Radially expanding laparoscopic access for renal/adrenal surgery

Objectives. To use a radially expanding system (Step) and a modified port l ocation for intra-abdominal access to decrease the access-related complicat ions in renal and adrenal surgery. Access-related complications during lapa roscopic renal surgery are frustrating and are more common in patients with previous abdominal surgery and associated adhesions. Methods. Laparoscopic upper tract procedures were performed in 62 patients using radially expanding trocars, and the results were reviewed with regard to access, port placement, and associated complications. For initial acces s, a Veress needle was placed subcostally in the midclavicular line. An exp andable mesh sleeve trocar was used for trocar insertion after a pneumoperi toneum was established. A blunt-tipped fascial dilator was used to dilate t o 10 or 12 mm. Additional ports were placed in an L shape (nephrectomy) or a subcostal configuration (adrenalectomy) under direct vision using the Ste p ports. Results. Of 62 patients, 24 had had prior abdominal surgery. Open insertion of the mesh sleeve was necessary in 20%, of whom 60% had had prior abdomin al surgery. In 9% of cases, the liver was punctured with the initial pass o f the Veress needle. Only minimal bleeding from the injury site was noticed . The liver punctures did not require cauterization and did not result in c onversion to an open procedure. At a mean follow-up of 12 months, no access -related complications or port-site hernias were noted. Conclusions. Placement of the initial access subcostally at the level of th e midclavicular line helps to prevent visceral injury, especially in patien ts with previous abdominal surgery. The use of the radially expanding acces s system with the modification of port location allows safe and rapid lapar oscopic access for upper urinary tract surgery. This trocar system is an ex cellent alternative to the standard laparoscopic trocars. (C) 2001, Elsevie r Science Inc.