(1)
Department of Paediatric Surgery, Royal Hospital for Sick Children, Edinburgh, UK
Abstract
The retroperitoneoscopic approach to renal surgery is a well-established technique that allows direct access to the kidney without transgression of the peritoneal cavity, as occurs in the laparoscopic approach. This has the advantage of having no intestinal loops obscuring the view, minimal risk of ileus, reduced postoperative pain, and avoidance of the risk of intestinal adhesions. The majority of children successfully undergoing this procedure are therefore fit for discharge within 24 h of surgery. It can be undertaken in patients who have had previous transperitoneal surgery and also preserves the integrity of the peritoneal cavity for those in end-stage renal failure who require immediate postoperative peritoneal dialysis.
Keywords
RetroperitoneoscopyPeritoneal cavity36.1 General Information
The retroperitoneoscopic approach to renal surgery is a well-established technique that allows direct access to the kidney without transgression of the peritoneal cavity, as occurs in the laparoscopic approach. This has the advantage of having no intestinal loops obscuring the view, minimal risk of ileus, reduced postoperative pain, and avoidance of the risk of intestinal adhesions. The majority of children successfully undergoing this procedure are therefore fit for discharge within 24 h of surgery. It can be undertaken in patients who have had previous transperitoneal surgery and also preserves the integrity of the peritoneal cavity for those in end-stage renal failure who require immediate postoperative peritoneal dialysis.
36.2 Working Instruments
5-mm ports (balloon blunt tip preferable to maximize working space and avoid gas leakage or accidental displacement)
5-mm 30° telescope
5-mm Endopledgets
5-mm Johan forceps
5-mm Maryland forceps
5-mm right-angled dissector
5-mm hook diathermy
5-mm Metzenbaum scissors
Bipolar or ultrasonic forceps (essential for heminephrectomy)
36.3 Positioning, Port Siting, and Ergonomic Considerations
Retroperitoneoscopy can be performed in either the lateral or prone position, according to the surgeon’s preference. My personal preference is for the lateral approach (as illustrated in this chapter) because it is more versatile and allows access to the lower ureter for complete ureterectomy when required. The lateral approach is also used in retroperitoneoscopic pyeloplasty, and therefore familiarity with this approach will provide a consistent orientation to the kidney for a variety of procedures.
The patient is placed in a full lateral position with flexion of the operating table to increase the distance between the costal margin and the iliac crest (Fig. 36.1). Stabilization of the patient using a vacuum bag and strapping is advised to allow for rolling of the operating table if required. The surgeon and assistant stand at the patient’s back with the video screen on the opposite side.
The primary port is inserted in the midaxillary line below the last rib (11th or 12th depending on rib length) using open cut-down to the retroperitoneal space (Fig. 36.2). A space is then created using blunt dissection just anterior to the quadratus lumborum with a wet pledget to accommodate a homemade balloon; the balloon is inflated with air to expand the working space within the retroperitoneum (Fig. 36.3). Following insertion of the primary port, the space is further expanded with CO2 insufflation to 10 mmHg pressure and blunt dissection using the tip of the telescope. The working ports are then inserted under direct vision posteriorly just lateral to the erector spinae in the costal angle and superior to the iliac crest.
Fig. 36.1
The patient is placed in full lateral position with flexion of the operating table to increase the distance between the costal margin and iliac crest
Fig. 36.2
The primary port is inserted in the mid-axillary line below the last rib (11th or 12th depending on rib length) using an open cut-down procedure to the retroperitoneal space
Fig. 36.3
A space is then created using blunt dissection just anterior to the quadratus lumborum muscle with a wet pledget to accommodate a homemade balloon, which is inflated with air to expand the working space within the retroperitoneum
36.4 Relevant Anatomy (Figs. 36.4, 36.5 and 36.6)
Fig. 36.4
Since the retroperitoneal space needs to be created, it is easy to become disorientated initially within such a confined space. It is best to orientate the telescope and camera to keep the peritoneum anterior and to develop the space by sweeping it off the quadratus lumborum to expose the perinephric fat. The anatomic landmarks are then gradually exposed by extending this working space on the posterior aspect of the kidney
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