Despite the skepticism, the technique of retroperitoneal Iaparoscopic radical nephrectomy evolved into a standardized approach.

The indications for laparoscopic retroperitoneal radical nephrectomy are similar to the indications for open radical nephrectomy.

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. Because the working space in the retroperitoneum is small, optimal placement of the secondary working ports is also critical.

Placement of the posterior port 1.5 cm below the 12th rib and 1.5 cm above the psoas will result in safe port placement.

If a hole in the peritoneum occurs early in the procedure, the surgeon may elect to convert the procedure to a transperitoneal approach.

The most efficacious way to prevent extension of CO2 gas through the tissue is to limit CO2 gas insufflation to 12-15 mm Hg pressure.

Bleeding from the renal hilum is avoided by meticulous dissection with circumferential control and isolation of the vessels prior to applying clips or the vascular endo-GIA stapler. Injury to surrounding structures is avoided by maintaining surgical orientation, recognition of retroperitoneal landmarks, and meticulous dissection.

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