Hand-Assist Placement
Choosing a site for placement assist devices such as the HandPort should wait until the abdomen has been insufflated. The distortion of the abdominal wall under pneumoperitoneum would change the ultimate position and length of any incision attempted prior to insufflating. A site is then chosen in the high left upper quadrant just lateral to rectus abdominus. We believe that the optimal position of the hand is one that allows for triangulation with the other laparoscopic instruments and therefore substitutes for a typical port site in standard laparoscopy. The length of incision correlates mainly with breadth of the palm. This length also approximates the size of the surgeon’s glove (for most 7-8 cm). The incision is then carried full thickness. Loss of pneumoperitoneum will occur at this stage.

The hand is then introduced through the base retractor and the wider end of the sleeve is secured to the base retractor and the abdomen re-insufflated.

(Note: many of the operator, incision, and port site positions to be mentioned are what have worked for us. Others may find modifications more comfortable for them, specifically with respect to the ultimate hand-assist device placement. In our description, we have chosen to introduce our right hand for hand-assistance and use our left hand to handle laparoscopic instruments. Our team involves both a left-hand and right-hand dominant surgeon, and we have both operated comfortably through the set up provided. Conceptually, a right- handed surgeon may prefer to introduce his/her non-dominant hand through a mirror image set up while operating from the patient’s left side. Either should allow good exposure and functional assistance. Either would have the potential for conversion if necessary. Also of note, we have experimented with and rejected a vertical, midline, epigastric incision for various reasons including not offering advantageous triangulation to the stomach and because it tends to block the camera view).  

With the hand introduced, a combination of visual and tactile exploration may be carried out.  Laparoscopic ultrasound is a useful adjunct to the initial exploration in cases of suspected malignancy.  Initial port placement consists of a 5 mm trocar in the epigastric region. This port will be used for dissection and/or left lobe retraction. A 12 mm port is placed several centimeters below the right subcostal margin in the anterior axillary line. It will also be used for dissection and for introduction of linear staplers. For safety, the hand should be retracted into the sleeve above the base retractor whenever introducing trocars.