Retro-extraperitoneal laparoscopic approach to excise retroperitoneal organs: Kidney and adrenal gland

Abstract

Retroperitoneal organs may be better managed by laparoscopy through a retro-extraperitoneal approach. Five posterior laparoscopic nephrec-tomies and two posterior laparoscopic adrenalectomies were performed on this premise. The procedure begins under fluoroscopic guidance, by highlighting the homolateral renal collecting system and inserting the Veress needle just between the ureter and the lower pole of the kidney, with the patient in the prone position. The retropneumoperitoneum is created by insufflating directly with one litre of CO2 in the perirenal fatty space, without any additional device. The four trocars are inserted under fluoroscopic guidance, in the space between the 12th rib, the sacrospinalis muscle, the iliac crest and the posterior axillary line. With scissors and dissectors the organs are freed by clipping the major arterial vessel and by firing an EndoGIATM (AutoSuture Company, USA) for large veins. Small organs are removed through a port enlarged to 2cm. Larger solid organs are removed through a 5cm vertical dorsal lumbotomy. The average operative time is 4 h 30min and mean operative blood loss 100 ml. No major complications due to the procedure have been observed. All patients were discharged on the fourth day after surgery. The posterior extra-peritoneal laparoscopic approach to the kidneys and adrenals is a feasible method, with all the advantages of minimally invasive surgery and without the possible complications of transperitoneal laparoscopy.