Although the insufflation technique with the Veress needle can be used, we recommend an open access for the camera port placement. It is commonly inserted at the level of the umbilicus lateral to the ipsilateral rectus muscle. The abdomen is insufflated to 13 to 15 mm Hg. Some surgeons prefer a pressure of 20 mm Hg during the trocar placement. Typically, a 10- or 12-mm trocar is placed lateral to the rectus at the level of the umbilicus using a visual obturator trocar (e.g., Visiport, AutoSuture or Optiview, Ethicon Endo-Surgery). Once the peritoneum has been entered, the intraperitoneal contents are inspected for injury or adhesions. Trocar site placement varies significantly based on surgeon preference and patient body habitus. Most surgeons prefer the laparoscope (“camera”) port positioned between the working ports, which is the authors’ preference. Some place it caudad to the working ports. Many surgeons use a 30-degree laparoscope placed through an umbilical port, with working ports widely spaced in the subxiphoid midline and the far lateral abdomen (anterior axillary line, umbilical level), creating a 90-degree angle in relation to the umbilical trocar. Other surgeons place the working ports closer to the umbilical trocar, keeping them at least 10 cm apart. Others reduce the angle of the working ports in relation to the umbilicus to approximately 60 to 70 degrees, creating a trocar “diamond” configuration. Alternatively, one can use a 0-degree laparoscope placed through a trocar lateral to the rectus muscle and just cephalad to the umbilicus, with the working ports shifted slightly cephalad and laterally, respectively, to maintain at least 10-cm or five-fingerbreadths distance between trocars. A 5-mm trocar is often placed in the far lateral (anterior to posterior axillary line) position for retraction, and another 5-mm trocar is often placed below the xiphoid process for right-sided procedures to elevate the liver using a locking grasper attached to the lateral abdominal wall.
Obese patients or patients with protuberant abdomens will need to have the trocars shifted laterally to maintain effective working angles into the retroperitoneum. Although technically more challenging, single-portal access nephrectomy can be performed for small hypotrophic kidney.

The ipsilateral ascending or descending colon must be mobilized to gain access to the kidney and renal hilum. The parietal peritoneum is first incised medial to the line of Toldt, approximately 1 cm lateral to the mesenteric fat lying lateral to the colon. This incision is carried from the iliac vessels to the level of the spleen (left) or liver (right). Atraumatic graspers are used in the nondominant hand to provide counter tension, and a hook electrode, Endoshears (scissors), or harmonic scalpel is used in the dominant hand to perform the dissection. Endoshears are particularly useful when dissecting in close proximity to bowel and when tissue planes are relatively avascular. Selective use of monopolar cautery through the instrument or use of a bipolar grasper in the nondominant hand allows for an efficient and elegant dissection by an experienced surgeon. Conversely, the harmonic scalpel excels at maintaining hemostasis when tissue planes are more vascular, and it is an excellent blunt-tipped dissection tool. Less experienced surgeons and surgeons in training may find the harmonic scalpel an easier tool to master. For left-sided procedures, many surgeons advocate carrying the peritoneal incision above the spleen laterally, allowing the spleen to fall medially with the pancreas and colon. Others prefer to carry the peritoneal incision through the phrenicocolic ligament to the spleen but then carry the dissection medially, leaving the spleen suspended on a “hammock of peritoneum caudad to the spleen and extending to the left abdominal sidewall” (Fig. 6.2). The splenophrenic attachments are left intact while the splenocolic and then renocolic fascial attachments are divided in layers until the descending colon is fully mobilized medially and the left gonadal vein is visible.

For right-sided procedures, the peritoneum just lateral to the ascending colon is divided and carried to the level of the liver. This peritoneal incision is also carried medially, staying approximately 1 cm away from the lateral border of the colonic hepatic flexure. This incision then proceeds cephalad to approximately 1 cm below the liver and back laterally along the inferior surface of the liver to the sidewall. This approach will leave a wedge-shaped area of peritoneum covering the anterior aspect of the right kidney (Fig. 6.3). Once the ascending colon is mobilized medially, the duodenum is subsequently identified and a fascial incision is made approximately 1 cm lateral to its second stage. A Kocher maneuver is performed to move the duodenum medially. Third, the inferior vena cava (IVC) is exposed by incising the fascia and dissecting along its lateral border. For both left- and right-sided procedures, care is taken to preserve the lateral attachments of the kidney to prevent it from falling medially, inhibiting dissection of the renal hilum and the medial aspect of the Gerota fascia.

Once the colon is fully mobilized, the gonadal vein is identified. Many urologists find the gonadal vein to be the “gateway” for initiating the nephrectomy portion of the procedure and carrying the dissection to the renal hilum. For left-sided nephrectomies, the fascia overlying the gonadal vein is divided and this dissection is carried cephalad to the renal vein. Care must be taken to dissect anterior to the gonadal vein to prevent injuring small gonadal venous tributaries or hilar vessels. The harmonic scalpel is useful for dividing these fascial attachments and maintaining hemostasis. This will allow for exposure of the anterior
aspect of the left renal vein and subsequently the adrenal vein. The adrenal vein may be dissected using the harmonic scalpel or a gently curved dissector (e.g., Maryland). It is subsequently cauterized (e.g., with a paddle bipolar instrument), clipped (e.g., with Hem-O-Lok clips), and divided. The gonadal vein is then divided 1 to 2 cm below the renal vein in a similar fashion. It is included with the radical nephrectomy specimen, particularly for large and lower pole tumors. For right-sided procedures, the fascia over the gonadal vein may similarly be divided along the course of the vein up to its junction with the IVC. The right gonadal vein may, particularly for large tumors, be divided and removed with the specimen. Conversely, the dissection can be made just lateral to the right gonadal vein for smaller mid and upper pole tumors. The plane of dissection between the gonadal vein and the tail of the Gerota fascia (containing the ureter) is developed, and the latter is elevated anterolaterally by the assistant (using a laparoscopic Kittner, atraumatic grasper, or suction device) to allow dissection to the renal hilum via an inferoanterior approach (Fig. 6.4A and B).

For right-sided procedures, the ureter and tail of the Gerota fascia are elevated anterolaterally and the dissection carried along the gonadal vein to the IVC cephalad and to the iliac vessels caudad. For left nephrectomies, the dissection of the ureter and medial tail of the Gerota fascia is often performed after dividing the left adrenal and gonadal veins, if a true radical nephrectomy is to be performed. The adrenal gland and gonadal vein are spared when performing a simple nephrectomy or in select cancer patients without evidence of invasion on preoperative imaging. The tail of the Gerota fascia is mobilized medial to the gonadal vein from the renal hilum to the iliac vessels.

Firm anterolateral elevation of the lower pole is critical in order to facilitate dissection of the hilum. This is accomplished by placing a laparoscopic Kittner or atraumatic grasping instrument under the tail of the Gerota fascia, the ureter, and the lower pole and lifting to the abdominal sidewall. With the hilum on tension, a harmonic scalpel, suction instrument, hook electrode, dissector (e.g., Maryland), or Endoshears can be used to dissect out the renal artery and vein and any necessary tributaries (e.g., lumbar or accessory vessels). Lymphatic vessels and fascial attachments inferior to and occasionally encasing the renal artery must be divided bluntly or sharply. Once adequate vessel exposure (at least a 2-cm space) is created, an endovascular gastrointestinal anastomosis (GIA) stapler is used to divide first the renal artery and then the vein. Alternatively, a series of at least three Hem-O-Lok clips may be applied to the vessels, dividing them approximately 1 cm lateral to the clips. Hilar side branches (gonadal, adrenal, lumbar, and accessory) may be ligated and divided in a variety of ways. Cauterization with either the LigaSure device or three overlapping deployments of a standard paddle bipolar cautery is effective. Standard titanium or locking polymer Hem-O-Lok clips may be used. The authors favor sequential paddle bipolar cauterization of the vessel and placement of a Hem-O-Lok clip on the stay side of the vessel if it will not be in the path of the endovascular GIA stapler when dividing the renal vessels.

Once all hilar vessels have been divided, the dissection is carried superiorly. For right radical nephrectomies (RNs), the adrenal vein must be identified, ligated, and divided. Hem-O-Lok clips, preferably two on the stay side, may be used. The remaining suprarenal attachments and middle suprarenal arteries are divided with the harmonic scalpel or stapler (Fig. 6.5). A similar dissection can be performed for left RNs, separating the adrenal from the aorta and diaphragm. Alternatively, for simple nephrectomies and selectively for small, non-upper pole renal tumors with a normal ipsilateral adrenal gland on preoperative abdominal CT or MRI and intraoperative exam, the adrenal gland can be spared by placing the kidney on caudad traction and dividing the attachments between the adrenal gland and upper pole, staying adjacent to the adrenal. At this point, if it has not been performed previously, the ureter is clipped and divided and any remaining posterior or lateral attachments are divided by rotating the kidney as necessary.

Benign kidneys may be morcellated in a durable entrapment sac, but malignant kidneys should be removed intact. The risk for tumor spillage and the loss of histologic staging information virtually always outweigh the morbidity benefits of minimizing the extraction incision. The kidney is placed into a deployable entrapment sack (e.g., Endo Catch II, U.S. Surgical, Norwalk, Connecticut). Hemostasis is checked, and then the sack is brought out through an incision extended from a 12-mm trocar site. Alternatively, the specimen may be removed through a Pfannenstiel incision. Trocar sites larger
than 5 mm should have a fascial closure suture (e.g., interrupted 0 Vicryl) placed prior to specimen extraction.

A 2-cm incision is made just below the tip of the 12th rib in the midaxillary line. A Kelly clamp is used to separate the subcutaneous fat and expose the flank musculature. The muscle is bluntly divided, and the underlying thoracolumbar fascia is pierced to enter the pararenal fat of the retroperitoneum. “S” type or Army-Navy retractors are used for exposure, and a fingertip is inserted and rotated 360 degrees in order to palpate the psoas muscle and confirm an appropriate retroperitoneal location. A balloon dilator is introduced and filled to 800 mL with room air. During insufflation, a 10-mm laparoscope may be introduced to view the dissection. A 10-mm blunttipped cannula is introduced with 30 mL of air in the balloon (U.S. Surgical). After tightening the outer ring sponge to compress the balloon against the inner abdominal wall, the retroperitoneum is insufflated to 15 to 20 mm Hg. Of note, some surgeons alternatively make the incision midway between the iliac crest and the tip of the 12th rib in the posterior axillary
line. Additionally, a visual obturator trocar with a 10-mm 0-degree laparoscope may be used instead to enter the retroperitoneal space. Entry must be at a 10-degree anterior angle. Angling too far posteriorly will injure the quadratus or psoas musculature, whereas too anterior of a trajectory may allow entry into the peritoneum or cause colon injury.