ABSTRACT
Since its introduction in 1990 by Clayman et al. 1 laparoscopic nephrectomy is being increasingly performed at numerous institutions worldwide. When removal of kidney is indicated for a benign pathological condition laparoscopic nephrectomy has largely superseded the traditional open approach. One of the major advantages of the retroperitoneoscopic approach is the quick access to the vessels, without any interference of bowel, liver, spleen, or adhesions. The need to mobilize the ascending or descending colon is obviated. The most frequent arguments against the retroperitoneoscopic approach are the difficulty in establishing the topography, the smaller working space, and the steeper learning curve compared with the transperitoneal approach. The patient is positioned in the standard full-flank position with the kidney rest elevated and the operative table flexed. This maximizes the space between the iliac crest and the 12th rib. https://s3-euw1-ap-pe-df-pch-content-public-p.s3.eu-west-1.amazonaws.com/9780429095351/5661ef80-120f-4819-9057-3fc505946132/content/fig1_1.jpg" xmlns:xlink="https://www.w3.org/1999/xlink"/> At the tip of the 12th rib a skin incision is made and the initial retroperitoneal space is created bluntly by index finger dissection. A straight Kocher's clamp is ideal for gentle and controlled perforation of the deep fascia and the quadratus lumborum ligament instead of using a scissor or scalpel, because the index finger can guide the instrument safely. Afterwards the dissection balloon is inserted. This self-made dissection balloon is an efficient tool for all kinds of extraperitoneal sugery. At the tip of the trocar sheet two separated surgical glove fingers, that are placed one inside the other, are fixed with twine. Finally 800–1000 ml (cold) sterile saline solution is injected. The anterior hump (dotted line) is visible as a sign of correct extraperitoneal space dissection. If no hump is visible, the balloon is not placed correctly (probably intraperitoneal). After removal of the balloon dissector, a pneumoperitoneum is established with an intra-abdominal pressure of 12–15 mmHg. https://s3-euw1-ap-pe-df-pch-content-public-p.s3.eu-west-1.amazonaws.com/9780429095351/5661ef80-120f-4819-9057-3fc505946132/content/fig1_2.jpg" xmlns:xlink="https://www.w3.org/1999/xlink"/> Initial extraperitoneal endoscopic (syn: retroperitoneoscopic) appearance after blunt retroperitoneal balloon dissection. The psoas muscle is one of the most important landmarks in retroperitoneal orientation and usually appears horizontally on the video screen. In case of disorientation because of bleeding or excessive perirenal fatty tissue, the surgeon should come back to the psoas muscle to get an anatomic overview. https://s3-euw1-ap-pe-df-pch-content-public-p.s3.eu-west-1.amazonaws.com/9780429095351/5661ef80-120f-4819-9057-3fc505946132/content/fig1_3.jpg" xmlns:xlink="https://www.w3.org/1999/xlink"/> By turning the 30° optical system of the laparoscope upwards to the abdominal wall, the peritoneal reflexion is easily identified. The peritoneum is softly dissected medio-ventrally using the tip of the camera. In order to control the position of the camera tip and to prevent injury of the peritoneum it is important that the dissection is controlled by the surgeon's other hand on the outer abdominal wall. https://s3-euw1-ap-pe-df-pch-content-public-p.s3.eu-west-1.amazonaws.com/9780429095351/5661ef80-120f-4819-9057-3fc505946132/content/fig1_4.jpg" xmlns:xlink="https://www.w3.org/1999/xlink"/> After the peritoneal border is dissected medially, via diaphanoscopy the second trocar is localized just a few centimeters above and medial to the superior anterior iliac spine. Usually a 10 or 12 mm trocar is inserted at this position. https://s3-euw1-ap-pe-df-pch-content-public-p.s3.eu-west-1.amazonaws.com/9780429095351/5661ef80-120f-4819-9057-3fc505946132/content/fig1_5.jpg" xmlns:xlink="https://www.w3.org/1999/xlink"/> The third 5 mm trocar is inserted just in the middle between the two trocars that have already been inserted. Sometime it is advisable to insert the third trocar a little bit more laterall in this connection line because the working angle is more comfortable. A fourth trocar is optional; however, it is advisable in complex surgery. https://s3-euw1-ap-pe-df-pch-content-public-p.s3.eu-west-1.amazonaws.com/9780429095351/5661ef80-120f-4819-9057-3fc505946132/content/fig1_6.jpg" xmlns:xlink="https://www.w3.org/1999/xlink"/> The surgeon, the assistant, and the theatre nurse are positioned dorsally to the patient. The video tower is placed in front of the patient. The assistant is holding the camera and serving the optional fourth trocar (blue rubber in the right lateral picture). Finally, four trocars are placed in a classic rhombus position. https://s3-euw1-ap-pe-df-pch-content-public-p.s3.eu-west-1.amazonaws.com/9780429095351/5661ef80-120f-4819-9057-3fc505946132/content/fig1_7.jpg" xmlns:xlink="https://www.w3.org/1999/xlink"/>
