Caveat

■ In select cases with thin overlying parenchyma and known milk of calcium or small stone burden, only 5-mm trocars may be utilized if a 5-mm laparoscope is available.

For the "retroperitoneal approach," the patient is placed in the 90° flank position, with the iliac crest just below the break of the operating table. The patient is supported with an axillary roll, and all pressure points adequately padded. The table is maximally flexed to expand the retroperitoneal working space. The patient is secured to the table with a 3-inch. cloth tape across the greater trochanter of the ipsilateral femur and across the upper chest at the nipple line. Landmarks include the tips of the 11th and 12th ribs, iliac crest, and the angle between the body of the 12th rib and the paraspinous musculature. A 15-mm incision is made along the mid-axillary line between the tips of the 11th and 12th ribs and carried through the lumbodorsal fascia. The plane between Gerota's fascia and the psoas fascia is created bluntly with index finger dissection. The retroperitoneal space is created with balloon dilation of 800 cc. A cuffed balloon port is placed at this entry site. Under laparoscopic visualization, a 12-mm trocar is placed anteriorly. Additional blunt mobilization of the peritoneum medially using the tip of the laparoscope may be necessary in order for this trocar to be placed extraperitoneally. Lastly, a 5-mm trocar is placed at the posterior angle.

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