Optimal Initial Trocar Placement for Morbidly Obese Patients

Background and Objectives: Rates of morbid obesity are skyrocketing worldwide. Not only bariatric surgeons, but also general surgeons are often operating on morbidly obese patients. Many general surgeons still use the same anatomic landmarks for patients with body mass index (BMI) over 35 mg/kg(2) as they do for patients of normal weight and can therefore find accessing the morbidly obese abdominal organs difficult. This paper will describe a technique that is easily reproducible and applicable in a wide range of laparoscopic cases. Method: The xiphoid process is the only landmark referenced. From the xiphoid process, the surgeon puts 2 fists together and places the first trocar inferiorly 2 cm lateral to the midline in either direction. The umbilicus is not used as a landmark. This placement is 15-18 cm inferior to the xiphoid process, but allows adequate visualization for any foregut case. An optical trocar is used. Results: In over 1400 bariatric cases, the initial trocar was safely placed with this technique. Most of these cases were performed with the method, but some had one modification: the first trocar was placed in the midclavicular line in the subcostal area if there were previous midline scars. In no cases was an extra-long, or bariatric, trocar used. Conclusions: Laparoscopic access in morbidly obese patients does not have to be difficult. Using an optical trocar off the midline 15-18 cm below the xiphoid process will provide reliable, safe access in the morbidly obese patient, with excellent visualization of the target anatomy.