Description

Laparoscopic surgery has revolutionized modern surgical practice by minimizing trauma, reducing postoperative pain, and enabling faster recovery. However, the safety and success of any laparoscopic procedure begin with the first step – abdominal access and correct placement of ports. In a detailed lecture, Dr. R. K. Mishra, a world-renowned laparoscopic and robotic surgeon and Director of World Laparoscopy Hospital, explained the critical concepts, techniques, and principles that guide surgeons in achieving safe and effective laparoscopic access. Importance of Safe Abdominal Access Dr. Mishra emphasized that abdominal access is one of the most crucial and potentially dangerous steps in laparoscopy. Complications such as vascular injury, bowel perforation, or failed entry can compromise the entire procedure. Therefore, a surgeon must be well-trained in multiple entry techniques and must individualize the approach based on the patient’s anatomy, BMI, and previous surgical history. Methods of Abdominal Access In his lecture, Dr. Mishra outlined the main techniques used in laparoscopic surgery for gaining entry: Closed Technique (Veress Needle Insertion) Involves blind insertion of a Veress needle, usually at the umbilicus. Requires precise angle, proper testing (saline drop test, aspiration test, insufflation pressure monitoring), and careful handling. Open Technique (Hasson’s Method) Direct access under vision with a small incision at the umbilicus. Preferred in patients with previous abdominal surgeries or suspected adhesions. Optical Trocar Entry Uses an optical trocar with a telescope to visualize each layer of the abdominal wall during entry. Reduces blind injury risks and is gaining popularity worldwide. Palmer’s Point and Alternate Sites In obese patients or those with multiple previous laparotomies, access through Palmer’s point (left upper quadrant) or other safe anatomical sites may be considered. Principles of Port Position Once safe access is achieved, port placement strategy determines the ergonomics, visualization, and efficiency of the surgery. Dr. Mishra highlighted the following principles: Triangle of Port Placement The target organ should be at the apex of an imaginary triangle formed by the camera port and two working ports. This allows proper visualization and comfortable instrument handling. Optimum Distance Working ports should generally be placed 5–7 cm apart to avoid clashing of instruments. The camera port is ideally 10–15 cm from the operative target. Angle of Dissection A 60° angle between the two working instruments allows precise dissection and suturing. Surgeon Comfort and Ergonomics The height of the operating table, monitor positioning, and port alignment must all support surgeon comfort, reducing fatigue during long procedures. Customized Port Placement Port strategy varies depending on the surgery type (cholecystectomy, appendectomy, hernia repair, gynecological surgery, etc.). For example, gynecological procedures often require a suprapubic working port, while upper GI surgeries may need higher subcostal access. Teaching Perspective by Dr. Mishra Through live demonstrations and interactive discussions, Dr. R. K. Mishra illustrated how minor errors in port positioning can complicate even simple procedures. He emphasized the importance of anatomical landmarks, patient positioning, and tailored strategies in laparoscopic entry. The lecture combined theoretical knowledge with practical surgical wisdom gained from decades of global experience. Conclusion The lecture by Dr. R. K. Mishra on “Abdominal Access and Principles of Port Position in Laparoscopic Surgery” provided invaluable insights for both novice and experienced surgeons. His systematic approach underscored that a safe entry and well-planned port positioning are the foundations of successful minimal access surgery. By mastering these principles, surgeons can significantly enhance patient safety, operative efficiency, and surgical outcomes.