Posterior Retroperitoneal Technique

This technique is well described by Baba et al. (10,21,55,75). The patient is placed prone with the lumbar area flexed on a jack-knife table. Open Hasson cannulation is employed at the primary port site 2 cm below the tip of the 12th rib. Once the posterior pararenal space is entered, it is further developed with balloon dissection. Three ports are generally used: a 12 mm trocar 3 cm below the 12th rib on the lateral edge of sacrospinalis, a 5 mm trocar on the posterior axillary line in the 11th intercostal space, and a 12 mm trocar placed through the primary port site. If retraction of the kidney is necessary, then a further 5 mm port may be placed in the posterior axillary line above the iliac crest.

Gerota's fascia is incised along its medial aspect along quadratus lumborum and the crus of the diaphragm. The incision is continued transversely over the adrenal gland. The middle adrenal arteries are controlled as they emerge from the crus. The renal pedicle is then identified. On the right side, the inferior vena cava is observed below the level of the adrenal arteries along the crus of the diaphragm. The right adrenal vein runs in a retrocaval direction and therefore is easily dissected from the dorsal side. The vein is clipped and transected, Gerota's fascia is incised transversely, and the inferior aspect of the adrenal is mobilized from the upper pole of the kidney and the inferior adrenal vessels are controlled. The dissection then continues laterally and superiorly, and the superior vessels are controlled.

Siperstein et al. describe a similar approach but state that the position of the adrenal gland and kidney relative to the 12th rib is variable and therefore utilize transcutaneous ultrasound prior to skin preparation to mark out the position of the kidney and the adrenal gland (54). All three ports are placed below the 12th rib posteriorly. The balloon dissection is performed within Gerota's fascia. A 12 mm Optivue® e trocar with a 0° laparoscope is used to create the primary port site inferior to the 12th rib and enter into Gerota's fascia at the upper pole of the kidney. Balloon dissection is performed, and two additional 12 mm ports are inserted on either side of the primary port. Laparoscopic ultrasound is used to confirm the position of the adrenal and the lesion. The harmonic scalpel is used for dissection, and the atraumatic suction grasper to manipulate the gland. The adrenal is mobilized initially superiorly and then laterally and inferiorly. The medial dissection is performed last, and the vein transected. The specimen is then placed in a retrieval bag and removed.

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