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More than two decades after the replacement of much traditional open abdominal and chest surgery by minimally invasive surgery (MIS), certain observations have become accepted truths. For the minimally invasive surgeon, little is more important than understanding that poor port position not only impairs operative performance, it leads to career shortening injuries, particularly carpal tunnel syndrome, rotator cuff and other shoulder injuries. In addition, sore necks, sore backs, sore hands, and sore feet can impair performance, especially at times when patience is required. In this chapter we address patient positioning, monitor placement, and trocar positioning to optimize ergonomics for the busy minimally invasive surgeon.


In each chapter of this atlas, we demonstrate the room setup for that particular operation. The general principles of room setup are focused on the “delivery” of the target organ to the surgeon with optimal ergonomics. The first principle in room setup is to align the primary monitor, the operative target, the laparoscope, and the surgeon in a single straight line. This is possible for most, but not all, MIS procedures. For right upper quadrant procedures (e.g., cholecystectomy), the surgeon’s primary monitor is placed above the patient’s right shoulder, the laparoscope is placed in the umbilicus, and the surgeon stands off the patient’s left hip, facing the monitor over the patient’s right shoulder (Figure 1A). For surgery around the esophageal hiatus (e.g., hiatal hernia repair), the monitor is placed over the head of the patient, the laparoscope is positioned near the midline, usually above the umbilicus, and the surgeon stands between the abducted legs (Figure 1B). For right lower quadrant procedures (e.g., appendectomy), the monitor is placed over the patient’s right hip, the laparoscope is placed in the umbilicus, and the surgeon stands adjacent to the patient’s left costal margin (Figure 1C). Although this principle works for almost all procedures, such an alignment cannot be applied to pelvic surgery, as the surgeon would have to straddle the patient’s head. It is for this reason, among others, that robotic surgery is particularly popular for pelvic procedures, as it is difficult to optimize ergonomics for procedures in this region.


In open surgery, exposure is gained by proper retraction of the abdominal wall, chest wall, and structures blocking access to the organ of interest. In MIS, abdominal and chest wall retraction is unnecessary. Structures blocking access are moved with retractors, such as the right lobe of the liver for right adrenalectomy. The small and large bowel is displaced from the field of interest with gravity rather than retraction. For upper abdominal MIS, the patient is placed in steep reverse Trendelenburg position, and for pelvic surgery, Trendelenburg is used to displace the small bowel toward the diaphragm. For right upper quadrant ...

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