Retroperitoneal Access

An open technique is employed. A horizontal 2-cm transverse skin incision is made just below the tip of the last (12th) rib. S retractors are employed to separate the flank muscle fibers. The retroperitoneum is accessed by piercing the dorsolumbar fascia with the index finger or a hemostat. Using the index finger, gentle dissection is performed to

No. 15 or 11 scalpel blade (1) S retractors (2) Balloon dilator device

Laparoscopic trocars: Bluntip balloon port 10 mm (1), 12 mm (1-2 ), 5 mm (2), 2 mm (1) (if required) Laparoscope (10 mm, 30°: 5 mm, 30°) Electrosurgical scissors (5 mm) Electrosurgical hook (5 mm)

Laparoscopic right-angle dissecting forceps (5 mm, 10 mm) Laparoscopic grasping forceps (short straight clamp, small bowel clamp, locking grasping clamp, Maryland clamp) Laparoscopic irrigation/suction probe (5 mm) Laparoscopic clip applicators, for metal and plastic clips (5 mm, 10 mm)

Laparoscopic stapler with vascular cartridge Endocatch bag (10 mm shaft, 15 mm shaft) Bipolar forceps (5 mm)-optional Harmonic scalpel-optional Laparoscopic staplers

Attention to the patient's cardiorespiratory status, bony or spinal abnormalities, coagulation studies, and history of prior surgery is imperative.

FIGURE 1 ■ Port placement and patient positioning during right retroperitoneal laparoscopy.

FIGURE 1 ■ Port placement and patient positioning during right retroperitoneal laparoscopy.

create a space for subsequent placement of the balloon dilator. It is important that the finger dissection be performed between the psoas muscle (and fascia) posteriorly and Gerota's fascia anteriorly. Proper entry into the retroperitoneum is important. The anterior surface of the psoas muscle is our primary anatomic landmark, during both the initial finger palpation and the subsequent intraoperative laparoscopic viewing. If the finger dissection is performed immediately along the anterior surface of the psoas muscle and fascia, it automatically stays posterior to, and outside of, Gerota's fascia.

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