Time Management

Two concerns about retroperitoneal laparoscopy have been difficulty in identifying various anatomic landmarks and a lack of a clear understanding of the sequential operative steps toward this end. Sung and Gill (10) employed a uniform database to record predetermined intraoperative parameters prospectively in 16 patients who underwent 18 retroperitoneoscopic radical nephrectomies. They documented the anatomic landmarks seen immediately after balloon dilation prior to any laparo-scopic manipulations (vide supra). Additionally, they recorded the time taken to complete each specific part of the operation to create a realistic framework of its sequential operative steps. They found that port placement time ranged from 6 to 20 minutes, decreasing with experience. Hilar dissection time was impacted by specimen weight and whether four or more retroperitoneal landmarks could be identified immediately after balloon dilation. When specimen weight was greater than the median value of 436 g, the hilar dissection time was 78 minutes, compared with 47 minutes for those specimens weighing less than 436 g. When the initial balloon dilation resulted in visibility of four or more anatomic landmarks, hilar dissection time was significantly shorter (47 as against 82 minutes). Adrenal mobilization added a mean of 49 minutes (range, 20-68) to the radical nephrectomy procedure. In the analysis of surgical time for the entire operation, specimen weight was again significant. In patients with a specimen weight greater than 436 g, the surgical time averaged 230 minutes compared with 176 minutes for specimens weighing less than 436 g. Specimen entrapment of large tumors could be a technically cumbersome operative step, given the confines of the retroperitoneal working space. Entrapment could be completed retroperitoneo-scopically in 16 of 18 cases (89%). In two cases, for specimens weighing 867 g and 774 g, an intentional peritoneotomy had to be created at the end of the procedure solely for purposes of specimen entrapment (10).

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