15 H.M. Ross et al. (eds.), Minimally Invasive Approaches to Colon and Rectal Disease: Technique and Best Practices, DOI 10.1007/978-1-4939-1581-1_2, © Springer Science+Business Media New York 2015 Key Points • Position patients in a manner to pad all pressure points and maximize gravity’s effects, while avoiding nerve damage and undue traction. • Appropriate abdominal access should be based on patient factors and surgeon preference. • Avoid complications by understanding the limitations and strengths of laparoscopic instruments. Introduction The utilization of laparoscopy in general surgery became pop- ularized over the decade following its introduction by Erich Mühe in 1982 [1]. The observation of decreased postoperative pain and length of stay following laparoscopic cholecystec- tomy, when compared to the conventional Kocher incision for an open cholecystectomy, further supported this approach [1]. The improved outcomes, in conjunction with the advent of new technology, led many surgeons to rapidly apply these approaches to their practice, resulting in laparoscopic cholecystectomy becoming the standard of care in a relatively short time span. Yet, this has not always translated to all oper- ative procedures. Consider that the first laparoscopic colec- tomy was reported by Moises Jacobs and J. C. Verdeja in Miami, Florida, in 1990. Furthermore, Joseph Uddo per- formed the first sigmoid resection utilizing a circular end-to- end anastomotic stapler in 1990 [2]. Yet, here we are almost 25 years later, and still less than 50 % of colon resections are being performed via a laparoscopic approach. In part, the technical difficulties of laparoscopic colectomies, combined with the fear of port-site recurrence and the possibility of poor oncological outcomes for cancer, initially hindered the wide acceptance of this approach [2]. These concerns were subse- quently dissipated by numerous multicenter randomized con- trol trials that concluded that no differences between conventional open colectomy and minimally invasive colec- tomy exist in terms of long-term survival, disease-free survival, and local and distant recurrence [3]. Laparoscopic Instrumentation Since the introduction of laparoscopy in 1902, minimally invasive surgery has been evolving and has expanded dra- matically over the past two decades [4]. This expansion can mainly be attributed to the exponential growth in technology over this period of time. The evolution of laparoscopic instrumentation and, most importantly, the laparoscope have allowed for the growth of this approach. Trocars There are a variety of precision-engineered laparoscopic tro- cars available on the market. Most institutions will have a set of available trocars, each of which will have advantages and disadvantages to their use. The design of trocars has been evolving since their introduction in 30 AD (Fig. 2.1) [5]. Patient Positioning, Instrumentation, and Trocar Placement Mehraneh Dorna Jafari, Michael J. Stamos, and Steven Mills 2 M.D. Jafari, M.D. Department of Surgery, University of California, Irvine School of Medicine, 333 City Blvd. West, Suite 850, Orange, CA 92868, USA e-mail: Jafarim@uci.edu M.J. Stamos, M.D. • S. Mills, M.D. (*) Department of Surgery, Division of Colorectal Surgery, University of California, Irvine School of Medicine, 333 City Blvd. West, Suite 850, Orange, CA 92868, USA e-mail: mstamos@uci.edu; sdmills@uci.edu Electronic supplementary material: Supplementary material is avail- able in the online version of this chapter at 10.1007/978-1-4939-1581-1_2. Videos can also be accessed at http://www.springerimages.com/videos/ 978-1-4939-1580-4.