It is logical and expedient to place the hand device first, before establishing pneumoperitoneum and placing cannulae. The hand device is placed centrally in the suprapubic region via either a low transverse Pfannenstiel incision or a vertical midline incision (Figure 9.1.2). The latter is advised in situations in which conversion is deemed more likely (obesity, multiple prior operations, etc.). The length of the handdevice incision will vary depending on the surgeon's hand size. Transverse incisions should be made at least 2 cm cephalad to the pubic symphysis to minimize device leakage and to provide access to the left upper quadrant. Once the incision has been completed, the hand device is placed and a hand is inserted into the abdomen after which the can-nulae are placed.
It is important to take into account the "footprint" of the hand device when choosing cannula positions. If the cannula and hand are placed too closely together, the intracorporeal hand is more likely to block the path of instruments inserted through the cannula. A four-cannula arrangement with an optional fifth cannula is recommended. A 10-mm cannula, usually placed just above the umbilicus, is the first to be inserted. The hand is used to protect the abdominal viscera as the first cannula is placed in the absence of pneumoperitoneum; the latter is established once this first cannula is fully inserted. A 12-mm cannula is inserted in the right lower quadrant, lateral to the rectus muscle, about at the level of the anterior superior iliac spine (more cephalad in those with long and broad abdominal walls). This cannula should either be placed at the site chosen for a diverting loop ileostomy (marked in the holding area preoperatively) or, at least, 3-4 cm away from the stoma site. Utilizing the stoma location usually requires that the cannula be placed through the rectus muscle. A 5-mm cannula is inserted approximately 4 fingerbreadths above the 12-mm cannula, also lateral to the rectus muscle. Finally, a 5- or 10-mm cannula is placed in the left lower quadrant lateral to the rectus muscle and below the level of the umbilicus (10 mm is needed if a 10-mm tissue ligating and dividing device is to be used from this location). The optional fifth cannula is best placed in the left upper quadrant lateral to the rectus
border. It is advised that some type of cannula anchor be used (threaded cannula or grip, or skin suture tethers that are wrapped around the insufflation arm of the cannula).
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