6.3 Surgical approach: Access

The first puncture is performed in the umbilical scar where a 10 mm trocar is placed to introduce the optic (Figure 4–black circle) and the patient is kept in dorsal decubitus. After exploration of the cavity, the patient is placed in Trendelenburg (Lloyd Davies) position and the surgeon inserts two 5 mm trocars (Figure 4–blue circles) and a fourth trocar for the first assistant. The second assistant stands between the patient's legs to manipulate the uterus after placement of the uterine manipulator (Figure 4–second assistant). With the surgical team members in these positions it is possible to perform ureterolysis, uretero-ureteral anastomosis and ureterovesical reimplantations on the right (Figure 4-A) or on the left (Figure 4-B).

#### Figure 4. Trocar sites. Position of surgeons for access to the right distal ureter (A) and for access to the left distal ureter (B).
