V8-04: Percutaneous Externally Assembled Laparoscopic (PEAL) Nephrectomy

V8-04: Percutaneous Externally Assembled Laparoscopic (PEAL) Nephrectomy



Laparoendoscopic single-site nephrectomy (LESS) provides excellent cosmetic outcomes, but is technically challenging due to loss of triangulation and increased instrument collision. A novel Percutaneous Externally Assembled Laparoscopic (PEAL) surgical paradigm was developed to simplify minimally invasive surgery while providing a nearly scarless outcome. In this video, we will demonstrate how PEAL instruments restore triangulation and simplify LESS nephrectomy.


The PEAL instrument is composed of a reusable handpiece and a disposable 2.96 mm shaft and interchangeable 5 mm instrument tips. These instruments are inserted without a trocar which minimizes their cosmetic impact. This video will demonstrate a PEAL nephrectomy in a 69 year-old female with a nonfunctional duplicated right kidney. Initially a multi-access port was inserted into the umbilicus and used to take down adhesions from a previous surgery. Adhesions to the liver were left intact to provide liver retraction. A 2.96 mm instrument shaft was introduced in the right mid-clavicular line at the level of the umbilicus using a special introducer tip. It was brought out through the multi access port and switched to a 5 mm grasper tip. This PEAL instrument was able to reestablish triangulation and upon its removal required no wound closure.


The use of the PEAL surgical paradigm restored triangulation and allowed a nearly scarless nephrectomy despite this patient’s giant duplicated kidney. This 2.96 mm instrument shaft was inserted through a small puncture and maintains the nearly scarless cosmesis of LESS surgery. The 5 mm grasping tip, which can be changed through any conventional laparoscopic port, was robust and allowed for the effective manipulation of this giant kidney. The estimated blood loss was 100 cc and the operative time was 310 min. The patient tolerated the procedure well without any perioperative complications. The patient was discharged home on POD 1 and required no narcotic pain medications.


The addition of the PEAL instrument facilitated the completion of LESS nephrectomy in a patient with complicated anatomy. By using these externally assembled instruments, PEAL provides a functional, robust 5 mm tip and reestablishes instrument triangulation, thereby greatly simplifying LESS surgery. In addition the

Funding: None