Five ports are used (Fig. 47.1A). The size of these ports depends on the instruments used. Five 10-mm ports will accommodate all needed instruments; if 5-mm instruments are available (e.g., 5-mm liver retractor, ultrasonic shears), correspondingly smaller trocars may be substituted.

Place the midline port for the laparoscope well above the umbilicus. This is crucial for adequate visualization of the hiatus. Use a 45-degree angled laparoscope for hiatal dissection.
Place a right subcostal port along the anterior axillary line for a liver retractor, and a left subcostal port along the anterior axillary line. This left subcostal port will be used by the assistant surgeon for retraction. The final two ports are inserted on either side of the camera port along the midclavicular line 3 inches below the costal margin. These allow the operating surgeon to work using both hands with good triangulation with the camera and operative field. Incline the patient into 35 to 45 degrees of reverse Trendelenburg position. Stand to the right side of the patient with the assistant to the left. Some surgeons prefer to stand in between the patient’s legs with the patient in a modified lithotomy position.