Step 3 Balloon Dilation of the Retroperitoneal Space

Further dissection and expansion of the retroperitoneal space is accomplished using blunt camera dissection or by using a retroperitoneal balloon (20,21,26). The working space in the retroperitoneum can be created with blunt camera dissection between Gerota's fascia and the psoas muscle (6). While this technique obviates the need for additional potentially expensive equipment, it is hampered by the need for frequent cleaning of the camera lens and limited by the small space.

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

Gaur et al. originally described balloon dissection with a self-fashioned balloon created from a red rubber catheter and a glove finger secured to the catheter with a suture (1,15). Although economical, self-fashioned balloons are hampered by imprecise placement of the balloon because of flexibility of the catheter and the potential for rupture of the finger balloon with resultant radiolucent foreign material being deposited into the patient. For these reasons, commercial retroperitoneal balloon dilators commonly used for dilation of the retroperitoneum are the Pre-Peritoneal Distention Balloona and the Spacemakerb (Fig. 4). The retroperitoneal balloon is placed into the retroperitoneal space at an oblique cephalad orientation. The balloon should be positioned anterior to the psoas muscle and posterior to Gerota's fascia in the space previously created by the blunt finger dissection (16,17).

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.

With proper balloon placement, the balloon dissection mobilizes the kidney and Gerota's fascia anteromedially, allowing posterior access to the renal helium (Fig. 5). For an average-sized adult, the balloon is then inflated to 800 cc. Confirmation of balloon position within the retroperitoneum and the adequacy of the dissection are assessed by passing a laparoscope down the transparent balloon sheath (Fig. 4). Progressive sequential balloon dilation is performed in either the upper retroperitoneum to facilitate large upper pole tumor dissection or down toward the pelvis to facilitate dissection of the ureter as part of a nephroureterectomy.

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

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