title: Supraumbilical primary trocar insertion for laparoscopic access: the relationship between points of entry and retroperitoneal vital vasculature by imaging.
abstract: OBJECTIVE
  Advances in laparoscopy have demonstrated that supraumbilical primary ports can be desirable in complex cases with large masses. This study evaluated distances to vital retroperitoneal vasculature that were encountered with 45- and 90-degree angle entry from the umbilicus and 2 commonly described supraumbilical entry points at 3 and 5 cm cephalad from the umbilicus.
  
  
  METHODS
  Retrospective analysis of computed tomography scans of the abdomen and pelvis from 100 randomly selected women who were 18-50 years old with normal anatomy was performed. Three-dimensional models of sagittal sections were generated using IMPAX software. Measurements from the abdominal wall at the umbilicus and 3 and 5 cm cephalad with 45- and 90-degree angles to retroperitoneal structures were performed.
  
  
  RESULTS
  With 90-degree angle entry, the abdominal wall thickness (AWT) was thinnest at the umbilicus; however, the thickness at 3 and 5 cm was similar. AWT increased at all sites with 45-degree angle entry, and the same pattern was observed. AWT and intraperitoneal distance positively correlated with body mass index and supraumbilical entry points. With 90-degree angle entry, the aorta was 1.9 cm (95% confidence interval [CI], 1.4-2.4) and 2.5 cm (95% CI, 2.0-2.9) farther away at 3 and 5 cm cephalad compared with umbilical entry. In one-third of the cases, regardless of port placement, a vascular structure other than the aorta was the most anterior vessel. With 45-degree angle entry at the umbilicus, no vessels were encountered. With 45-degree angle entry at 3 and 5 cm cephalad, the aorta was the most anterior vessel in 1% and 2% of cases, respectively, and was noted to be 1.0 cm (95% CI, 1.0-1.0) and 2.3 cm (95% CI, 1.2-3.3) farther away than with 90-degree angle entry. A vessel other than the aorta was encountered in 4% and 7% of cases at 3 and 5 cm, respectively.
  
  
  CONCLUSIONS
  According to theoretic modeling, supraumbilical primary port placement can be implemented safely in laparoscopy. With supraumbilical entry, the distance to retroperitoneal vessels was greater than at the umbilicus. Compared with a 90-degree angle, with a 45-degree angle entry, it was uncommon to encounter vasculature, and all measured distances were greater.
authors.affiliation: Women's Health Institute, Cleveland Clinic, Cleveland, OH.
authors.forename: Jamie
authors.initials: J
authors.lastname: Stanhiser
authors.affiliation: Women's Health Institute, Cleveland Clinic, Cleveland, OH.
authors.forename: Linnea
authors.initials: L
authors.lastname: Goodman
authors.affiliation: Women's Health Institute, Cleveland Clinic, Cleveland, OH.
authors.forename: Enrique
authors.initials: E
authors.lastname: Soto
authors.affiliation: Women's Health Institute, Cleveland Clinic, Cleveland, OH.
authors.forename: Ibraheem
authors.initials: I
authors.lastname: Al-Aref
authors.affiliation: Department of Radiology, Cleveland Clinic, Cleveland, OH.
authors.forename: Jenny
authors.initials: J
authors.lastname: Wu
authors.affiliation: Women's Health Institute, Cleveland Clinic, Cleveland, OH.
authors.forename: Anar
authors.initials: A
authors.lastname: Gojayev
authors.affiliation: Women's Health Institute, Cleveland Clinic, Cleveland, OH.
authors.forename: Benjamin
authors.initials: B
authors.lastname: Nutter
authors.affiliation: Women's Health Institute, Cleveland Clinic, Cleveland, OH. Electronic address: falcont@ccf.org.
authors.forename: Tommaso
authors.initials: T
authors.lastname: Falcone
mesh_terms: D034861:Abdominal Wall / Q000033:anatomy & histology*; D000328:Adult; D001011:Aorta / Q000033:anatomy & histology*; D015992:Body Mass Index; D015331:Cohort Studies; D005260:Female; D013509:Gynecologic Surgical Procedures / Q000379:methods*; D006801:Humans; D010535:Laparoscopy / Q000379:methods*; D008875:Middle Aged; D008962:Models, Theoretical; D012187:Retroperitoneal Space / Q000033:anatomy & histology / Q000000981:diagnostic imaging*; D012189:Retrospective Studies; D013525:Surgical Instruments; D014057:Tomography, X-Ray Computed; D014472:Umbilicus / Q000033:anatomy & histology / Q000000981:diagnostic imaging*; D055815:Young Adult
keywords: laparoscopic; supraumbilical; trocar; vasculature