Trocar Placement
Tommaso Falcone 
Mark D. Walters
The most important prerequisite for proper trocar placement is knowledge of abdominal wall anatomy. Patient position is critical for a safe procedure. The patient is placed in the dorsal lithotomy position with foam-padded leg stirrups (Allen Medical Systems, Acton, Massachusetts), in which the calves and heels are supported and can be elevated for the vaginal portion of the surgery. The legs are checked for pressure points, and the arms are placed at the side wrapped in sheets and with cushions placed at pressure points.
An examination is performed with the patient under anesthesia, and the bladder is catheterized. For operative laparoscopy, a Foley catheter is left in the bladder. A uterine manipulator is inserted. For infertility cases, we use a RUMI (Cooper Medical, Oklahoma City, Oklahoma) or a Cohen manipulator (Eder Instruments, Oak Creek, Wisconsin).
Veress Needle Insertion
A local anesthetic, such as an equal mixture of 1% lidocaine without epinephrine and 0.25% bupivacaine, is infiltrated into the umbilical area. A 20-gauge, 2-inch needle is used so that the skin and fascia are infiltrated. The abdominal skin should be elevated while this procedure is performed.
An orogastric tube should be inserted if intubation has been difficult or ventilation prior to intubation has been prolonged. A dilated stomach can be punctured easily under circumstances that result in gastric dilation. It is mandatory that the patient be kept in a horizontal position. An incision is made intraumbilically in the natural folds. It is a matter of preference whether a pneumoperitoneum is created before insertion of the primary trocar. Several articles have documented the safety of a direct trocar insertion without a pneumoperitoneum. Injuries to intraperitoneal structures such as the bowel and blood vessels have been clearly associated with Veress needle insertion. The abdominal wall should be elevated prior to insertion. If the bowel is adherent to the anterior abdominal wall, it will not move away with elevation. If the bowel is not adherent, it will be farther away from the needle. Vascular structures also will be farther away. The Veress needle should be aimed toward the uterus at a 45° angle and in the midline (Fig. 115–1). Before insufflating, correct intraperitoneal placement of the needle should be performed by one of these techniques:
A drop of fluid placed on the needle hub will trickle downward, especially if the anterior abdominal wall is elevated.
A syringe of fluid can be attached to the needle and easily injected. This fluid can then be aspirated. If there is no return, the needle has been placed correctly. If there is return of blood or bowel content, there is a problem.
