The number of cannulae, unlike their size and the length of the wound incision, has very little impact, if any, on postoperative outcomes. Although as few as three cannulae can be sufficient in uncomplicated cases, as preferred by some surgeons, we choose to standardize cannula placement and routinely use five or six cannulae for left-sided colectomies (Figure 8.4.2). This allows us to achieve an excellent exposure which may be particularly valuable at the beginning of a surgeon's learning curve. Using six cannulae allows the use of more instruments in the abdominal cavity for retraction of bowel and structures especially in the presence of abundant intraabdominal fat or of dilated small bowel, as well as during mobilization of the splenic flexure. We also believe that we are able to teach better using this approach.
Cannula fixation to the abdominal wall is important, to avoid CO2 leakage, and in cases of malignancy, to minimize the passage of tumor cells and help reduce the incidence of port-site metastases.4 This is mainly achieved by fitting the size of the incision to the cannula size or by fixing the cannula to the abdomen with a suture placed around the stopcock of the cannula. We no longer use screw-like cannulae, because they increase parietal trauma.
We usually perform an "open" technique for the insertion of the first cannula, which is placed at the midline, above the umbilicus, to reduce
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