Step 4 Port Placement

The primary port or camera port is placed at the site of balloon dilator. While a reusable 10 -mm Hasson type port secured with sutures can be used, nonsealing ports of this type will be problematic because of CO2 leakage and CO2 subcutaneous emphysema. As such, it is preferable to use a port with a sealing mechanism such as the 10- or 12-mm blunt-tip port (Fig. 6), which creates an airtight seal between an internal fascial balloon and a external foam ring. Pneumoretroperitoneum is then established with 15 mm Hg pressure of CO2. Typically, only two other secondary ports are required.

FIGURE3 ■ At the tip of the 12th rib, access is gained to the retroperitoneum by bluntly piercing the thoracolumbar fascia. Finger dissection is then performed to establish the posterior plane between Gerota's fascia and the psoas muscle, while also mobilizing the peritoneum anteromedially away from the kidney.

FIGURE3 ■ At the tip of the 12th rib, access is gained to the retroperitoneum by bluntly piercing the thoracolumbar fascia. Finger dissection is then performed to establish the posterior plane between Gerota's fascia and the psoas muscle, while also mobilizing the peritoneum anteromedially away from the kidney.

aAutosuture, Norwalk, CT. bGSI, Palo Alto, CA.

FIGURE4 ■ Balloon dissector used for retroperitoneal dissection and creation of retroperitoneal space.

aAutosuture, Norwalk, CT. bGSI, Palo Alto, CA.

Optimization of the positions for secondary ports is important due to the limited working space and potential for "clashing" of instruments.

Surgical orientation is achieved by orientating the psoas muscle in the horizontal plane, allowing the renal vessels to be orientated vertically.

Dissection is performed one layer at a time, checking for the monophasic pulsations of the renal artery. The monophasic pulsations are in contradistinction to the biphasic pulsations seen from the inferior vena cava.

Optimization of the positions for secondary ports is important due to the limited working space and potential for "clashing" of instruments. The secondary ports are placed under either direct vision or under bimanual control. One port is placed posterior at the inner angle of the 12th rib and the paraspinal muscles. An anterior port is placed approximately 3 cm superior to the iliac crest between the anterior and mid axillary line (Fig. 1). Placement of this port too close to the iliac crest will impede surgical dissection.

The secondary ports can be 5, 10, or 12 mm, disposable or reusable, depending on the clinical scenario.

A larger 12-mm port is placed on the ipsilateral side as the surgeon's dominant hand for clip application and vascular stapler application, and a smaller 5-mm port on the side of the surgeon's nondominant hand for retraction.

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