Step 2 Retroperitoneal Access

Access to the retroperitoneum is obtained using an open technique. A 1-1.5-cm incision is made in the skin just below the tip of the 12th rib. The muscle fibers below the fascia are bluntly separated with S-retractors until the thoracolumbar fascia is identified, which is then bluntly entered with a fingertip (18,25).

Occasionally, particularly in younger patients, the thoracolumbar fascia is too dense to be pierced with a fingertip. In such an instance, a hemostat is employed to enter the retroperitoneal space.

After entering the retroperitoneal space, blunt finger dissection is used to initially develop and expand the potential space (Fig. 3). The dissection proceeds anterior to the psoas muscle and posterior to Gerota's fascia until sufficient space has been created to allow for further mechanical expansion of the space.

Precise dissection between the psoas muscle and the posterior aspect of Gerota's fascia is critical. In fact, failure to do so will adversely affect retroperitoneal balloon dilation.

Alternatively, access to the retroperitoneum can be obtained using a closed technique with a Veress needle (4,5). The Veress needle is inserted into Petit's inferior lumbar triangle. CO2 insufflation creates a pneumoretroperitoneum, which allows blind insertion of the primary trocar.

The blind placement of the Verses needle can occasionally result in insufflation of retroperitoneal musculature such as the quadratus lumborum or too deep placement of the needle, resulting in accidental pneumoperitoneum. For these reasons, the open Hasson technique for retroperitoneal access is faster and safer and considered the preferred technique.

A retroperitoneal balloon dilator to dissect the retroperitoneal connective tissue is a more efficacious and precise technique to establish working space in the retroperitoneum.

Failure to position the balloon between the psoas and Gerota's fascia will result in dissection between the peritoneum and the anterior surface of Gerota's fascia, leaving the kidney in a posterior orientation adherent to the psoas muscle.

Finger dissection and balloon dilation in the proper surgical plane allows the gas pressure obtained with insufflation of the retroperitoneum to hold the kidney away from the surgeon, maintaining the working space and providing exposure to the renal hilum.

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