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  1. Before you start, mark the midline from the xyphoid to the pubis with a marking pen. This will help you to extend the incision in the midline if you need to do so for extraction of the specimen or conversion to an open operation.

  2. A supraumbilical skin incision about 2 to 3 cm in size is made using electrocautery or a knife. If the plan is to use the midline for extraction of the specimen, then it is beneficial to make a larger skin incision (5 cm) at the very beginning of the case, especially in morbidly obese patients.

  3. Use two S-retractors or Army-Navy retractors to expose the fascia. This can be done by blunt dissection using the retractors or by dividing the adipose tissue with electrocautery while the tissue is placed under tension by the retractors. The choice of method is dependent on the thickness and quality of each patient’s body wall. A combination of blunt and sharp dissection works best for morbidly obese patients.

  4. Use two Kocher clamps to elevate the fascia, and then divide it with scissors.

  5. When you divide the fascia, limit it to the size of the port. Otherwise, it will be a source of leakage of the pneumoperitoneum, this is especially important if the initial skin incision is large, for example, you plan to extract from the midline and so have made a larger skin incision for exposure.

  6. Use two Kelly clamps (or hemostats) to elevate the peritoneum—hold the peritoneum with one Kelly clamp and lift it up so that the underlying tissues are away from the clamp, hold adjacent to it with another Kelly clamp and then release the first clamp and regrasp; this is important to make sure no underlying tissue gets caught in the clamp when you take the first grasp. The peritoneum between the two clamps is then divided with a pair of scissors to gain entry into the abdomen; it is important not to make a big hole in the peritoneum because this can cause a leak in the pneumoperitoneum, a 1-cm cut is sufficient. For patients with a thicker abdominal wall, one can substitute longer instruments like a Tonsil clamp or Pean clamp. It is important not to use a perforating clamp like the Kocher clamp for this step because it can damage the underlying bowel if it is grasped in error by the surgeon.

  7. To make sure that there are no adhesions before you place the port, feel the peritoneal cavity with your little or index finger or place an S-retractor in the peritoneal cavity.

  8. Place two stay sutures on each side of the fascia to secure the Hasson trocar. Alternatively, use a balloon-tipped Hasson trocar.

As an alternative technique, perform the following as step number 6, that is, after dividing the fascia.

  • Use your index finger or a Pean clamp and push toward the umbilicus through this ...

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