V401: Supine retro-peritoneoscopy for laparoscopic nephrectomy

Video

Introduction and Objectives
This is the first video presentation of a supine retro-peritoneoscopic nephrectomy. The procedure performed by a solo-surgeon is further simplified with a new version of a camera controller and a novel reusable visible insertion trocar.

Methods
A 62 year old female patient with recurrent urinary tract infections secondary to chronic ureteropelvic junction obstruction was consented for a supine retro-peritoneoscopic nephrectomy. Her past medical history includes thrombo-embolic disease, hepatitis C, open bilateral aorto-femoral bypass and emergency admissions for cardiac and pulmonary embolism.

Under general anaesthetic and in the supine position with her right arm resting on her chest, the primary 12 mm port was inserted using a reusable optical device. The retroperitoneal space was developed at an insufflation pressure of 12 mmHg using a 10 mm endoscope as a blunt dissector which allowed the peritoneum to be reflected off the anterior abdominal wall. Two additional 5mm ports were inserted in an ergonomically comfortable position for a sitting surgeon. A motorised camera controller was set up for a solo-surgeon. Dissection was carried out using an ultrasound based energy device and the pedical artery and vein were controlled with suture ligation with absorbable ties. The relative difficulties observed were simply those related to a chronically infected kidney, rather than the novel approach. The kidney was retrieved through a 20 mm incision at the primary port site after digital morcellation.

Results
The operative time was 180 minutes, the estimated blood loss less than 50 ml and the short term recovery was uneventful with a hospital stay of 48 hours. Retro-peritoneoscopic nephrectomy is a well established procedure that requires a full lateral position. Supine retro-perineoscopic procedures have been reported in vascular surgery for lumbar sympathectomy, in onco-gynaecology and urology for aorto-caval lymph node dissection and percutaneous nephrolithotomy. Having accumulated experience in all of those fields we found it sensible to propose the supine position for this particular patient which gained full support from our anaesthesiologist in view of her co-morbidities.

Conclusions
We successfully demonstrate the feasibility of supine retro-peritoneoscopy for laparoscopic nephrectomy. Although this is an initial experience, we feel this uncomplicated position provides the surgeon with the versatility and freedom of movement in a space comparable to the transperitoneal approach by using the peritoneum as a natural bowel retractor.

Funding: none