Surgical Technique Access

Transperitoneal access is obtained by placement of the Veress needle. Aspiration and saline injection should be used to assure proper placement in the peritoneum. The

The indications for laparoscopic pyeloplasty include ureteropelvic junction obstruction associated with the following:

1. Flank pain

2. Deteriorating renal function

3. Renal calculus

4. Urinary tract infections

5. Associated hypertension

Relative contraindications for laparoscopic pyeloplasty include:

1. Previous open renal surgery

2. Bleeding diathesis

3. Untreated active pyelonephritis

Although not technically a preoperative measure, stent placement is an important step prior to laparoscopic pyeloplasty. Prepyeloplasty stent placement is much easier than intraoperative placement.

author's preference is to place the needle via the umbilicus where the abdominal wall is thinnest. Because the patient is in a 60° lateral decubitus position, the table is rotated until the patient is in a relatively supine position to facilitate access. Maintenance of low intra-abdominal pressure while insufflating the abdomen with carbon dioxide at a low flow rate confirms good intraperitoneal position. Once satisfied with the needle placement, the gas can be turned to high flow rate. The gas should be insufflated to a pressure of 10 to 15 mmHg. Initial placement of a 10 mm trocar can be performed under direct vision with an optical trocar such as the Optiview™a or Visiport™b devices. The first port can be placed at the umbilicus or in the lateral abdomen.

Retroperitoneal access is achieved by making a 12 mm incision anterior to the tip of the12th rib. The incision is taken through the intercostal muscles and fasciae using the surgical cautery. The surgical plane between the Psoas fascia and Gerota's fascia is developed bluntly. A retroperitoneal dissecting balloon is placed and inflated to create a retroperitoneal workspace. The balloon is deflated and a balloon-tip trocar placed and secured. Carbon dioxide gas is insufflated to expand the retroperitoneal space.

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