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Indications

  1. Top of page
  2. Indications
  3. Method
  4. Advantages and disadvantages
  5. References

Retroperitoneoscopic access for laparoscopic nephrectomy provides a more direct approach to the kidney. It helps to avoid mobilization of visceral structures and allows the rapid dissection of the kidney [1]. However, the confined space within the retroperitoneum is a major limitation of this approach and greatly restricts instrument mobility and attempts to entrap organs [2]. During hilar dissection adequate retraction of the partially mobilized kidney is essential for proper visualization of the renal vessels. The collapsed sac, a result of the deflation of a grossly hydronephrotic kidney, is unwieldy within the limited space and adequate retraction that places the hilar structures under tension is difficult. The technique of extracorporeal renal retraction described here addresses to this problem.

Method

  1. Top of page
  2. Indications
  3. Method
  4. Advantages and disadvantages
  5. References

Once preliminary dissection of the posterior surface, lateral border and renal poles is completed, the renal sac is deflated by percutaneous aspiration using a Veress needle, under laparoscopic guidance. Dissection of the hilar structures is then begun posteriorly. The lower pole of the kidney is held in an endo-Babcock’s forceps passed into the retroperitoneal space through an anterior 10 mm port (Fig. 1). The instrument holding the collapsed renal sac along with the cannula is brought out. The part of the renal sac extracted extracorporeally is then held in a sponge-holder for extracorporeal retraction (Fig. 2). By this manoeuvre, the kidney can be retracted anteromedially and the renal hilar structure placed under tension, facilitating dissection of the renal vessels posteriorly (Fig. 3). The sac also helps plug the port site and prevents leakage of retroperitoneal gas.

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Figure 1. The various port sites, showing posterior (arrow) and anterior (double arrow) ports.

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Figure 2. The collapsed renal sac (arrowhead) retracted extracorporeally through the anterior port, with the hilar structures (arrow) stretched extracorporeally.

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Figure 3. a, A laparoscopic view showing the hilar structures under tension. b, The partially extracted collapsed kidney.

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Advantages and disadvantages

  1. Top of page
  2. Indications
  3. Method
  4. Advantages and disadvantages
  5. References

Laparoscopic nephrectomy for large hydronephrotic nonfunctioning kidneys is usually performed transperitoneally, because of the limited retroperitoneal space [3]. This requires extensive mobilization of the visceral structures and consequently may be associated with injury to the intraperitoneal organs. The present technique facilitates retroperitoneoscopic nephrectomy by extracting the redundant renal sac away from the field of dissection and placing the hilar structures under tension. Adequate counter-traction helps improve vision, facilitates hilar dissection, improves the speed of dissection and also helps in the final retrieval of the organ. We have undertaken this procedure in 16 patients with giant hydronephrotic kidneys and found it extremely helpful. A similar procedure may be of benefit in patients undergoing partial nephrectomy for duplex systems, bladder diverticulectomy and even for excision of large renal cysts. A limitation of this procedure is that it cannot be used during surgery on solid organs.

References

  1. Top of page
  2. Indications
  3. Method
  4. Advantages and disadvantages
  5. References