During laparoscopic procedures and other minimally invasive surgeries (MIS), trocars are used to create small incisions in outer tissue layers. These incisions allow surgeons to insert cannulas through which surgical instruments can be introduced. To ensure optimal access to the operative field (in this case, the pelvis), trocars should be arranged in an arc. Laparoscopic surgery poke hole is the channel for implanting laparoscope and surgical instruments, which is equivalent to the incision of laparotomy, but the choice of poke hole placement is completely different from that of open surgery.
Choice of Puncture Point
1. Observation hole
In terms of histological origin, the tissue structure at the umbilical foramen on the abdominal wall is the weakest, with few blood vessels, and its anatomical layers from outside to inside are skin, thin subcutaneous tissue, rectus abdominis tendon, posterior sheath, and parietal peritoneum.
Therefore, the umbilical foramen is the most suitable site for blind punctures such as observation holes.
For most laparoscopic operations, a puncture hole of 10 mm is often selected in the middle of the umbilical cord or slightly above or below the umbilical cord. If the umbilical foramen is too deep, or if thereis infection, you should choose below the umbilicus. If the pelvic mass is too large, supraumbilical puncture can also be selected.
2. Operating hole
The selection of the puncture point of the operation hole follows the principles of easy operation, aesthetics, and minimal trauma. At the same time, the inferior epigastric artery and other running vessels must be avoided, such as the superficial epigastric artery, deep circumflex iliac artery, and superficial circumflex iliac artery.
The first operation hole: the observation hole.
The second operation hole: the 1-2cm medial side of the left anterior superior iliac spine is the common puncture site.
The third operation hole: at the McBurney point on the right.
The fourth operation hole: The puncture point can generally be outside the midpoint of the connection between the observation hole and the second operation hole, and the distance from the above two operation holes is greater than 8-9cm. If necessary, for the convenience of operation, puncture can be done at any point on the abdominal wall.
1. Trocar direct insertion method
Do not form pneumoperitoneum first, and insert Trocar directly. The technical requirements are relatively high and only suitable for experienced surgeons.
2. Direct-looking trocar puncture method
After the skin is cut at the first Trocar, a laparoscope is inserted into the Trocar, and the incision of each layer of abdominal wall tissue can be observed under the microscope, thus ensuring the safety of the operation.
Enter the Veress Veress needle, and then enter the first Trocar after the pneumoperitoneum is formed. This is a classic puncture mode and is most widely used in clinical practice. However, "blind puncture" can cause damage to retroperitoneal vessels, abdominal wall vessels, and gastrointestinal tract.
After incision of each layer of tissue in the umbilicus into the abdominal cavity, a blunt Trocar was inserted to form a pneumoperitoneum. It is time-consuming, and there is a possibility of air leakage due to the incision being too large. It is suitable for high-risk patients with a history of abdominal surgery or suspected abdominal adhesions, and can also be used for laparoscopic surgery during pregnancy.
Poke hole placement positions for different procedures
1. Laparoscopic appendectomy
Poke a hole on the left side next to the umbilicus as an observation hole, poke a hole horizontally at the level of the navel at the outer edge of the right rectus abdominis as the main operation hole, and poke a hole at McBurney’s point as a secondary operation hole.
Or poke a hole 2 cm medial to the left anterior superior iliac spine as the main operation hole, and poke a hole 2 cm above the pubic symphysis as the auxiliary operation hole.
2. Laparoscopic cholecystectomy
Poke holes at the lower edge of the umbilical cord as observation holes, and poke holes under the xiphoid process, right midclavicular line, and right anterior axillary line as the main, auxiliary operation holes, and assistant auxiliary operation holes.
3. Laparoscopic liver lobectomy
Poke a hole on the upper or lower border of the umbilicus to make an observation hole. The main operation hole is as close to the lesion as possible. If the lesion is in the right liver, take it under the xiphoid process;
The auxiliary operation hole must be kept at a certain distance from the main operation hole and the lens. Generally, the subcostal margin of the right midclavicular line and the subcostal margin of the right anterior axillary line are used, and additional operation holes can be added according to the actual situation.
4. Laparoscopic hepatic cyst drainage
Poke holes at the lower edge of the umbilicus as observation holes, and poke holes under the xiphoid process, at the level of the right midaxillary line at the level of the umbilicus, or below the costal margin of the right midclavicular line as the main and auxiliary operation holes, respectively.
5. Laparoscopic splenectomy
Poke holes below the umbilical cord as observation holes, poke holes at the intersection of the left midclavicular line and umbilicus horizontal line as the main operation hole, poke holes about 3 cm above the umbilicus through the rectus abdominis line as auxiliary operation holes, and poke holes at the left anterior axillary line and below the spleen as secondary operations Auxiliary operating hole.
6. Laparoscopic tail pancreatectomy
An observation hole is made below the umbilical cord at the lower edge of the umbilical cord, the main operating hole is made at a position 2 cm above and below the left midclavicular line and the umbilicus horizontal line, an auxiliary hole is made at a position about 8 cm above the umbilicus to the left of the right midclavicular line, and 2 cm below the costal margin of the right anterior axillary line As an assistant to operate the hole.
7. Laparoscopic duodenal ulcer perforation repair
Poke holes at the lower edge of the umbilicus as observation holes, and poke holes 1 cm below the costal margin on the left anterior axillary line and at the level of the left midclavian line at the level of the umbilicus as the main and auxiliary operation holes, respectively, with a distance of about 1 cm between the two holes.
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