Principles of Laparoscopy- Trocar Positioning and Placement 
Richard Davis 
 
OPEN MANUAL OF SURGERY IN RESOURCE-LIMITED SETTINGS 
www.vumc.org/global-surgical-atlas 
This work is licensed under a Creative Commons Attribution-ShareAlike 3.0 Unported License  
 
Introduction:  
Laparoscopic surgery has the potential to 
decrease postoperative pain and shorten recovery. 
Although a laparoscopic surgery generally takes 
longer than its equivalent open surgery, this is not 
always the case, especially in experienced hands. 
The disadvantage of longer surgery time can be 
offset by shorter in-hospital recovery, which allows 
the hospital to perform more operations overall. 
Often, a hospital that does laparoscopic surgery well 
will have a good reputation in the community, 
attracting more patients for that reason as well. 
 
Becoming facile at laparoscopic surgery 
takes time and commitment, both on the part of the 
surgeon and the hospital. New equipment must be 
purchased, learned about, and maintained. New 
procedures will be billed differently. The equipment 
is more complex and prone to breakage and 
malfunction, especially if mishandled. The surgeon 
is well advised to seek a mentor and perform 
laparoscopic surgery under supervision as much as 
possible before starting to practice it alone.  
 
There are a number of complications 
particular 
to 
laparoscopic 
surgery, 
including 
complications of pneumoperitoneum, injury to 
adjacent structures during trocar placement, and 
injury to intra-abdominal structures during surgery. 
Vascular injury during trocar placement, in 
particular, can be fatal. Some complications arise 
when a familiar operation is done in a new way; one 
example is the increase in biliary tract injuries that 
occurred after laparoscopic cholecystectomy was 
widely adopted in the United States.  
 
Some critics will argue that laparoscopy has 
no role in resource-limited settings like ours. With 
scarce resources, they would say, the focus should be 
on procedures that are likely to help the most people. 
Certainly we agree that safe access to lifesaving and 
disability-preventing procedures should be primary 
in importance. However, in settings where these 
“basics” are done well and are accessible to all, we 
feel that the advantages of laparoscopy should not be 
withheld from patients.  
It is possible to do laparoscopic surgery well 
in a resource-limited setting, but it must be done 
differently than in a resource-rich 
country. 
Specifically, the use of disposable instruments 
should be minimized. Reusable stainless steel 
laparoscopic trocars and energy devices are available 
from India and China, where laparoscopy is being 
done perhaps more commonly. Conversely, single-
use trocars and instruments from industrialized 
countries will be harder to source and adapt for our 
setting, and will malfunction if re-used beyond their 
intended lifespan.  
 
The cannulas that allow laparoscopic access 
without letting pneumoperitoneum escape are 
variably called ports or trocars; these two words are 
essentially interchangeable. In this chapter we will 
explain trocar positioning and trocar placement. 
Other chapters will discuss pneumoperitoneum 
options and alternatives, scopes and cameras, and use 
of energy devices. We will further discuss some 
specific procedures in other chapters.  
 
Trocar positioning: 
 
The main goal of trocar positioning is to 
allow access of the camera and working trocars to the 
surgical site. The best way to accomplish this is to 
think in terms of a 4-sided “diamond,” with the 
surgical site at one corner, the camera’s trocar at 
another, and two working trocars at the other two 
corners. Sometimes the two working trocars will be 
at opposite ends of the square with the camera 
looking between them. At other times, the two 
working trocars will be next to each other with the 
camera opposite. 
Principles of Laparoscopy- Trocar Positioning and Placement 
Richard Davis 
 
OPEN MANUAL OF SURGERY IN RESOURCE-LIMITED SETTINGS 
www.vumc.org/global-surgical-atlas 
This work is licensed under a Creative Commons Attribution-ShareAlike 3.0 Unported License  
 
 
 
Consider the figure above, demonstrating one 
possible trocar configuration for laparoscopic 
appendectomy. The appendix (Red “X”) is at one 
corner of the “diamond.” In general, visualization is 
best when the camera is far from the surgical site, 
through the blue trocar, on the opposite side of the 
“diamond.” However, this configuration forces the 
camera operator to reach in between the surgeon’s 
two hands, which can be awkward.  
If the scope is placed through the purple 
trocar, visualization may be more difficult because 
the scope is closer to the appendix. But the surgeon 
and camera operator will be more comfortable, as 
their arms will not need to overlap. 
 
 
Surgeon (Red) operating through the two trocars on opposite 
sides of the “diamond” while the camera operator (Blue) must 
hold the camera (through the Blue trocar) in between the 
surgeon’s arms, an awkward position that is difficult to hold for 
a long time. Visualization may be better, because the camera is 
farther away from the pathology (Red “X”.)  
 
 
Surgeon (Red) operating through two adjacent corners of the 
“diamond” while the camera operator (Blue) uses the Purple 
trocar on the opposite corner of the diamond. The camera 
operator is more comfortable and can hold this position for 
Principles of Laparoscopy- Trocar Positioning and Placement 
Richard Davis 
 
OPEN MANUAL OF SURGERY IN RESOURCE-LIMITED SETTINGS 
www.vumc.org/global-surgical-atlas 
This work is licensed under a Creative Commons Attribution-ShareAlike 3.0 Unported License  
 
longer. The disadvantage is that the camera is closer to the 
pathology (Red “X”) so the view may not be as useful.  
 
 
We demonstrate other examples of the 
“diamond” principle in trocar placement below:  
 
The “diamond” trocar setup for laparoscopic esophageal 
surgery. The camera is in the Red umbilical trocar. The Purple 
and Blue trocars are the working trocars. The patient will be 
placed in lithotomy position and the surgeon will stand between 
the patient’s legs. The camera operator will stand on one side 
holding the camera between the surgeon’s arms. Other trocars 
on the right and left flank can be placed for additional 
assistance and liver retraction.  
 
 
The “diamond” setup for laparoscopic trans-abdominal right 
inguinal hernia repair. The camera will go through the Purple 
trocar and the camera operator will stand on the patient’s right. 
The Red and Blue trocars will be the working trocars for the 
surgeon, who stands on the patient’s left. Both arms are tucked. 
For bilateral inguinal hernia repair, the Blue trocar is placed 
directly opposite the purple one; the surgeon and camera 
operator switch sides midway through the operation.  
 
 
The “diamond” setup for laparoscopic cholecystectomy. The 
camera is in the umbilical trocar, the Blue and Purple trocars 
are the working trocars, and both surgeon and camera operator 
stand on the patient’s left side. We prefer to place the trocar as 
cranially as possible, and the Purple trocar as laterally as 
possible, to avoid crowding the “diamond.” Another trocar will 
be placed on the patient’s right flank- this will retract the dome 
of the gallbladder as cranially as possible, expanding the 
“diamond” even further. 
 
When the Hasson open technique is used 
(described further below) the umbilical trocar will be 
an 11mm one. 10mm scopes are easier to maintain 
and less fragile, so many surgeons in resource-
limited settings are often forced to use these. If the 
other trocars are 5mm, then a 10mm scope can be 
placed in the umbilical trocar only, which will also 
affect the conduct of the operation. In the 
configurations above, consider how the surgery 
would be limited if the camera could only go in the 
Red trocar.   
If, on the other hand, the surgeon has a 5mm 
scope available, it can be placed in any trocar, or 
even changed from one trocar to the other as the 
operation proceeds. Of course, other 11mm trocars 
can be placed besides the umbilical one. For 
Principles of Laparoscopy- Trocar Positioning and Placement 
Richard Davis 
 
OPEN MANUAL OF SURGERY IN RESOURCE-LIMITED SETTINGS 
www.vumc.org/global-surgical-atlas 
This work is licensed under a Creative Commons Attribution-ShareAlike 3.0 Unported License  
 
example, it is common to place a 11mm trocars at the 
epigastric site during laparoscopic cholecystectomy.  
 
 
Trocar Placement:  
 
There 
are 
many 
ways 
to 
introduce 
laparoscopic trocars. We present one simple and 
reliable method, consisting of open placement of the 
first trocar through the Hasson technique, and 
percutaneous placement of subsequent trocars under 
direct laparoscopic visualization. 
 
Open Trocar Placement 
 
In a patient with no previous abdominal 
surgeries, we prefer to use the supraumbilical 
position. This approach allows an inconspicuous 
scar, in an area where access is easy because the 
preperitoneal layer is thin.  
1. Make a transverse incision just above the 
umbilicus. If there is any chance that the 
operation will convert to an open one, make 
the incision vertical. Otherwise, a transverse 
incision heals with a better cosmetic result. If 
the patient is not obese the incision is 2.5cm 
in length. If the patient is obese, it can be 4cm 
long. 
 
The transverse supraumbilical incision is made just above the 
umbilicus, and curves slightly downward on either side for 
improved cosmesis.  
 
2. Carry 
the 
dissection 
through 
the 
subcutaneous tissue, using small retractors to 
help dissection. Clear the anterior rectus 
sheath at the midline.  
 
Using a combination of diathermy and blunt dissection with the 
retractors, the anterior rectus sheath is cleared. 
 
Principles of Laparoscopy- Trocar Positioning and Placement 
Richard Davis 
 
OPEN MANUAL OF SURGERY IN RESOURCE-LIMITED SETTINGS 
www.vumc.org/global-surgical-atlas 
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3. Incise the anterior rectus sheath transversely. 
Continue dissection until you reach the 
preperitoneal fat but do not continue through 
the peritoneum. This maneuver allows you to 
have the smallest possible hole in the fascia 
to minimize gas leakage during the surgery.  
 
The fascia is divided until the preperitoneal fat is seen. With 
excellent retraction and some practice, it is possible to 
consistently divide the fascia only, without dividing the 
preperitoneal fat or the peritoneum.  
 
4. Using the small finger, bluntly perforate the 
peritoneum and enter the abdominal cavity. 
Probe the intraperitoneal space, making note 
of any adhesions or masses. If your finger 
meets  resistance, you have not completely 
divided the fascia. Expose and divide further 
with diathermy.  
 
Once the fascia has been divided, the preperitoneal space and 
peritoneum are entered bluntly with the small finger. Probe the 
adjacent space to make sure there are no adhesions or 
structures that can be injured when the cannula is placed.  
 
 
After blunt fingertip entry, the intra-abdominal contents can be 
seen in the base of the wound.  
 
Principles of Laparoscopy- Trocar Positioning and Placement 
Richard Davis 
 
OPEN MANUAL OF SURGERY IN RESOURCE-LIMITED SETTINGS 
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This work is licensed under a Creative Commons Attribution-ShareAlike 3.0 Unported License  
 
5. Place retention sutures through both edges of 
the fascia on either side of the incision. With 
proper retraction, you can grasp the fascial 
edges with forceps and place the suture in 
them easily. Each will be about ¼ of the way 
from the edge of the fascial incision; once the 
trocar is in place, pulling on  them will tighten 
the fascial incision and minimize gas leakage. 
 
With proper retraction, the fascia edge can be grasped with a 
forceps and a suture passed, taking care not to injure intra-
abdominal contents. With a slightly longer incision, this 
technique can be used even on obese patients.  
 
 
Retention sutures after placement.   
 
6. Grasp the fascia with forceps and insert the 
trocar into the peritoneum using a blunt 
obturator. Do not pull on the retention sutures 
during this stage, this will make insertion 
more difficult. If only a sharp obturator is 
available, be very careful and withdraw the 
obturator after you feel the trocar pass 
through the fascia.  
 
Insert the trocar tip through the fascia, grasping the edge of the 
fascia with a forceps. The sutures are kept loose until the tip of 
the trocar is within the peritoneum.  
 
 
A blunt obturator tip inside a Hasson trocar. This tip can be 
gently passed into the abdominal cavity without concern for 
injury. 
 
Principles of Laparoscopy- Trocar Positioning and Placement 
Richard Davis 
 
OPEN MANUAL OF SURGERY IN RESOURCE-LIMITED SETTINGS 
www.vumc.org/global-surgical-atlas 
This work is licensed under a Creative Commons Attribution-ShareAlike 3.0 Unported License  
 
 
A sharp obturator tip inside a Hasson trocar. These are made 
to be passed under direct visualization, through tissue, with the 
laparoscope already inside the abdomen. Be very careful when 
using this obturator for an open approach. Withdraw the 
obturator as soon as the tip of the trocar is past the fascia.  
 
7. Secure the trocar in place by attaching the 
retention sutures tightly to the trocar.  
 
Once the trocar is inserted fully, it is secured with the retention 
sutures 
 
 
One technique for decreasing air leak is applying a penetrating 
towel clamp to one or both sides of the skin incision adjacent to 
the trocar.  
 
8. Upon completion of the surgery, withdraw 
the trocar. Pull up on the two retention 
sutures while spreading them, to expose the 
incision. Place a third suture through the 
fascia between the two previous ones, lifting 
each side individually to see the needle and 
make sure there is no bowel injury.  
 
The two retention sutures, still attached to hemostats, can be 
spread and pulled laterally to show the fascial edges. If this is 
Principles of Laparoscopy- Trocar Positioning and Placement 
Richard Davis 
 
OPEN MANUAL OF SURGERY IN RESOURCE-LIMITED SETTINGS 
www.vumc.org/global-surgical-atlas 
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properly done, you do not need a retractor. A third suture is 
then placed in between the retention sutures. Be sure to see the 
tip of the needle while placing this suture to avoid entrapment 
or injury of peritoneal contents.  
 
 
Before cutting the sutures, pull them upwards while injecting 
local anesthetic into the fascia around the closure site.  
 
Percutaneous Trocar Placement Under Visualization 
1. Once you have pneumoperitoneum, insert the 
scope and visualize the area where you plan 
to place a trocar from the inside. Inject the 
peritoneum with local anesthetic under 
visualization. Avoid the epigastric vessels, 
which run parallel and about 5 cm lateral to 
the linea alba on each side. 
 
The surgeon injects local anesthetic into the skin, fascia and 
peritoneum under direct visualization with the laparoscope.  
 
2. Make a skin incision about 2mm longer than 
the diameter of the trocar.  
 
Make an incision in the area where the trocar is planned, after 
visualizing that area with the laparoscope. 
 
3. Grip the head of the trocar between your 
thumb and middle, ring, and small fingers, 
extending your index finger along the shaft of 
the trocar. 
 
The proper way to hold a trocar while inserting it 
percutaneously. The palm grip maintains firm control, but the 
index finger resting on the skin of the abdominal wall stops the 
trocar if it plunges  in suddenly.  
 
Principles of Laparoscopy- Trocar Positioning and Placement 
Richard Davis 
 
OPEN MANUAL OF SURGERY IN RESOURCE-LIMITED SETTINGS 
www.vumc.org/global-surgical-atlas 
This work is licensed under a Creative Commons Attribution-ShareAlike 3.0 Unported License  
 
 
Improper way to hold a trocar while inserting it: grip is 
excellent, but there is no way to slow a sudden plunge into the 
abdominal cavity.  
 
4. Insert the tip of the trocar and place your 
finger on the skin adjacent to the entry point. 
Push in a controlled manner, twisting 
slightly, while using your index finger to 
prevent the trocar from “plunging” into the 
abdomen. Watch the tip of the trocar 
continuously with the scope. If there is 
excessive resistance, do not push harder.  The 
most common cause of resistance will be a 
skin incision that is not big enough. Be aware 
that devastating complications can occur if 
the trocar “plunges” in suddenly, including 
bowel or vascular injury. Perforation of the 
aorta or an iliac artery with a 5mm or 11mm 
trocar can lead to rapid blood loss and even 
death.  
 
Proper technique, with the fingertip resting on the skin.  
 
 
As the surgeon begins to apply pressure to the trocar, the 
peritoneum begins to bulge inwards at the location that it will 
eventually break through (Black arrow.)  
 
 
The camera operator must keep the tip of the trocar in view at 
all times. Here, the sharp tip of the trocar is about to break 
completely through the fascia and peritoneum. As the tip 
becomes more apparent, the surgeon applies less pressure to 
maintain control and prevent the trocar from “plunging” into 
the abdomen out of control.  
 
5. Upon completing the surgery, withdraw all 
percutaneously 
placed 
trocars 
while 
watching from the inside with the scope. If 
there is any bleeding from the abdominal wall 
it must be controlled, as described below in 
“Pitfalls.”  
6. The site of any trocar 10mm or larger must be 
closed at the end of the surgery. The 
Principles of Laparoscopy- Trocar Positioning and Placement 
Richard Davis 
 
OPEN MANUAL OF SURGERY IN RESOURCE-LIMITED SETTINGS 
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exception is an epigastric location, as there is 
no tissue that is likely to herniate in this area. 
A percutaneous closure device such as the 
Carter-Thomason device allows you to do 
this under laparoscopic guidance. Otherwise, 
expand the skin incision a little, dissect down 
to the fascia, and close it with a simple 
interrupted absorbable suture.  
 
 
Pitfalls 
● Poor trocar placement can make an easy surgery 
difficult and a difficult surgery impossible. Try 
to make the “diamond” as wide as possible and 
try to make the trocar sites as far as possible away 
from the surgical site.  
● Some trocar positions will place the surgeon in 
an awkward position: rotating the patient towards 
the surgeon will help with this problem.  
 
With the patient completely flat, the surgeon must take an 
awkward angle to approach the intra-abdominal pathology. 
Note that this condition will not change by merely raising or 
lowering the table.  
 
 
With the patient rotated, the surgeon’s posture is much more 
relaxed. This will lead to less pain and more endurance for the 
surgeon, and a safer surgery overall.  
 
● Epigastric vessel injury. This may be noted 
immediately, or after removal of the trocar. If it 
occurs, do not withdraw the trocar. Replace it if 
necessary and then pass a Foley catheter through 
it. Inflate the balloon, slide the trocar out of the 
abdominal wall along the catheter, and then pull 
upwards on the balloon, applying pressure to the 
bleeding site. This will stop the bleeding and give 
you time to plan definitive hemostasis. You can 
then ligate the vessels on either side of the 
balloon without deflating it. To ligate the vessels, 
use 
either 
intracorporeal 
sutures 
or 
a 
percutaneous trocar site closer, such as a Carter-
Thomason device. 
● Bowel 
or 
vascular 
injury 
during 
trocar 
placement: we favor 
initial open 
trocar 
placement (as explained here) to make this 
complication less likely, even though other 
options exist. Special care must be taken during 
percutaneous placement of trocars- be sure you 
are aware of where the tip of the cannula is at all 
times, and that you are in full control of it at all 
times during placement. Be especially careful in 
the right and left lower quadrants, as the external 
iliac arteries are very nearby. A trocar headed in 
the wrong direction can perforate these vessels 
without entering the peritoneal cavity (i.e. before 
Principles of Laparoscopy- Trocar Positioning and Placement 
Richard Davis 
 
OPEN MANUAL OF SURGERY IN RESOURCE-LIMITED SETTINGS 
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you see the tip,) so be aware of what direction it 
seems to be going as you place it.  
● Trocar site hernia: any trocar that is 10cm or 
larger is prone to forming an incisional hernia 
and must be closed. Be meticulous about closing 
an open supraumbilical trocar well, as described 
in this chapter. For obese patients, we use non-
absorbable sutures at the Hasson cannula site. 
Other 
10mm 
trocars 
that 
were 
placed 
percutaneously must be closed, except those 
anterior and superior to the liver where hernia is 
less likely. A percutaneous closure device is 
available for this purpose; if this is not available, 
widen the skin incision and close the fascia from 
outside with a figure of 8 suture.  
 
Richard Davis MD FACS FCS(ECSA) 
AIC Kijabe Hospital 
Kenya 
 
June 2022 
