Principle of Laparoscopic Port Position
The relative position of the instrument ports is very important in the performance of surgical
procedures endoscopically. The angle the instruments make with the operative site and to each
other should mimic, as far as possible to the natural relationship of the hands and eyes during
conventional surgery. It is proved that the most common cause of stressful minimal access
surgery is wrong port position. Ninty five percent of surgeon and gynecologists use umbilicus as
primary port but at the time of inserting secondary port there is controversy among operator
and they lack the principles behind secondary port position.
PRIMARY PORT POSITION
The central location and ability of the umbilicus to camouflage scars makes it an attractive primary port site for laparoscopic surgery. There are many drawbacks with umbilicus as well.
Umbilicus is a naturally weak area due to absence of all the layers. Weakness is also due its location at the midpoint of the abdomen’s greatest diameter.
It is easy to believe that there is a difference between the umbilicus and other trocar sites in both susceptibility to infection and postoperative incisional herniation.
The study showed that the increased infection rate at the umbilicus seems to be related to retrieval of infected organs through the umbilicus and not to the umbilicus itself. When umbilicus was used to retrieve gallbladder after cholecystectomy the rate of infection was high due to port contamination with infected gallbladder. Excluding cholecystectomy, the umbilical infection rate was two percent, similar to that of any alternative site. The postoperative ventral hernia rate was at 0.8 percent, the same at the umbilicus as elsewhere if the port more than 10 mm size is not repaired. It is now proved that the wound infection at the umbilicus is similar to that at other sites; postoperative ventral hernia at the umbilicus is similar to that at other sites and most of the infection after laparoscopic cholecystectomy is due to the contamination of wound due to infected gallbladder.
SECONDARY PORT POSITION
The obligatory passage of the laparoscopic instruments through the abdominal wall generates a fixed point after which all movements are reversed. For instance, when the hand moves to the left, the end of the instruments moves right, and when the hand moves downwards, the end of the instrument moves upwards. For some surgeon’s the fulcrum effect is not a problem, but for others it is an insurmountable obstacle to the performance of advanced laparoscopy.
