The patient is placed in right lateral position (left side up). The patient is positioned at the right edge of the table, with the patient’s belly hanging down as opposed to the open surgery where the patient is on the left edge of the table for left-sided surgery. Patient is positioned at an angle of 60^° with the table depending upon the habitus of the patient. The left leg is extended, and right leg flexed with two pillows between the legs; the first pillow is at the level of the thigh placed vertically and other at the level of the leg and the ankle placed horizontally. Patient’s back is supported by three cuboid-shaped bolsters. The right arm is extended and kept of an arm board after placing an axillary roll; the left arm is flexed at elbow and placed on a mayo’s stand or pillow, after placing an axillary roll. Care has to be taken that the patient’s left hand is placed in such a way that it does not come in the way of the surgeon’s left hand movements, inadvertent pushing of the patient’s left hand during surgery may cause a stretch injury to the brachial plexus, and also improper positioning causes limitation of left hand movement of the surgeon. Special attention is paid to securing and strapping pressure points. Padding devices used include commercially available gel pads, cotton rolls, or locally available things like egg crates or foam sheets. The pressure points include the knee, ankle, shoulder, and axilla, and lateral cutaneous nerve of the thigh, the peroneal nerve, and the brachial plexus which are at risk of injury.

The straps are applied on the lower hip and the chest. The straps can be rubber or leather straps available in the market or can be a broad cloth, Elastocrepe, or white cloth sticking. The straps should go all around the patient so that the patient can be rotated during the surgery if required. The anesthetist gives special attention to the strap on the lower chest.

Surgical advantage of such a positioning is that in obese patients the pannus falls away from the operative site and port placement becomes easier.

A Pfannenstiel incision, which is 5–6 cm in length two to three fingerbreaths above the pubic symphysis pubis, is marked in supine position. A bikini line incision can also be marked in females. The incision is taken once the patient is positioned and prepared. The skin and subcutaneous tissue is incised, and the rectus sheath is opened horizontally and undermined cranially and caudally. Rectus abdominis muscle, pyramidalis muscle, and the midline are identified. The midline is scored with electrocautery, and using an atraumatic forceps and artery forceps, it is split. Preperitoneal fat is now exposed; using atraumatic forceps and artery forceps, this fat is peeled off from the peritoneum, and peritoneum is thus exposed. The incision is packed with wet mop.

Advantage of this incision is that it can be used in any emergency, vascular accident, where surgeon can use his hand to temporize bleeding. It is a muscle-splitting incision, and hence there are less chances of developing hernia and good healing. Cosmetically, it is a very appealing incision. This incision can be used to train surgeons; the surgeons are allowed to do kidney retrievals from this incision in early part of their training, and when they actually start performing this surgery, they can use this incision in salvaging vascular accidents.

A similar incision can be placed in the left iliac fossa; the disadvantage is that it is a muscle-cutting incision, is less cosmetic, and increases chances of incisional hernia. But it is useful in extremely obese patients and in patients with operative history in lower abdomen.

The operating surgeon and the camera driver stand on the right of the patient; for most of the situations camera driver standing cranially and surgeon caudally is more ergonomic. The instrument trolley is placed at the foot end of the patient. The scrub nurse stands caudal to the surgeon. The assistant surgeon stands on the left of the patient and the anesthesiologist at the head end.

The vision cart with the main video monitor is placed in front of the operating surgeon; it should be at a distance, which is equal to five times the diagonal length of monitor. For a 21 inch monitor, the distance of the monitor should be at 105 in. from the surgeon and placed just below the eye level so that the surgeon looks 15^° down while operating; this causes the least fatigue on sternocleidomastoid muscle. The insufflator and energy sources should be placed on the vision cart below the monitor so that they are in direct view of the surgeon. The second monitor is placed behind the surgeon so that the assistant can visualize the surgical steps clearly.

The principles of port positioning include triangulation, positioning the camera in front of the hilum; distance between the two ports is at least four fingerbreaths, so that there is no sword fighting, and the camera port should be midway of the two working ports. The ports should be placed in such a way that the angle between the two working instruments, i.e., the manipulation angle is 60–75°, and the angle between each of the working instrument and the camera, i.e., the azimuth angle, should be between 30 and 45°.

The anterior superior iliac spine (ASIS), the umbilicus, the lateral border of the rectus muscle, midline, subcostal margin, 12th rib, midpoint of the line joining ASIS, and umbilicus are marked using a skin marker. The placement of the port is dictated by the location of the kidney in relation to the costal margin and the truncal obesity.