Insufflation and Trocar Placement

The peritoneal cavity is insufflated through a Veress needle to establish a pneu-moperitoneum of 15 mmHg. A 5-mm incision is made just lateral to the umbilicus to accommodate the Veress needle. The needle is inserted directly perpendicular to the skin surface, with the distal tip stabilized by the surgeon's hand to prevent past-pointing during placement. The position of the needle tip is confirmed by the saline drop test. If the saline passes through the needle without resistance, the insufflation bEthicon Endo-Surgery, Cincinnati, OH. cU.S. Surgical Corp., Norwalk, CT.

TABLE 1 ■ Laparoscopic Instrumentation and Intraoperative Medications

Instruments

■ Veress needle

■ Two 5-mm laparoscopic trocars

Endoscopic shears

■ One 12-mm laparoscopic trocar

10-mm right-angled dissector

■ One 15-mm laparoscopic trocar

10-mm Titanium clip applier

■ 30° laparoscope (5 or 10 mm)

15-mm Endocatch deviceb

■ Harmonic scalpela

Endo-GIAb vascular stapler with two

■ Antifog lens solution

reload cartridges

■ Debakey forceps/Maryland dissector

Carter-Thomasonc fascial closure device

■ Suction-irrigation device

Sterile ice slush

Standard open nephrectomy tray,

retractors, and instrumentation

Optional equipment

■ 12-mm Endo Paddle Retractb

■ Hemo-lok clipsd

■ Electrocautery hook

Hand-access device

■ Bipolar electrocautery forceps

Medications

■ Mannitol (12.5 g intravenous X 2 doses)

■ Papaverine (30 mg/mL solution, 20 mL total)

■ Heparin (5000 U intravenous)

■ Protamine (30 mg intravenous)

■ Cephazolin (1 g intravenous)

aEthicon Endo-Surgery, Cincinnati, OH.

bU.S. Surgical Corp., Norwalk, CT.

cInlet Medical, Eden Praire, MN.

dWeck, Research Triangle Park, NC.

In patients who have had extensive intra-abdominal surgery, a direct cut down to the peritoneal space (Hasson technique) is recommended.

Alternative to a 30° laparoscope, an optical trocar may be used, which allows the surgeon to visualize the layers of the abdominal wall and confirm safe placement of the initial trocar.

tubing is connected and the flow of carbon dioxide is initiated. An initial intraabdominal pressure of less than 10 mmHg confirms achieved access to the peritoneal cavity.

In patients who have had extensive intra-abdominal surgery, a direct cut down to the peritoneal space (Hasson technique) is recommended.

Three transperitoneal trocars are used to perform left laparoscopic live donor nephrectomies (Fig. 4). The initial 5-mm trocar is placed at the site of the Veress needle. The abdominal contents are inspected using a 30° laparoscope to ensure that no injury occurred during placement of the Veress needle or the first trocar.

Alternative to a 30° laparoscope, an optical trocar may be used, which allows the surgeon to visualize the layers of the abdominal wall and confirm safe placement of the initial trocar.

Next, another 5-mm trocar is placed under direct vision, approximately three fingerbreadths below the xiphoid process just lateral to the abdominal midline. This will be used for operating the laparoscope during the procedure. The surgeon may choose a 10-mm trocar if he/she wishes to use a 10 mm, 30° laparoscope to perform the operation. A 12-mm trocar is placed on the mid-clavicular line, halfway between the umbilicus and the anterior superior iliac spine. The position of this trocar is important to avoid injury to the epigastric vessels. A 12-mm trocar must be used here to accommodate a standard endovascular stapling device, which is used to control the renal hilum. Some surgeons describe making the Pfannenstiel extraction incision, at the beginning of the procedure, and inserting a 12-mm trocar, through which an instrument can be placed to assist with retraction of the colon, pancreas, or mesentery (12,14). This trocar site is then extended during extraction of the renal allograft at the conclusion of the procurement. In most cases, if these intra-abdominal structures are fully mobilized during the initial steps of the procedure, further retraction is not necessary.

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