Preferences by Procedure

For extirpative renal surgery, we generally favor hand-assisted laparoscopy for procedures that require intact specimen extraction (nephroureterectomy and donor nephrec-tomy) as well as for large radical nephrectomies. Approaches to partial nephrectomy are in flux. For procedures with smaller specimens (adrenalectomy, prostatectomy, and lymph node dissection) and most reconstructive procedures, we prefer either the standard or robotic approaches. Other novel procedures, such as cystectomy and diversion, simultaneous bilateral nephrectomies and nephrectomy for polycystic kidneys, also favor hand-assisted laparoscopy. Regardless, guiding principles of selection for handassisted laparoscopy focus on approach (morcellation vs. intact removal), prior history (abdominoplasty and prior operations), body habitus, and surgeon's competence.

The benefit of hand-assisted laparoscopy is greater in the setting of more complex procedures (such as nephroureterectomy and donor nephrectomy), but is less when there is extensive prior experience or when compared to retroperitoneoscopy.

Patients with prior peritonitis, or abdominal surgery with postoperative complications that would be expected to worsen abdominal scarring, are the only subgroups in which we distinctly avoid a transperitoneal laparoscopic approach. Interestingly, patients with smaller abdomens, or prior abdominoplasty procedures, tend to be more challenging for hand assistance, because there is less room to work once the surgeon's hand is in the abdomen. These patients may benefit more from standard laparoscopy.

Hand-assisted laparoscopy allows shortened operating time, reduced need for conversion, enhanced teaching capability, and ease of control of hemorrhage, all if which benefit the busy clinician.

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