Bridging the gap: how higher surgical training programmes can produce consultant laparoscopic colorectal surgeons

with the fingers spread apart is 16–18 cm [5]. Thus, it can be determined in advance whether the hand device will be accessible in every abdominal quadrant including the hepatic flexure. We generally prefer a midline periumbilical incision, which is more versatile, especially for surgeons with shorter arms and patients with a long torso. Moreover, such an incision lies directly over the anastomotic area, which facilitates ileotransverse anastomosis and permits examination under direct vision. For laparoscopic right colectomy, however, the authors extend the epigastric port into an incision for specimen retrieval and extracorporeal ileotransverse anastomosis, although this may be more painful postoperatively than a midline non-muscle-splitting incision. Most surgeons extract the specimen through an incision made at the site of the umbilical trocar when performing a laparoscopic right colectomy [6]. In addition to appropriate positioning of the handaccess device, correct trocar placement is equally important. This is based on the experience and preference of the surgeon. For total right colectomy, 50% of surgeons use four trocars, 30% use three and 20% use five. The first trocar (10 or 12 mm) is placed at the umbilicus, then a 10-mm trocar is placed suprapubically and in the epigastric region by 70% of surgeons. Some surgeons place a 5 mm trocar in the left iliac fossa or right subcostal space [6]. Whatever trocar arrangements are chosen, basic principles of instrument triangulation should be adhered to. More importantly, however, the camera port should be placed to facilitate full vision of the operative field, for otherwise the hand is unable to be helpful and can become a hindrance to performing laparoscopic colectomy. The camera port site may be better when placed in the midline just below the xiphoid process allowing views of the entire operative area. When a medial-to-lateral approach is applied in HALC, the surgeon’s hand can only lift the colon and cannot provide adequate traction and countertraction to create the tunnel beneath the mesocolon at the level of the major blood vessels. In this situation, the additional trocar for the retraction of the bowel by the assistant is of vital importance. Therefore, while we do not routinely try to keep the number of trocars used to a minimum, we accept that the surgeon should have a low threshold to insert an additional trocar to facilitate exposure. The aim of hand-device placement and secondary trocar arrangement is to increase safety and ensure good surgical practice. Whatever is chosen, ergonomics and surgeon comfort are paramount to successful surgery. Simplicity, comfort and safety should be the rule. Author contributions