Skip Navigation LinksHome > July 2014 - Volume 24 - Issue 6 > Surgical Trocar Insertion Among Pregnant Patients
International Journal of Gynecological Cancer:
doi: 10.1097/IGC.0000000000000182
Letters to the Editor

Surgical Trocar Insertion Among Pregnant Patients

Huang, Kuan-Gen MD; Chua, Angelica Anne A. MD; Lee, Chyi-Long MD

Free Access
Article Outline
Collapse Box

Author Information

Department of Obstetrics and Gynecology Chang Gung Memorial Hospital at Linkou and Chang Gung University College of Medicine Kweishan, Taoyuan, Taiwan

Department of Obstetrics and Gynecology St. Luke’s Medical Center Quezon City and Global City Metro Manila, Philippines

Department of Obstetrics and Gynecology Chang Gung Memorial Hospital at Linkou and Chang Gung University College of Medicine Kweishan, Taoyuan, Taiwan chyilong@ms21.hinet.net

The authors declare no conflicts of interest.

To the Editor

We have read your article by Vercellino et al1 with great interest. We agree that pelvic lymphadenectomy among pregnant patients with cervical cancer is a safe procedure that can improve patient’s prognosis. We would like to commend the authors for making such an extensive study involving pregnant patients with cervical cancer. However, we would like to make a suggestion regarding the methodology.

The authors mentioned that, “for patients less than 16 weeks (group16), the Palmer’s point was used as the camera trocar. A 10-mm umbilical trocar was used to take out the specimen and 2 accessory 5-mm trocars was placed on each side. They noted that in order to perform the lymphadenectomy on the contralateral side, the surgeon has to exchange places with the assistant. For patients more than 16 weeks (group 24), 2 additional 10 mm trocars 2 cm above and below the umbilicus were used. In order to perform the lymphadenectomy on the contralateral side, the camera from the Palmer’s point was shifted to the 10 mm sub-umbilical port.” It is worthy to note that their method for pregnant patients with advanced gestation required the use of three 10-mm trocars. Changing places during surgery and changing where the camera port is placed can be cumbersome and time consuming especially when dealing with malignancy cases. Among pregnant patients, lessening operation time decreases their risk for complications; thus, changing places during surgery may not be recommended for these patients.

We would like to suggest placing the camera port in the Lee-Huang point. The Lee-Huang point is the midpoint between the umbilicus and xiphoid process.2 Once a skin incision is made, a 10-mm laparoscope is inserted perpendicular to the abdominal wall. This method not only saves time but also provides high central vision allowing surgeons to approach both sides of the pelvis easily despite the gravid uterus (Fig. 1). This means that we do not need to use 2 different surgical techniques for pregnant patients less than 16 weeks age of gestation or more than 16 weeks age of gestation. It is also important for surgeons to make a standard operative procedure.

Figure 1
Figure 1
Image Tools

Pregnancy poses limitations in performing laparoscopic surgery because the enlarged uterus limits the operative field, thereby restricting the instruments’ range of motion. This makes the placement of the camera port of primary importance. As the pregnancy progresses, the uterus enlarges and gets closer to the umbilicus. Therefore, all trocars should avoid the umbilical area during insertion. We would like to suggest using the Lee-Huang point as the camera port for better operative view and wider operative space.3 Aside from increased working space, the Lee-Huang point offers a proper visual angle compared with the Palmers point.2,3 This eliminates the need to shift positions during surgery.3 In fact, we have been routinely using the Lee-Huang point for the primary trocar and major trocar for large pelvic pathologies since 1993.4 Aside from cervical cancer, we have been using the Lee-Huang point for cases of endometrial cancer and ovarian cancer, and this is especially useful for advanced oncology cases that require para-aortic lymph node dissection.3,4 Other applications include obese patients, cases of severe endometriosis, and patients with previous abdominal surgeries.4

Kuan-Gen Huang, MD

Department of Obstetrics and Gynecology

Chang GungMemorial Hospital at Linkou

and Chang Gung University College of Medicine

Kweishan, Taoyuan, Taiwan

Angelica Anne A. Chua, MD

Department of Obstetrics and Gynecology

St. Luke’s Medical Center

Quezon City and Global City

Metro Manila, Philippines

Chyi-Long Lee, MD

Department of Obstetrics and Gynecology

Chang Gung Memorial Hospital at Linkou

and Chang Gung University College ofMedicine

Kweishan, Taoyuan, Taiwan

chyilong@ms21.hinet.net

Back to Top | Article Outline

REFERENCES

1. Vercellino GF, Koehler C, Erdemoglu E, et al. Laparoscopic pelvic lymphadenectomy in 32 pregnant patients with cervical cancer: rationale, description of the technique, and outcome. Int J Gynecol Cancer. 2014; 24: 364–71.

2. Lee C-L, Huang K-G, Jain S, et al. A new portal for gynecologic laparoscopy. J Am Assoc Gynecol Laparosc. 2001; 8: 147–50.

3. Thepsuwan J, Huang K-G, Wilamarta M, et al. Principles of safe abdominal entry in laparoscopic gynecologic surgery. Gynecol Minim Invasive Ther. 2013; 2: 105–9.

4. Huang K-G, Lee C-L. Lee–Huang point 20 years on. Gynecol Minim Invasive Ther. 2013; 2: 103–4.

© 2014 by the International Gynecologic Cancer Society and the European Society of Gynaecological Oncology.

Login

Article Tools

Images

Share

Connect With Us

Twitter
twitter.com/IJGConline

For additional oncology content, visit LWW Oncology Journals on Facebook.