Surgical Technique

TABLE 1 ■ Summary of Surgical Procedure

Place patient in lateral decubitus position

Place 10-mm port in posterior axillary line midway between 12th rib and iliac crest Insufflate to 15 mmHg

Bluntly dissect retroperitoneal space with laparoscope

Place 5-mm port in anterior axillary line at level of first port under direct vision

Incise Gerota's fascia with scissors and clear perirenal fat from inferior pole of kidney

Using laparoscopic toothed cup biopsy forceps, obtain one to five biopsies

Obtain hemostasis with argon beam coagulator and Surgical

Desufflate to 5 mmHg and observe for bleeding

Evacuate all CO2 and remove ports

Close skin with absorbable suture

The technique for the placement of the first trocar described here applicable to all patients, but is particularly useful in morbidly obese patients.

medial to the lateral border of the sacrospinalis muscle as indicated in Figure 1. Using the Visiport® introducera, the laparoscope is inserted through the incision and advanced sequentially through the fascial layers under vision. The tip of the scope should be maintained at an approximately 10° to 15° angle toward the umbilicus to achieve the correct trajectory to allow entrance into the retroperitoneum. An angle completely perpendicular to the body wall may result in an inadvertent penetration of the psoas muscle, while too dramatic of an angle may result in dissection of the layers of the abdominal wall musculature with the laparoscope and failure to enter the retroperitoneum. Once the retroperitoneum is entered, the Visiport device is removed, leaving the 10-mm trocar in place in the retroperitoneum. The trocar is then secured to the skin with sutures, and carbon dioxide insufflation is achieved to 15 mmHg. Blunt dissection with the laparoscope during insufflation may be necessary to further develop the retroperitoneal space anterior to the psoas muscle.

The technique for the placement of the first trocar described above is applicable to all patients, but is particularly useful in morbidly obese patients.

In fact, Chen et al. (15) described using this technique in conjunction with intraoperative transabdominal ultrasound to assist in the placement of the first trocar in patients in whom normal anatomic landmarks were obscured due to obesity, making placement of trocars dangerous. Ultrasound was used to identify bony landmarks such as the iliac crest and 11th and 12th ribs as well as the inferior pole of the kidney. Yap et al. (16) described a modification of the use of intraoperative ultrasound such that by obtaining transverse images through the liver, the authors were able to simultaneously view

Figure 1 ■ Port placement for retroperitoneal laparoscopic renal biopsy. A, location of 10 mm port: midpoint between the 12th rib and iliac crest in the PAL; B, location of 5 mm port: AAL at similar level to 10 mm port. Abbreviations: PAL, posterior axillary line; AAL, anterior axillary line.

0 0

Post a comment