1 Shoulder Arthroscopy Portals Successful shoulder arthroscopy begins with safe and accurate portal placement. By using proper technique, damage to soft tissues, especially neurovascular structures and articular cartilage, can be avoided. In addition, properly located portals will provide the necessary field of view and instrument access to desired locations within the glenohumeral and acromioclavicular joints and subacromial space. Once established, the portals must be protected to prevent fluid extravasation that distorts anatomical relationships. Replacing cannulas becomes increasingly more difficult and dangerous as swelling escalates. General Technique 1. Bony landmarks are identified by palpation and mapped along with portal locations using a surgical marker. (All anatomical references and diagrams are provided here with the patient in the lateral decubitus position. Minor adjustments may be necessary if the patient is supported in the beach chair orientation.) 2. The posterior portal is typically established first. It is recommended that all subsequent portals be made from outside-in under direct vision after first establishing the desired tract with a spinal needle. While it is possible to create portals using a Wissinger rod technique, the intraarticular path of the rod may place some constraint on its path out through the soft tissues and result in less than ideal portal orientation as the cannula is delivered in a retrograde fashion from outside-in over the rod. 3. A small skin incision is made at the entry site and a trocar and cannula are directed along the path identical to the spinal needle and into the selected joint or subacromial space. 4. Primary portals are those used on a routine or frequent basis to conduct a thorough diagnostic evaluation and perform common therapeutic procedures. Accessory portals are typically employed only for selected procedures to provide instrument access to specific locations. Primary Portals Posterior (P) (Figs. 1–1A,B and 1–2A) Uses: primary viewing portal; instrument approach to posterior glenoid, labrum, capsule Field of view (Fig. 1–2B): anterior glenoid, labrum, biceps and subscapularis tendons, articular surface supraspinatus tendon, anterior capsule, glenohumeral ligaments, and posterior humeral head Entry site: 1.5 cm inferior and 1 cm medial to the posterolateral corner of the acromion Path/orientation: cannula directed toward the coracoid tip Structures transgressed: posterior deltoid, infraspinatus Risk: minimal—axillary and suprascapular nerves Anterior (A) (Fig. 1–3A) Uses: view posterior structures; instrument approach to anterosuperior glenoid, labrum, capsule, supraspinatus, and subscapularis Field of view (Fig. 1–3B): posterior labrum and glenoid articular surface, infraspinatus tendon, posterior capsule, glenohumeral ligaments, and anterior humeral head Entry site: midway along a line between the anterolateral acromial corner and the tip of the coracoid Path/orientation: cannula directed toward the center of the glenohumeral joint Structures transgressed: anterior deltoid, rotator interval Risk: minimal Anterosuperior (AS) (also called superolateral by some authors) Uses: view anterior capsule, labrum, glenoid, glenoid neck, and posterior structures; instrument approach to superior glenoid and labrum (i.e., superior labrum anterior and posterior [SLAP] repair), supraspinatus Field of view: same as anterior portal, optimal for anterior glenoid neck view Entry site: 1 cm lateral to anterolateral corner of the acromion Path/orientation: direct spinal needle/cannula immediately anterior to biceps tendon and inferior toward the anterior glenoid rim Structures transgressed: anterior deltoid, rotator interval Risk: minimal—supraspinatus tendon, biceps
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