title: Survey of Abdominal Access and Associated Morbidity for Robot-Assisted Radical Prostatectomy: Does Palmer's Point Warrant Further Awareness and Study?
abstract: Laparoscopic access for robot-assisted radical prostatectomy (RARP) is often initiated in the periumbilical location. Palmer's point, located in the left upper quadrant, has been reported as an alternative access site for pelvic laparoscopy to reduce morbidity, but not widely reported among urologists. To better understand surgeons' preferences for access and its associated morbidity during RARP, we surveyed surgeons from two urologic organizations.
  
  
  
  An anonymous online questionnaire (SurveyMonkey) consisting of 17 questions that assessed training, experience, and preferences for RARP was emailed in December 2014 and collected until February 2015 to members performing RARP of the Endourology Society (ES) and the Michigan Urological Society Improvement Collaborative (MUSIC). Surgeons were also asked to share their personal experience with a vascular, death or life-threatening event (DOLTE), or bowel injury during RARP.
  
  
  
  Questionnaires were answered by 111 surgeons in total (ES, n = 71 and MUSIC, n = 40) with an estimated total response rate of 5.5%. In total, 77% reported prior experience with the Veress needle method before exposure to RARP and 71% of respondents primarily use the Veress needle for RARP, with 73% reporting access primarily at the periumbilical location. A personal experience with a vascular or a bowel injury during Veress needle insertion was reported in 18% and 9% of surgeons, respectively; furthermore, 26% of respondents were personally aware of at least 1 DOLTE among colleagues (5% reported 3 or more). The majority (56%) of respondents were unaware of Palmer's point, while among the minority aware of Palmer's point, only 33% reported ever using this location.
  
  
  
  In this survey, surgeons most commonly access the abdomen at the periumbilical location with a Veress needle for RARP with the majority not aware or utilizing Palmer's point. Nearly one in five surgeons reported a personal experience with a vascular injury during access for RARP. Palmer's point, located away from major vasculature, may reduce the morbidity of access for RARP and warrants further awareness and study.
authors.affiliation: 1 Michigan Institute of Urology, Beaumont School of Medicine, Oakland University , Novi, Michigan.
authors.forename: William K
authors.initials: WK
authors.lastname: Johnston
authors.affiliation: 2 Department of Urology, University of Michigan , Ann Arbor, Michigan.
authors.forename: Susan
authors.initials: S
authors.lastname: Linsell
authors.affiliation: 2 Department of Urology, University of Michigan , Ann Arbor, Michigan.
authors.forename: David
authors.initials: D
authors.lastname: Miller
authors.affiliation: 2 Department of Urology, University of Michigan , Ann Arbor, Michigan.
authors.forename: Khurshid R
authors.initials: KR
authors.lastname: Ghani
mesh_terms: D000005:Abdomen / Q000601:surgery*; D000328:Adult; D001291:Attitude of Health Personnel; D007722:Health Knowledge, Attitudes, Practice; D006801:Humans; D010535:Laparoscopy / Q000379:methods*; D008297:Male; D008824:Michigan; D008875:Middle Aged; D011468:Prostatectomy / Q000379:methods*; D011471:Prostatic Neoplasms / Q000601:surgery*; D065287:Robotic Surgical Procedures / Q000379:methods*; D011795:Surveys and Questionnaires
keywords: Veress needle; laparoscopic access; robotic prostatectomy; vascular injury