Ergonomic Implications of Variations in Sub-Xyphoid Port Placement during Laparoscopic Cholecystectomy

Lawrence N Cetrulo, MD, Pak Leung, MD, Amit Joshi, MD. Einstein Medical Center Philadelphia


Laparoscopic cholecystectomy is one of the most common laparoscopic procedures performed worldwide. Prior research has been devoted to ergonomics and operator comfort during laparoscopic surgery. Our aim was to determine if altering the placement of the subxyphoid port had any effect on ergonomics, comfort, and operative time during laparoscopic cholecystectomy.


Two surgeons at a teaching hospital measured the angle between the port and the skin of the subxyphoid port during twenty-five consecutive laparoscopic cholecystectomies. One surgeon (surgeon A) placed the subxyphoid port in the midline three to five centimeters below the xyphoid process. The other (surgeon B) placed the sub-xyphoid port on the lateral border of the Left rectus abdominus muscle, three to five centimeters inferior to the costal margin. We measured the angle between the port and the skin with a grasper touching the infundibulum of the gallbladder. We also measured the distance to the gallbladder through that port, the operative time, estimated blood loss, BMI, and patient age.


There was a significant discrepancy between the angles using each technique. Each individual surgeons felt more comfortable with his preferred technique. Surgeon A’s angle between the skin and the port ranged between 30-60 degrees while surgeon B’s angle ranged between 15-30 degrees. There was no difference in overall operative time or estimated blood loss.


This is a small prospective case series analyzing whether port placement has an effect on case performance and operator comfort. We found that there was a significant difference in the angle of interest between the two surgeons. Extrapolated from this, we found that posturing of the arm and wrist was different as well. This study also reveals that with no difference in operative time or blood loss, port placement at the left epigastric position does not negatively affect the procedure. We plan to examine whether port angulation affects performance during validated laparascopic simulation tasks such as the peg transfer test and the ring cutting test among surgical trainees.

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