We make an arc-shaped incision immediately above the umbilicus, introducing the first cannula (12 mm) by an open (minilaparotomy)
method, performing a purse string suture of the peritoneum and fascia, f \
Figure 8.5.2. Positions of the cannulae for the laparoscopic anterior resection. Note that the surgeon works mainly through the right lower quadrant and the suprapubic cannulae.
fixing the cannula using a tourniquet method. After initiating a pneumoperitoneum (8-10 mm Hg), we introduce an endoscope (Figure 8.5.2). We then place cannulae in the order of: Left middle abdominal region (5 mm), the left lower abdominal region (5 mm), the midline suprapubic region (12 mm), 1-2 fingers above the pubis, and the right middle abdominal region (12 mm).
If an additional cannula is needed, a right lower abdominal cannula (5 mm) is added. The skin incision at the suprapubic site is made vertically so that open surgery can be performed at any time using a midline incision. At the remaining locations, the incision should be made horizontally for better healing from an aesthetic standpoint. We are cautious at the lower quadrant cannula sites to avoid injuring the inferior epigastric artery and vein. For the puncture in the right midabdomen, placement of the laparoscope into the suprapubic cannula will provide good visualization for a safer puncture. We usually use a flexible lapa-roscope to assist in visualizing the abdominal wall, but if a rigid scope is used, we advocate using an angled scope (30 or 45°).
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