THE TECHNIQUE OF TRANSPERITONEAL LAPAROSCOPIC NEPHRECTOMY, ADRENALECTOMY AND NEPHROURETERECTOMY

In the traditional kidney position three trocars are inserted after cr eation of a pneumoperitoneum: 10 mm periumbilical (port I), 10/12 mm s ubcostal (port II) and 12/10 mm above the iliac spine (port III) in th e mamillary line. After laterocolic incision the colon is dissected aw ay from the lateral wall. Thereafter two 5-mm trocars (ports IV, V) ar e inserted into the lateral abdominal wall parallel to ports II and II I. Following clipping and dissection of the ovarian (spermatic) vein, the ureter is isolated and incised. Then the cranial part of the urete r is used as a retractor exposing the renal hilum for dissection of th e renal vessels. The main renal artery and vein are dissected separate ly by use of an endoscopic stapling device (Endo-GIA(R), white magazin e). Finally, the kidney including Gerota's fascia is isolated from the adrenal and the upper peritoneum. Entrapment of the organ is performe d with a specially designed bag (Lapsac(R)). The neck of the bag is br ought out onto the surface of the abdomen (via port II/III) allowing d igital morcellation with index finger inside the bag and removal of th e organ in several pieces. We have applied this technique for 17 proce dures in the upper retroperitoneum: 9 transperitoneal laparoscopic nep hrectomies (TLN) for benign disease (5 hydronephrosis, 3 renovascular disease, 1 chronic pyelonephritis), 3 radical TLN including adrenalect omy for renal cell carcinoma (T2G2), 1 adrenalectomy for a cortical ad renaloma, 1 nephroureterectomy, 1 diagnostic ureterolysis and 2 modifi ed retroperitoneal lymphadenectomies for stage I testicular cancer. Th e mean operation time was 4 h (2-5), the mean postoperative hospital s tay 6 days (4-12). Two complications (postoperative bleeding, bowel in jury during adhesiolysis) required open revision with an uneventful po stoperative course.