Don't forget to look up: operating in the upper abdomen

Given the marked improvement in laparoscopic technology, gynecologic surgeons feel comfortable operating in the pelvis for a variety of gynecologic pathologies. When pathology is found outside of the pelvis, however, gynecologic surgeons find operating in the upper abdomen challenging. Operating in the upper abdomen is difficult because of the loss of ergonomics and the impression of operating backward. It is prudent for gynecologic surgeons to master operating in the upper abdomen given the variety of pathologies a gynecologist can encounter outside of the pelvis, both benign, such as endometriosis and adhesions, and malignant, like staging procedures, omentectomy, and debulking. We aimed to describe our operating room modifications that help to simulate operating in the upper abdomen as if one was operating in the pelvic cavity. Strategies to improve efficiency and ergonomics when operating in the upper abdomen include operating room setup, switching monitors to the patient's shoulders bilaterally, changing surgeon location to the right side of the patient, port hopping, and 30-degree camera selection. We have also created an instructional video with the tools to improve surgeon confidence and ergonomics when operating in the upper abdomen.