Step 11 Inspection of the Renal Bed Closure

The anterior rectus fascia is immediately closed with a running 0-polyglactin suture. Pneumoperitoneum is reestablished, and the renal bed is inspected at a low insufflation pressure. The renal artery and vein stumps are closely inspected. In addition, the splenic capsule, colon, and its associated mesentery, pancreas, and adrenal gland are examined for injury and to ensure meticulous hemostasis. Small sites of bleeding can be controlled

An extra 5-mm trocar is placed laterally in the mid-axillary line to accommodate an instrument for retraction of the right lobe of the liver. Alternatively, this fourth trocar may be placed along the costal margin.

The duodenum must always be identified before dissection of the vena cava is initiated.

with electrocautery of hemoclips. A hemostatic agent, such as Surgicel, can be placed in the renal bed, if necessary.

The fascial defect from the 12-mm trocar site is closed under direct laparoscopic visualization with 2-0 polyglactin suture using the Carter-ThomasonĀ®d fascial closure device. All 5-mm trocars are removed without the need for fascial closure. The remaining pneu-moperitoneum is released before the last trocar is removed. The fascial defect created from bladed trocars 10 mm in size or greater must be closed to minimize the risk of port-site her-niation. Some surgeons believe that conical blunt trocar insertion may eliminate the need for fascial closure in transperitoneal laparoscopic renal surgery (24). This concept applies to blunt trocar placement through muscular parts of the abdominal wall, relying on muscle splitting and eventual muscle retraction when the trocar is removed. Fascial nonclosure after transperitoneal 12-mm blunt trocar insertion may be safe and efficacious and eliminate the last step in transperitoneal laparoscopic renal surgery. However, port-site hernia at the site of insertion of 10-mm nonbladed trocars has been described (25). It is generally recommended that all trocar sites larger than 5 mm, whether bladed or nonbladed, be closed in patients undergoing transperitoneal laparoscopic live donor nephrectomies.

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