In case of very large uteri it is safe to create the pneumoperitoneum inserting the Verres needle through the Palmer Point: along the left emiclavear line, 2 cm below the costal margin. This will avoid a direct injury of the uterus which lays just above the umbilicus.
After insufflation of the abdomen and creation of the pneumoperitoneum, an Endotip cannula is gently inserted through the umbilicus.
The advantage of the Endotip cannula is that you do not need to apply pressure in the umbilical region. Moreover, it is a visual blunt trocar that could not cause a damage to the uterus with consequent bleeding. Once the umbilical trocar is inserted the optic shows the uterus so close and so big that is impossible to see and maneuver the instruments.
A second 10 mm trocar is then inserted under vision more or less 10nì cm above the umbilicus in the Lee-Huang point.
The optic inserted so high shows a better panoramic vision of the uterus. The two lateral trocars are inserted higher, according with the size of the uterus along two parallel lines passing 1.5-2 cm medially to the iliac spines. Usually this trocar position is enough to work properly both for hysterectomy and myomectomy.
Sometimes if the uterus is too big and any lateralization movement is very difficult, a midline suprapubic trocar 8-10 cm below the umbilicus is useful to apply a retractor. In this latest situation, at the left side the operator will use the umbilical and the left lateral trocar for bipolar and scissors, while the assistant will use the optic and the midline trocar for the retractor.
At the right side the operator will use the retractor in the midline trocar with is left hand and the umbilical trocar for the scissors, the assistant will use the right lateral trocar for bipolar or forceps.