The Technique of Transperitoneal Laparoscopic Nephrectomy, Adrenalectomy and Nephroureterectomy

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Abstract
In the traditional kidney position three trocars are inserted after creation of a pneumoperitoneum: 10 mm periumbilical (port I), 10/12 mm subcostal (port II) and 12/10 mm above the iliac spine (port III) in the mamillary line. After laterocolic incision the colon is dissected away from the lateral wall. Thereafter two 5-mm trocars (ports IV, V) are inserted into the lateral abdominal wall parallel to ports II and III. Following clipping and dissection of the ovarian(spermatic) vein, the ureter is isolated and incised. Then the cranial part of the ureter is used as a retractor exposing the renal hilum for dissection of the renal vessels. The main renal artery and vein are dissected separately by use of an endoscopic stapling device (Endo-GIA®, white magazine). Finally, the kidney including Gerota's fascia is isolated from the adrenal and the upper peritoneum. Entrapment of the organ is performed with a specially designed bag (Lapsac®). The neck of the bag is brought out onto the surface of the abdomen (via port II/III) allowing digital morcellation with index finger inside the bag and removal of the organ in several pieces. We have applied this technique for 17 procedures in the upper retroperitoneum: 9 transperitoneal laparoscopic nephrectomies (TLN) for benign disease (5 hydronephrosis, 3 renovascular disease, 1 chronic pyelonephritis), 3 radical TLN including adrenalectomy for renal cell carcinoma (T(2)G(2)), 1 adrenalectomy for a cortical adrenaloma, 1 nephroureterectomy, 1 diagnostic ureterolysis and 2 modified retroperitoneal lymphadenectomies for stage I testicular cancer. The mean operation time was 4 h (2-5), the mean postoperative hospital stay 6 days (4-12). Two complications(postoperative bleeding, bowel injury during adhesiolysis) required open revision with an uneventful postoperative course.

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