What are the recommendations for selecting and placing laparoscopic (minimally invasive surgical) ports?

Laparoscopic Port Selection and Placement

Use the smallest trocar size appropriate for the procedure, place ports off-midline when possible, use non-bladed trocars, and close fascial defects for all ports ≥10 mm to minimize trocar-site hernia risk. 1

Port Size and Type Selection

Trocar Size Recommendations

• Select the smallest trocar diameter that allows safe completion of the procedure to reduce trocar-site hernia (TSH) rates, which increase significantly with ports ≥10 mm 1
• The incidence of TSH ranges from 0.1-1.0%, though this is likely under-reported 1
• Both 5-mm and 10-mm diameter laparoscopes are appropriate depending on the procedure 1
• Consider using a 30-degree laparoscope to improve visualization and potentially reduce the need for additional ports 1

Trocar Type Selection

• Prefer non-bladed trocars over bladed trocars when available, as bladed instruments demonstrate a statistically significant higher incidence of TSH 1
• Balloon or self-sealing trocars may provide additional benefits for maintaining pneumoperitoneum 1

Port Placement Strategy

Location Principles

• Avoid midline trocar placement whenever possible, as midline location significantly increases TSH rates 1
• Place ports off-midline in pararectal or lateral positions to reduce hernia risk 1
• Avoid midline incisions as extraction sites when performing laparoscopic interventions (strong recommendation, high-quality evidence) 1

Initial Access Techniques

• Initial access can be safely achieved via open (Hasson), Veress needle, or optical trocar technique 1
• The Hasson entry technique may reduce risk of uterine trauma (in pregnancy) or spillage of ovarian cysts 1
• Determine uterine size by palpation or ultrasound before port placement in pregnant patients 1

Port Configuration Options

• Primary port location (umbilical, supra-umbilical, or Palmer's point) should be chosen according to organ size, pathology location, and operator experience 1
• A linear port configuration along the ipsilateral pararectal line can improve ergonomics and minimize interaction between camera holder and surgeon 2
• Ipsilateral secondary port placement may prevent the need for instrumentation across enlarged organs 1

Fascial Closure Requirements

Closure Indications

• Close the fascial defect for all trocar sites ≥10 mm to reduce TSH risk 1
• Recent evidence comparing 5-mm versus 10-mm ports showed no difference in TSH rates, though leaving fascia open may reduce operative time 1
• The strength of this recommendation is weak due to limited data specific to emergency settings 1

Special Considerations for Single-Port Surgery

• Conventional multiport laparoscopic procedures are strongly recommended over single-incision laparoscopic surgery (SILS) due to higher incisional hernia rates with SILS (moderate-quality evidence, strong recommendation) 1
• When SILS is performed, meticulous fascial closure is mandatory to decrease hernia formation risk 1

Pneumoperitoneum Management

Insufflation Pressure Guidelines

• Maintain operating pressure at 12 mmHg during the procedure 3
• Initial insufflation pressures of 20-25 mmHg are appropriate for port placement only, then reduce to operating pressure 3
• CO₂ insufflation of 10-15 mmHg is appropriate per ACOG, BSGE, and SAGES, with adjustments based on patient physiology 1, 3
• Consider reducing intra-abdominal pressure below 10-12 mmHg when possible to minimize physiological complications including decreased cardiac output, impaired renal blood flow, and elevated airway pressures 3

Special Population Adjustments

• In pregnant patients, create pneumoperitoneum gradually and use left lateral decubitus or partial left lateral decubitus positioning after the first trimester 1
• Account for fundal height when determining port placement in pregnancy 1
• For hemodynamically unstable patients, the cardiovascular effects of CO₂ insufflation preclude laparoscopic approaches 4

Safety Measures

Smoke Evacuation

• Use closed-circuit smoke evacuation or ultra-low particulate air filtration systems 1
• Minimize use of energy devices and use low power settings when electrocautery is necessary 1
• Evacuate all pneumoperitoneum gas through filtration systems at procedure completion 1

Intraoperative Monitoring

• Use capnography for intraoperative CO₂ monitoring and avoid maternal hypo- and hypercapnia 1
• In pregnant patients with viable fetuses, perform fetal heart rate monitoring before and after surgery; intraoperative monitoring may be appropriate when emergent cesarean delivery would be considered 1

Common Pitfalls to Avoid

• Do not place large trocars in the midline unless absolutely necessary, as this combination creates the highest TSH risk 1
• Avoid using bladed trocars when non-bladed alternatives are available 1
• Do not leave fascial defects ≥10 mm unclosed, despite potential time savings 1
• Avoid SILS techniques when conventional multiport laparoscopy is feasible 1
• Do not maintain unnecessarily high insufflation pressures throughout the procedure; reduce to 12 mmHg after port placement 3