Initial Intraoperative Steps and Patient Positioning

The patient is brought into the operating theater and a general endotracheal anesthesia is administered.

Combined team efforts of the operating surgeon and the attending anesthesi-ology staff lead to the best outcomes. Complete muscle relaxation is essential. In addition, the anesthesiologist should be experienced with the management of anesthetic agents and the monitoring of the patient during complex laparoscopic procedures, which may take several hours to complete. CO2 monitoring and relaying the extent of the hypercarbic state during the procedure to the surgeon are particularly important.

After induction of a general anesthetic, the bladder is drained with a standard indwelling Foley catheter. The stomach is decompressed with either an oral or nasogas-tric tube, and large-bore intravenous access should be obtained. Central venous access or arterial access is useful in complex patients or in those patients with comorbidities requiring special monitoring.

The patient is positioned in a standard complete flank position or at 45° to the operating table with the surgical side being elevated (Fig. 1). The majority of surgeons perform transperitoneal laparoscopic surgery in a full flank position. When the patient is placed in the full flank position, an axillary roll is employed. A pillow and padding are placed to protect the lower extremities and all bony prominences. Compression boots are applied to help preventing deep venous thrombosis of the lower extremities. The upper extremities, head, and neck are carefully padded and protected. The kidney rest elevator can be employed based on the surgeon's preference, most frequently, for smaller lesions and in small-size kidneys. In addition, in particularly large or obese patients, the kidney rest is useful in defining the organ. The abdomen and flank are prepared and draped in standard fashion.

FIGURE 1 ■ Patient positioning for a transperitoneal laparoscopic nephrectomy. (A) Patient in the complete lateral position for a left transperitoneal laparoscopic nephrectomy. (B) The 45°-midline lateral position is employed for large renal lesions and/or large kidneys (e.g., adult polycystic kidney disease).

FIGURE 1 ■ Patient positioning for a transperitoneal laparoscopic nephrectomy. (A) Patient in the complete lateral position for a left transperitoneal laparoscopic nephrectomy. (B) The 45°-midline lateral position is employed for large renal lesions and/or large kidneys (e.g., adult polycystic kidney disease).

The minimal number of ports that are required is three, with additional ports placed when specific retraction is required, e.g., patients with a relatively large liver require the placement of a fourth port to retract the liver during dissection of the right upper renal pole.

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