laparoscope (a 30° is recommended) is introduced and a complete examination of the abdominal cavity is carried out. The remaining trocars are then placed under direct visualization.
4. A 5- or 10-mm port is next inserted just below the costal margin, in the midline or 2–3 cm to the left of the midline. This port will be used mainly for the laparoscope.
5. In the right upper quadrant just a few centimeters below the costal margin in the midclavicular line, a 5- or a 10-mm trocar is inserted that will be used for the liver retractor.
6. In the left upper quadrant, a few centimeters below the costal margin, in the midclavicular line, a 5-mm port is placed. A retractor is placed through this port and used to provide exposure of the gastroesophageal area.
7. The last port, 5 or 10 mm in size, is inserted through the left rectus muscle in the left upper quadrant at the level of the initial trocar and will be used for the right hand of the surgeon.
8. This arrangement provides for a comfortable, ergonomic position for both hands of the surgeon, and has advantages not only for the dis- section, but also very importantly for suturing the plication [2, 3].
C. Port Placement 2
The following is a description of an alternative port arrangement that has been shown to be successful [4] (Figure 10.2.2).
1. This port placement puts the laparoscope lower in the abdomen, just cephalad and to the left of the umbilicus.
2. The surgeon’s hands work through ports placed higher on the abdomen.
The left hand controls an instrument through a 5-mm subcostal (or sub- hepatic, depending on size of the liver) port just to the right of the midline, and the right hand controls an instrument through a 5-mm sub- costal port in the left upper quadrant lateral to the rectus muscle.
Figure 10.2.1.Port arrangement 1 for antireflux surgery. Depending on the body habitus of the patient, the surgeon’s prefer- ence, and the available equipment, either 5- or 10-mm trocars can be used.
Figure 10.2.2.Port arrangement 2 for gastroesophageal reflux disease (GERD) procedures. (Suggested by A.E. Cuschieri [4].)
3. The liver retracting and assisting ports for the assistant are in the right upper quadrant.
D. Port Placement 3
In pediatric patients, because there is less distance between the umbilicus and the esophageal hiatus, a port at the umbilicus is usually appropriate. Other- wise, pediatric port arrangements are similar to the arrangements used in adults.
Depending on the size of the patient, 3-mm instruments may be used for all ports except for the port through which suturing is completed. For suturing, a 5- or 10-mm port may be necessary (Figure 10.2.3).
1. The laparoscope is placed through a port at the umbilicus.
2. The surgeon’s left hand utilizes the ports near the xiphoid process while the right hand controls instruments inserted via the left subcostal ports.
3. Liver retraction is accomplished through a port in the right upper quad- rant; the other assistant works through a port in the lower left upper quadrant at the lateral edge of the rectus muscle.
E. Port Placement 4
With this placement, the laparoscope and the instruments in the surgeon’s hands are in the same location as port placement 2.
Figure 10.2.3. Port arrangement 3 (for pediatric, very young, and/or short patients; five-port scheme). The umbilicus is used for one of the trocar sites. The trocars used can be 3, 5, or 10 mm in diameter.
just to the left of the umbilicus (Figure 10.2.4).
2. The surgeon’s hands control instruments through ports in the upper abdomen. The surgeon’s left hand controls an instrument through a port placed below the costal margin just a bit to the right of the upper midline. Some patients have a large lateral segment of the left lobe of the liver, requiring that this port be placed somewhat more caudally.
The surgeon’s right hand controls an instrument place through a port just below the left costal margin in the left upper quadrant.
3. The liver retractor is placed through a port in the right upper quadrant.
4. The assistant manipulates a retractor/grasper placed through the port in the left midabdomen at the lateral border of the rectus muscle.
F. Placement of Additional Trocars
In very complicated situations such as those of intense periesophagitis [2, 3], obesity, paraesophageal hernia, etc., or when otherwise needed, an additional trocar may be placed. The purpose of this port is usually to provide better exposure.
The location for this additional port will be determined by the nature of the condition requiring the additional port. It should be placed away from the other ports, yet provide access for retraction of omentum, liver, stomach, or whatever is limiting exposure. There is no specific prescribed location for this additional port. Making use of an added port has proved to be invaluable in many patients.
When an additional procedure is planned, such as a cholecystectomy (8% in our series [2, 3]), the right upper quadrant port is placed more laterally and an extra 3- or 5-mm trocar is placed in the right anterior axillary line to provide traction of the fundus of the gallbladder. Vagotomy usually can be done with the arrange- ment already described.
G. Reoperations in the Esophageal Hiatus
Reoperations of the esophageal hiatus are being performed more frequently.
If the previous procedure was laparoscopic, the initial puncture can be tried with the Veress needle in the umbilicus. Otherwise, it is best to insufflate via a left upper quadrant insertion site. After a careful inspection of the abdomen the extent and severity of the adhesions is evaluated. With careful and diligent blunt and sharp dissection using the bipolar electrocautery or the harmonic scissors, the areas selected for the placement of the trocars are carefully cleared of adhe- sions. Special care must be taken to avoid injury to the transverse colon. Among 23 reoperations for failed GERD procedures, there have been no conversions to laparotomy.
Figure 10.2.4.Port arrangement 4. This alternative plan for port placement uses four 5-mm ports and one 10-mm port.
1. Pasqualucci A, Contardo R, Da Broi U, Colo F. The effects of intraperitoneal local anesthetic on analgesic requirements and endocrine response after laparoscopic chole- cystectomy: a randomized double-blind controlled study. J Laparoendosc Surg 1994;4:405–412.
2. Cueto J, Weber A. Procedimientos antirreflujo. In: Cirugía Laparoscópica. México:
McGraw Hill Interamericana, 1997:68–79.
3. Cueto J, Swanstrom L. Antireflux procedures. In: Cueto J, Gagner M, Jacobs M, eds.
Laparoscopic Surgery. New York: McGraw-Hill (in press).
4. Cuschieri AE. Hiatal hernia and reflux esophagitis. In: Hunter JG, Sackier JM, eds.
Minimally Invasive Surgery. New York: McGraw-Hill, 1993:87–111.
I. Selected References
Bowrey DJ, Blom D, Crookes D, et al. Risk factors and the prevalence of trocar site her- niation after laparoscopic fundoplication. Presentation No. S-79. SAGES Scientific Session 2000, Atlanta, GA, March 29–April 1, 2000.
Cueto J, Melgoza C, Weber A. A simple and safe technique for closure of trocar wounds using a new instrument. Surg Laparosc Endosc 1996;6(5):392–393.
Cueto J, Vázquez JA, Nevarez R, Poggi L, Zundel N. Laparoscopic repair of traumatic diaphragmatic hernia. Surg Laparosc Endosc Percutaneous Tech 2001;11(3):
209–212.
Mealy K, Hylan J. Small bowel obstruction following laparoscopic cholecystectomy. Eur J Surg 1991;157:675–676.
Weber A, Muñoz J, Garteiz D, Cueto J. Use of subdiaphragmatic bupivacaine instillation to control postoperative pain after laparoscopic surgery. Surg Laparosc Endosc 1997;
7(1):6–8.
