TRANSPERITONEAL LAPAROSCOPIC NEPHRECTOMY - TRAINING, TECHNIQUE, AND RESULTS

Transperitoneal laparoscopic nephrectomy was integrated into our daily routine within a 6-month period by means of a step-by-step training p rogram progressing from a pelvic trainer to animal studies (N = 15) to laptent-assisted surgery. The pneumoperitoneum is created with the pa tient in the flank position, enabling insertion of three trocars: 10-m m periumbilical (Port I), 5/12-mm subcostal (Port II), and 12/5-mm abo ve the iliac spine (Port III). After medial mobilization of the colon, two additional 5-mm trocars (Ports IV and V) are inserted into the la teral abdominal wall parallel to Ports II and III. Once clipping and d issection of the ovarian (spermatic) vein has been carried out, the ur eter is identified and dissected. Retraction of the proximal ureter ex poses the renal hilum, allowing dissection of the renal vessels. The r enal vein is dissected using an endoscopic stapling device, while acce ssory veins and the renal artery are clipped. Organ retrieval is achie ved with a specially designed tissue pouch (Lapsac) and digital fragme ntation of the kidney within in the organ bag. Using this technique, w e have treated 24 patients with benign (N = 20) and malignant (N = 4, including adrenalectomy) renal disease. The mean operative time was 23 9 (115-300) minutes. In four cases, open surgery was required because of bleeding (N = 2), severe perinephric inflammation (N = 1), or bowel injury (N = 1). For relief of wound pain, an average of 1.15 vials of analgesic (morphine derivatives)/patient were administered for 2.4 da ys. The postoperative hospital stay averaged 6.2 (4-10) days.