Morbid Obesity

Laparoscopic procedures in morbidly obese patients are technically challenging. Difficulties may include inadequate length of instruments, decreased range of motion of trocars and instruments, need for higher pneumoperitoneum pressures to elevate the abdominal wall, and poor anatomic orientation owing to excessive amounts of adipose tissue. Traditionally, these difficulties translated into a higher rate of associated complications; in a multi-institutional review of laparoscopy in 125 morbidly obese individuals, one or more intraoperative or postoperative complications occurred in 30% (Mendoza et al, 1996). In comparison to open surgery, however, it has been found that the laparoscopic approach to renal and adrenal procedures actually has a lower complication rate than the open approach. In a comparison of major laparoscopic renal and adrenal procedures (N = 21) versus similar open procedures (N = 21) in obese patients (body mass index [BMI] ≥ 30), although operative time was longer in the former group (210 minutes vs. 185 minutes; P = .16), the laparoscopic group had significantly superior outcomes regarding blood loss (100 mL vs. 350 mL; P = .001), resumption of oral intake and ambulation (<1 day vs. 5 days; P = .001), narcotic analgesic requirements (12 mg vs. 279 mg; P = .001), median hospital stay (<1 day vs. 5 days; P = .001), and convalescence (3 weeks vs. 9 weeks; P = .001). The overall complication rate in the laparoscopic group was 29% (19% major, 10% minor) versus 67% in the open group (33% major, 33% minor) (P = .16) (Fazeli-Matin et al, 1999). These findings have been further confirmed at several other centers (Fugita et al, 2004; Kapoor et al, 2004) even for complicated procedures such as partial nephrectomy (Colombo et al, 2007; Romero et al, 2008) and nephroureterectomy (Brown et al, 2008).

With regard to laparoscopic and robotic radical prostatectomy in obese men, it has been found that although the operation can be performed without compromising pathologic outcomes, obese patients have a greater risk of perioperative complications (26% vs. 5%) (Ahlering et al, 2005). Obese patients had a higher rate of deep vein thrombosis and pulmonary embolism (10%). Additionally, obese patients were less likely to achieve continence and more likely to have higher urinary bother scores at 3-, 6-, and 9-month follow-up.

Extensive Prior Abdominal or Pelvic Surgery

When extensive intra-abdominal or pelvic adhesions are suspected, careful consideration must be given to the possible site of Veress needle insertion as well as to obtaining open access with a Hasson-style cannula. The surgeon needs to understand the five potential points of Veress needle access to the abdomen (umbilicus and at the Palmer point—midclavicular line subcostal on either side, and just off the iliac crest—two fingerbreadths up and two fingerbreadths medial) as well as have knowledge regarding open (e.g., Hasson type) access. Alternatively, in these patients a retroperitoneal approach may be preferable to a transperitoneal approach or the procedure can be initiated retroperitoneally and the peritoneum then entered (Cadeddu et al, 1999).

A patient history of prior retroperitoneal surgery increases the difficulty of reentering the retroperitoneal space and therefore should be approached with caution. Subsequent attempts at extraperitoneoscopy or retroperitoneoscopy should only be ventured by individuals with considerable experience and comfort with this approach. In the authors’ experience, prior percutaneous renal procedures do not necessarily constitute a contraindication to subsequent retroperitoneoscopy, provided that entry is away from the area of the prior nephrostomy tube placement.

Pelvic Fibrosis

Pelvic fibrosis owing to previous peritonitis, pelvic surgery, or extensive endometriosis may constitute a severe technical challenge to the laparoscopic surgeon when surgery of the lower urinary tract is indicated. Similar problems may be encountered when trying to perform pelvic lymph node dissection in patients who have a hip prosthesis; leakage of the polymethylmethacrylate cement can create a dense inflammatory reaction and fibrosis in the adjacent pelvis (Cooper et al, 1997).

Organomegaly

Known or preoperatively diagnosed organomegaly necessitates a cautious approach when obtaining the pneumoperitoneum. The site of Veress needle insertion must be chosen at a safe distance from any enlarged organs. Alternatively, open access with the Hasson cannula may be considered. Open access should be considered in cases of marked hepatomegaly or splenomegaly.

Ascites: Benign Etiology

Patients with severe ascites are under increased risk of injury to the bowel owing to closer proximity of bowel loops to the anterior peritoneum. In addition, a watertight wound closure is required and a firm wound dressing should be applied to prevent prolonged postoperative leakage.

Pregnancy

Initial access to the abdomen must be obtained at a safe distance from the fundus of the gravid uterus. As such, trocar placement is usually performed more cephalad on the abdominal wall, depending on the fundus of the uterus. The left or right upper quadrant in the subcostal midclavicular line (i.e., at Palmer point) is often the preferred site of access. Prolonged intra-abdominal pressures of 15 mm Hg or greater may result in hypotension, owing to significantly reduced venous return because the vena cava is already mechanically compromised by the enlarged uterus. Prolonged CO₂ pneumoperitoneum, which may result in maternal hypercarbia and acidosis with subsequent adverse effects on the fetus, should be avoided. Accordingly, a working pneumoperitoneum of 10 mm Hg is recommended in the pregnant patient. The second trimester is a preferred time for necessary surgery given the completion of fetal organogenesis and less chance of inducing labor.

As pregnancy progresses beyond the 20th week the technical possibility of performing laparoscopic procedures decreases significantly, correlating with the increasing size of the gravid uterus. Both laparoscopic nephrectomy and adrenalectomy have been successfully accomplished in the pregnant female (Nezhat et al, 1997; O’Connor, et al, 2004; Sainsbury et al, 2004).

Hernia

A diaphragmatic hernia may result in leakage of a significant amount of CO₂ into the mediastinum, which, although rarely noted, may eventually result in clinical problems such as respiratory compromise or cardiac tamponade (e.g., pneumopericardium) (Knos et al, 1991).

Any evidence of uncorrected or surgically corrected umbilical hernia or abdominal wall hernia should rule out these sites for obtaining a pneumoperitoneum.

Iliac or Aortic Aneurysm

Significant aneurysms warrant evaluation by the vascular surgeon. If the aneurysm does not require immediate surgical correction, insertion of the Veress needle should be performed in the left upper quadrant to stay well away from the area of the aneurysm. Of course, open access with the Hasson technique can be employed. Insertion of accessory trocars must be done under strict endoscopic control to avoid the area of the aneurysm.

Standard Laparoscopic Carts

Traditionally, the mandatory hardware for laparoscopic procedures (monitor, light source, insufflator) is located on carts or “towers” that can be rolled around the operating room and be adapted to various types of surgical procedures and approaches (Fig. 9–2A on the Expert Consult website). If only one monitor is used (as in intrapelvic procedures), it is typically placed at the foot of the table or between the legs if the patient is in stirrups or on split-leg positioners. If two monitors are used, they are positioned on both sides of the table to allow an unobstructed view for all key operative team staff.

Figure 9–2 A, A standard laparoscopic cart. B, An integrated laparoscopic vision system.

The main laparoscopic cart should contain the insufflator, placed at the surgeon’s eye level to allow continuous monitoring of the CO₂ pressure. The light source, camera controls, and any recording device are usually also on the cart. Placement of a sterile plastic sheet over the front of this cart enables the surgical team to directly control the intensity of the light as well as the pneumoperitoneum pressure with these controls on the equipment.

Integrated Endoscopy Systems

More recently, most major manufacturers of endoscopy equipment offer “integrated” systems that consist of flat panel displays and equipment towers that are mounted on adjustable ceiling booms (see Fig. 9–2B on the Expert Consult website). Thus, the display monitors can be suspended over the patient and placed directly in front of the surgeon at any height or angle. This feature may reduce eye and body strain. Furthermore, the tower containing the light source, camera system, and insufflator can be placed in any area around the patient depending on the operation at hand. The more sophisticated systems are frequently controlled by a touch screen display used by the surgeon or a nurse, or by voice command, or by using the controls on the camera head instead of manually adjusting instruments at the tower level. In addition to the laparoscopic equipment, other aspects of the operating room environment can be controlled from the touch screen or by voice, such as the room lighting, input from digital radiology systems, and recording devices. Although they are not a necessity, these types of systems offer unique advantages with regard to operating room efficiency and may further improve the ergonomics for the operating surgeon and staff.

Robotic Systems

Currently, the only robotic surgical system in widespread use for laparoscopic surgery is the da Vinci Robotic System (Intuitive Surgical, Sunnyvale, CA). In its current state this system can be used in almost any modern operating room. The three major components of the system are the robotic tower to which the instruments attach and are mechanically manipulated within the patient, a surgeon’s console that is the workstation at which the surgeon sits to manipulate the robotic instruments, and finally the ancillary vision cart that supports a flat screen monitor, an insufflator, light source, and components of the camera system (Fig. 9–3 on the Expert Consult website). Additional monitors (either standard or boom-mounted flat screen) can be linked with the robotic system and used for the assistant and support staff image viewing.

Figure 9–3 The da Vinci Robotic System (Intuitive Surgical, Sunnyvale, CA).

Placement of the Operative Team for Laparoscopic Procedures

Transperitoneal Procedures in the Upper Abdomen

For laparoscopic procedures such as nephrectomy the patient is positioned in a modified lateral decubitus position for transperitoneal laparoscopic renal surgery procedures. This is at approximately a 30-degree angle to the table and allows for more effective lateral retraction of the kidney and exposure of the renal vessels during the hilar dissection. The kidney rest may be elevated at the outset and the table slightly flexed if necessary to provide adequate exposure for port placement; after port placement, the kidney rest should be completely lowered. The surgeon and assistant usually stand opposite the area of surgical interest (i.e., for a left nephrectomy the surgeon and assistant stand on the patient’s right side). The instrument table and the scrub nurse are best located on the opposite side of the patient such that instruments can be handed to the surgeon over the table (Fig. 9–4). Incoming lines from insufflators, suction/irrigation, and electrosurgical devices enter from the contralateral side of the table. Optional technology (e.g., harmonic scalpel, argon beam coagulator) must be arranged in an orderly fashion using either preexisting or improvised pockets of the surgical drape. Again, these lines ideally should enter the field from the contralateral side of the table or from the ipsilateral head of the table. Additional technology (e.g., laparoscopic ultrasound probe) may be moved to the operating table depending on the surgeon’s needs as well as on the availability of space.

Figure 9–4 Placement of the operative team for transperitoneal procedures in the upper abdomen: 1, operating table; 2, surgeon; 3, assistant; 4, anesthesiologist; 5, scrub assistant; 6, laparoscopic cart/tower; 7, auxiliary video monitor; 8, anesthesia equipment; 9, suction/irrigation unit; 10, scrub assistant’s instrument table; 11, electrocautery unit #1; and 12, electrocautery unit #2.

To provide more comfortable positioning of the surgeon’s arms, a 6 × 4-foot, 6-inch lift can be used, because most operating tables designed before widespread use of laparoscopy cannot be lowered sufficiently to allow the surgeon to hold the laparoscopic instruments with his or her elbows held comfortably at the side rather than extended laterally. This is most important during suturing. Several newer tables recently on the market, however, can be set at very low elevations (e.g., 60 cm) for the Maquet Alphamaxx (Getinge USA, Rochester, NY) so that platforms are not necessary.

Retroperitoneal Upper Abdominal Procedures

For retroperitoneal procedures the patient is placed in the true, 90-degree lateral decubitus position with the body at a right angle to the table. All of the proper steps for padding in this position should be followed (see earlier). The table is angled at the hip to accentuate and increase the distance between the 12th rib and the iliac crest. Maximizing this distance is paramount with regard to port placement. If necessary, the kidney rest can be raised; however, the surgeon must keep in mind that this causes increased pressure on the tableside hip and may increase the risk of pressure necrosis if left elevated for prolonged periods of time. Most experts recommend lowering the kidney rest except when it is needed for key portions of a case. The operative field should include the space between the costal margin and the iliac crest and from the umbilicus to the spine. Both the primary surgeon and the camera assistant stand facing the patient’s back (Fig. 9–5). The scrub nurse/technician stands facing the patient’s front, and instruments are handed across the patient accordingly.

Figure 9–5 Placement of the operative team for retroperitoneal procedures in the upper abdomen: 1, operating table; 2, surgeon; 3, assistant; 4, anesthesiologist; 5, scrub assistant; 6, laparoscopic cart/tower; 7, auxiliary video monitor; 8, anesthesia equipment; 9, suction/irrigation unit; 10, scrub assistant’s instrument table; 11, electrocautery unit #1; and 12, electrocautery unit #2.

Closed Technique: Veress Needle

Sites for Needle Passage

Disposable (70- or 120-mm, 14-gauge, and 2-mm outer diameter) as well as nondisposable (metal) Veress needles can be used. Proper needle function is ensured before the procedure. The blunt tip of the needle is tested to make sure it retracts easily; also, the needle is connected to the CO₂ line to ensure that there is no resistance to gas inflow (i.e., at 2-L/min flow, pressure remains at ≤2 mm). Lastly, saline is flushed through the needle with the tip manually occluded to make sure there is no leakage at the juncture between the shaft and the hub of the needle.

With the patient in the supine position, the head of the bed is lowered 10 to 20 degrees; insertion of the Veress needle is commonly accomplished at the superior border of the umbilicus (Fig. 9–8). There are certain advantages to choosing the umbilical area as the site for initial trocar placement: the abdominal wall is thinnest, and postoperative cosmesis is excellent. However, this point of entry is fraught with the potential for injury to a major vessel, in particular the left common iliac vessels, aorta, or vena cava.

Figure 9–8 Insertion of Veress needle at umbilicus. The towel clips stabilize the abdominal wall as the needle is advanced.

(From Clayman RV, McDougall EM, editors. Laparoscopic urology. St. Louis: Quality Medical Publishing; 1993.)

Another important factor with regard to passing the Veress needle is body habitus; in obese patients, the umbilicus tends to migrate inferiorly. In nonobese patients the umbilicus lies in its commonly described position, directly above the bifurcation of the aorta and vena cava. Thus, for umbilical access in nonobese patients the Veress needle should be passed through the abdominal wall angled toward the pelvis to avoid injury to the bowel and great vessels that lie directly beneath. In more obese patients, because the umbilicus lies more caudad, less angulation is needed and the Veress needle should be passed perpendicular to the umbilical incision (Loffer and Pent, 1976). In addition, it has also been found that pneumoperitoneum pressure and volume as well as the ease of trocar or needle insertion is not significantly affected by body habitus. In a combined human and porcine study, McDougall and associates (1994) prospectively performed pressure-volume analysis on 41 individuals undergoing transperitoneal laparoscopic procedures and found that 94% of the maximal intraperitoneal volume is achieved with an insufflation pressure of 15 mm Hg. Additional pressure (up to 30 mm Hg) did not significantly increase volume. Furthermore, in the porcine component of the study, elevation of the pneumoperitoneum pressure above 15 mm Hg did not significantly ease bladed trocar insertion. Therefore the pneumoperitoneum pressure need never be raised above 15 mm Hg unless it is done so in the setting of a vascular venous injury to control bleeding (a discussion of this technique is outlined later).

If the patient is in a lateral decubitus position, then the Veress needle is passed 2 fingerbreadths medial and 2 fingerbreadths superior to the anterior superior iliac spine. Just before insertion of the Veress needle a 12-mm incision is made in the previously described area, in anticipation of placing a 10- to 12-mm trocar. The subcutaneous tissues are spread with a Kelly clamp, and the anterior fascia is secured with an Allis clamp. The abdominal wall is stabilized, but not lifted, with the Allis clamp. The Veress needle is grasped at midshaft and is passed perpendicularly through the 12-mm incision using a gentle, steady pressure; two points of resistance are traversed: the abdominal wall fascia and the peritoneum. With this approach, the only organ at risk is the bowel; neither a vascular organ nor a major vessel can be injured using this insertion site.

Other potential insertion sites when the patient is either supine or in a lateral decubitus position are at the Palmer point (i.e., subcostal in the midclavicular line on the right side) and at the corresponding site on the left side. In this instance, stabilization or even a slight upward tension on the Allis clamps is essential; the needle if inserted too deeply will potentially hit the liver on either side or, rarely, the spleen, so care must be exercised. Chung and coworkers (2003) applied this method of laparoscopic access and trocar placement in 622 consecutive cases. Prior abdominal surgery had been performed in 192 patients (31%), and the BMI was 30 or greater in 98 patients. Blind Veress needle placement was successful in 579 (93%), and outcome was not associated with laterality, type of surgery, or prior surgery. In 34 cases (5%), a minor laceration to the liver was managed conservatively without sequelae; and in 21 cases (3%) the omentum or falciform ligament was traversed without significant injury. No major complications, such as vascular or hollow-organ perforation, were caused by either the Veress needle or trocar. Neither the spleen nor bowel was ever injured. No patient developed an incisional hernia at the upper quadrant trocar site (Chung et al, 2003).

Open Access Techniques

The pneumoperitoneum can be more easily, and in one’s early experience, more safely established using an open technique; however, its use involves making a larger incision and increases the chances of port-site gas leakage during the procedure. The open technique is recommended specifically when extensive adhesions are anticipated. Studies in general surgery have shown the open technique to be as efficient as the closed approach and slightly more or equally as safe (Bonjer et al, 1997).

In the unscarred abdomen, a 2-cm semicircular incision is made at the lower edge or slightly below the umbilicus. The fascia and peritoneum are opened individually with a transverse incision, sufficient to accommodate the surgeon’s index finger. After visual and digital confirmation of entry into the peritoneal cavity, two 0 silk traction sutures are placed on either edge of the fascia. Next, the Hasson cannula is advanced through the incision with the blunt tip protruding (Fig. 9–9A). The funnel-shaped adapter of the Hasson cannula is advanced until it rests firmly in the incision, and it is then tightened onto the cannula with the attached screw; fixation to the abdominal wall is provided with the fascial sutures that are wrapped around the struts on the funnel-shaped adapter of the Hasson cannula, thereby anchoring it in place. After removal of the obturator, free flow of CO₂ into the peritoneal cavity is achieved by attaching the CO₂ tubing to the cannula. The insufflator can be set at maximum inflow, thereby creating the pneumoperitoneum quickly.

Figure 9–9 Various trocar designs showing (A) Hasson type, (B) bladed, (C) fascial dilating, and (D) screw-like designs. Enlarged images of the bladed and dilating tips are provided.

A far simpler type of open cannula is a balloon retention device (e.g., Blunt Tip Trocar With Balloon Tip, US Surgical, Norwalk, CT) (Fig. 9–10 on the Expert Consult website). Once the cannula is positioned in the abdominal cavity, the balloon is inflated; the cannula is pulled upward until the balloon is snug on the underside of the abdominal wall. Next, the soft foam collar on the outside surface of the cannula is slid downward until it is snug on the skin and locked in place. This process creates an excellent seal, precluding gas leakage as well as subcutaneous emphysema.

Figure 9–10 Blunt tip trocar with balloon tip.

(Courtesy of US Surgical, Norwalk, CT.)

Closed Technique

Hand Port Access

If the hand port is going to be placed in the midline, then the midline should be marked before placing the patient in the 45-degree (modified) flank position. The pneumoperitoneum can be obtained before or after making the hand port incision, but if one wishes to ensure the minimum size of the skin incision then the incision should be made after obtaining the pneumoperitoneum because this places the skin more on stretch. However, if the surgeon has little experience with achieving a pneumoperitoneum, the safest maneuver is to place the hand port into a 7-cm open incision and then create the pneumoperitoneum through the hand port.

If one elects to obtain a pneumoperitoneum first, then the surgeon should carefully plan out the hand port entry site as well as the additional instrument and camera port sites. Every hand port device has a “footprint” that can be drawn on the abdominal wall; that footprint varies depending on the diameter of the external appliance. Care should be taken to plan out the additional trocar sites carefully to avoid interference between the hand port and the instrument ports; this is most easily done once the pneumoperitoneum has been established. After the footprint is traced, the hand port incision site is marked; the length of the incision should correspond to the surgeon’s glove size (i.e., 7 glove size = 7-cm incision). The skin is incised, and the fascia is divided. The peritoneum is entered, and the insufflation is temporarily stopped. The hand port device is then placed according to the manufacturer’s instructions. Additional 5-mm or 10- to 12-mm ports can be placed rapidly under manual control with the surgeon’s intra-abdominal hand being used to guide the additional trocars through the abdominal wall. Alternatively, a trocar can be placed through the hand port and the abdomen can be re-insufflated. A laparoscope can then be placed through the port and the rest of the trocars can be placed under direct vision.

Laparoendoscopic Single-Site Surgery (LESS) and Natural Orifice Transluminal Endoscopic Surgery (NOTES)

Recent advances in abdominal access technology combined with the development of curved and articulating laparoscopic instrumentation have made it possible to perform selected procedures through a single incision (typically 2.5 cm transumbilical); using three access ports through this incision, the laparoscope and two working instruments can be introduced.

Much the same as for hand port access the incision can be made before or after obtaining a pneumoperitoneum depending on surgeon preference. Typically, the incision is made periumbilically for cosmetic purposes. If large/intact specimen extraction is required for the procedure at hand (as in donor nephrectomy), the incision should be made just large enough to remove the specimen. If specimen removal is not necessary or the specimen is small, then the incision can be minimized to as little as 2.5 cm. Once the incision is made, several ports side by side or a single tri-port access device can be placed and a pneumoperitoneum is re-established at high flow. Thus far, LESS has been used for a variety of upper abdominal procedures including adrenalectomy (Hirano et al, 2005; Castellucci et al, 2008); renal biopsy (Kaouk et al, 2008b); renal cyst decortication; renal tumor cryoablation (Goel and Kaouk, 2008); pyeloplasty (Kaouk et al, 2008a); ileal ureter interposition; psoas hitch ureteroneocystostomy; simple, radical, and donor nephrectomy (Gill et al, 2008; Ponsky et al, 2008b; Raman et al, 2008); and partial nephrectomy (Kaouk et al, 2008b). Additionally, pelvic procedures have been performed including varicocelectomy (Kaouk and Palmer 2008), sacroculpopexy (Kaouk et al, 2008b), radical prostatectomy, and radical cystectomy with extended lymphadenectomy (Kaouk et al, 2008b).

The theoretical advantages of LESS over standard multi-incision laparoscopy are improved cosmesis, decreased pain, and faster recovery time. At the present time, however, there are insufficient data regarding LESS available to either support or refute these potential benefits (Raman et al, 2008). Research in this area is ongoing, and until well established methods and results are available surgeons are urged to approach LESS in a responsible and graduated fashion. Proper training through a combination of educational courses, hands-on laboratory training, case observation, and proctoring should be undertaken by surgeons who wish to start a successful program in LESS. One method of transitioning from standard laparoscopy to LESS for selected procedures is to gradually decrease the number of ports one uses until the procedure can be performed through a single incision. Conversely, when one is having difficulty performing a procedure using LESS, the surgeon should not hesitate to place one or more extra trocars at separate incision sites to improve triangulation and thereby ensure safety and a quality result.

Although the transgastric removal of an appendix in 2004 and the transvaginal removal of the gallbladder in 2007 have stimulated much interest in the realm of general surgery, natural orifice transluminal endoscopic surgery (NOTES) has remained an investigational laboratory procedure in urology. Using a transgastric and transvaginal approach, Ponsky and colleagues (2008b) have removed a porcine kidney whereas Lima and colleagues (2007) have used a transgastric and transvesical approach to excise, but not remove, the porcine kidney. These latest developments are built on the original work by Gettman and associates in 2002 in which transvaginal nephrectomies were accomplished in the pig. However, to date, there have been no NOTES procedures in clinical urology (Lima et al, 2006; Isariyawongse et al, 2008).

Commercially Available Balloons

A commercially available trocar-mounted preperitoneal balloon dissector (PDB) (Covidien Ltd., Mansfield, MA) is commonly employed. The transparent, high-tensile strength silicone balloon is inflated with a sphygmomanometer bulb insufflator using room air (Fig. 9–11). The balloon has a maximum capacity of 800 mL (40 pumps of the inflating bulb). A primary advantage is that the balloon is affixed to the end of a stiff, hollow, transparent plastic shaft. The shaft allows precisely directed placement of the balloon dilator (see later). Furthermore, because the laparoscope can actually be inserted into the shaft of the balloon dilator during the inflation process it provides the capability for endoscopic confirmation of the proper positioning of the transparent balloon and of the adequacy of the controlled radial dilation of the extraperitoneal area. Balloon dilators are commercially available in two different shapes: a round balloon for dilation of the pelvic extraperitoneal space and a horizontally oriented, oblong-shaped balloon for dilation of the retroperitoneal space.

Figure 9–11 Example of a commercially available balloon dilator for creating space in the retroperitoneum: preperitoneal balloon dissector.

(Courtesy of Covidien Ltd., Mansfield, MA.)

Self-Styled Dilators

Gaur’s original (1992) version of the balloon dilator was a size 7 surgeon’s glove mounted on a No. 8 red rubber catheter. The external end of the catheter was connected to a sphygmomanometer bulb insufflator, and the balloon was insufflated to 110 mm Hg. After this initial description, several other self-styled dilators were described: the middle finger of a size 7 to 8 glove, two fingers of a size 7 to 8 glove tied over each other for additional strength, a sterile condom, and the cot of an O’Connor-style drape mounted on a 16- or 18-Fr red rubber or whistle-tip catheter (Webb et al, 1993; Chiu et al, 1995). For the balloons made from the middle finger of a surgeon’s glove, the finger is affixed to the rubber catheter with two 0 silk sutures. These self-styled dilators were filled with saline rather than air. The device may be backloaded into a well-lubricated (i.e., K-Y jelly) 30-Fr Amplatz sheath to facilitate introduction through a laparoscopic port. Although it is economically advantageous, drawbacks of the self-styled balloon include the lack of a stiff shaft to manually direct the balloon into a specific location for precise dilation as well as the inability to endoscopically monitor the dilation process from within the balloon.

An ex-vivo laboratory study demonstrated that increasing volumes of saline induced gradual pressure increments within the middle finger of a surgeon’s glove. At a volume of 1000 mL, the average pressure was 15 mm Hg. Pressures remained 15 mm Hg at 1500 mL and increased to 17 mm Hg at 2000 mL (McDougall et al, 1994). In practice there is no need to exceed the 1000-mL limit. Also, latex balloons have less tensile strength than silicone balloons, making them more likely to rupture. Regardless, with either balloon setup, on the few occasions that either type of balloon has ruptured there has been no obvious complication. However, the latex balloon has a tendency to rupture into multiple pieces whereas the Silastic balloon usually leaves only one large fragment, making retrieval an easier task.

Complications associated with balloon dilation stem from improper balloon placement or balloon rupture. Intramuscular dilation may result in hernia formation, or inadvertent peritoneal disruptions may occur (Gaur, 1992; Adams et al, 1996).

Manual Dilation

Creation of a working space within the retroperitoneum may be achieved exclusively with a combination of digital and laparoscopic instrument dissection (Kerbl et al, 1993). After access to the extraperitoneal area is gained, to-and-fro movements of the laparoscope are performed to create a working space (McKernan, 1995). This technique has been employed to perform various simple and advanced procedures in the retroperitoneum (Rassweiler et al, 1998a; Abbou et al, 1999). Although it is effective, potential disadvantages of this technique include frequent cleaning of the laparoscope and the lack of clear landmarks initially due to the smaller, undeveloped working space.

Technique for Balloon Placement: Open (Hasson) Technique

This is the most commonly employed technique because it affords the greatest precision during development of the retroperitoneal space (Gill, 1998). Initial access is obtained through a 2.0- to 2.5-cm transverse incision in the midaxillary line, just below the tip of 12th rib. The wound is opened with a pair of S-retractors. Under direct vision, the posterior layer of the lumbodorsal fascia is incised and muscle fibers are split or divided. The retroperitoneal space is entered, under direct vision, by making a small incision in the anterior thoracolumbar fascia with an electrocautery blade or, less commonly, by bluntly piercing the fascia digitally or with a hemostat. Care should be taken that this fascial opening is snug around the index finger and no larger, so that intraoperative air leak is minimized. Index finger palpation of the belly of the psoas muscle posteriorly and the Gerota fascia–covered inferior pole of the kidney anteriorly confirms proper entry into the retroperitoneal space (Fig. 9–12A). The index finger is employed to digitally create a space in this precise location for placement of the balloon dilator; two inflations of the balloon are then done—one directed cephalad and the second directed caudad to fully dilate the retroperitoneal space (see Fig. 9–12B). Thus, balloon dilation is performed anterior to the psoas muscle and fascia and outside and posterior to the Gerota fascia. In cases involving definitive ureteric mobilization (e.g., retroperitoneoscopic donor nephrectomy, nephroureterectomy, ureterolithotomy, pyeloplasty), an additional balloon dilation may be performed more caudad to the primary site of dilation (Gill et al, 1995). Similarly, during a retroperitoneoscopic adrenalectomy, it is helpful after the initial balloon dilation to move the balloon up higher in the retroperitoneum and perform a second even more cephalic balloon dilation along the undersurface of the diaphragm (Sung and Gill, 2000).

Figure 9–12 A, Access into the right retroperitoneum. Through the primary port incision at the tip of the lowest (12th) rib, open access is gained into the retroperitoneum after piercing the thoracolumbar fascia. Finger dissection is performed anterior to the psoas muscle and fascia to create a space for insertion of the balloon dilator. Confirmation that the finger dissection is indeed being performed in the proper plane is obtained by palpating the psoas and erector spinae muscles between the retroperitoneally located index finger and the fingertips of the opposite hand positioned on the patient’s back. The fat-covered lower pole of the kidney can be palpated in a cephalad direction by turning the finger clockwise in the retroperitoneum on the right side. B, Balloon dilation in the posterior pararenal space facilitates the creation of a working space for retroperitoneal laparoscopic nephrectomy (coronal view).

(Reprinted with permission, Cleveland Clinic Center for Medical Art & Photography © 1998-2011. All Rights Reserved.)