• Our aim is to provide free detailed comprehensive manual for urologic surgical procedures. This site should serve as a valuable reference for urologic residents and medical students in training.

  • Laparoscopic radical nephrectomy (adrenal gland sparing)

    About the authors: Matthew J. Maurice, MD and Lee Ponsky, MD

    Lee E. Ponsky, MD, FACS

    Dr. Ponsky received his B.A. from University of Rochester and his Doctor of Medicine degree from Case Western Reserve University School of Medicine. He began his training in Urology at the Cleveland Clinic and completed his residency and extended his training to do a research fellowship in urologic oncology, followed by an additional fellowship in advanced urologic laparoscopy and endourology. In 2005, Dr. Ponsky joined the faculty at University Hospitals, Case Western Reserve University School of Medicine, and is currently an associate professor of Urology and holds the Leo and Charlotte Goldberg Chair in Advanced Surgical Therapies, he is the Director Urologic Oncology & Minimally Invasive Therapies Center and the Co-Director of the Institute for Surgery and Innovation. He has over 50 publications and has been invited as a faculty/visiting professor at numerous national and international conferences.  He is the editor-in-Chief of a textbook on Robotic RadioSurgery and has authored more than 12 textbook chapters.  He has received several research grants. One of his recent innovative ideas was awarded the highest ranking from Ohio Third Frontier and received $1 million dollar grant towards its development and is currently submitted to the US Patent office.

    Dr. Ponsky has received numerous accolades for his medical contributions as well as his role and the founder of MedWish International, including U.S. Congressional Recognition, Crains Forty under Forty, as one of Northeast Ohio’s most influential people under the age of 40, Cleveland Upstander: Portraits of Courage, the recipient of the Golden Doc Award, from the Arnold P. Gold Foundation,  and received the Rescuer of Humanity Award from Project Love, which recognizes and honors an individual or an organization of national or international stature, which has chosen to use their leadership beyond professional or institutional requirements to positively change the course of humanity. He has also been recognized by the Manhattan Institute in New York with the The Richard Cornuelle Award for Social Entrepreneurship, for originating and effectively implemented a new nonprofit organization providing direct services to those in need. In 2011, he was recognized by Smart Business as the nonprofit board executive of the year and also received the University Hospitals Case Medical Center, Urology Institute Faculty Teaching Award from his students and residents, for recognition of outstanding commitment and efforts to student and resident teaching. Dr. Ponsky also serves as a founding board member of the non-profit MedWorks, which provides free healthcare to the uninsured and underinsured.

    Matthew J. Maurice, MD

    Matt is a fourth-year Urology resident at University Hospitals Case Medical Center, Case Western Reserve University School of Medicine, in Cleveland, Ohio. He was born and raised in Chicago, Illinois. He received his Bachelor of Science degree in Biology from Saint Louis University in 2005 and his medical degree from Northwestern University Feinberg School of Medicine in 2009. He is currently performing a year of dedicated research as part of his residency training. He anticipates completing residency in 2015, at which time, he plans to pursue further specialization in urologic surgery. His interests include: minimally-invasive surgery, oncology, reconstruction, and surgical innovation.

    ~38 minute video of laparoscopic right radical nephrectomy. You may click button right button to enlarge to full screen.


    Renal cell carcinoma (RCC) accounts for 2-3% of adult malignancies and is the most lethal urologic malignancy.(1) In the United States, the annual incidence of RCC has risen steadily for the past three decades, increasing by 2.6% annually between 1997 and 2007.(2) This upward incident trend in RCC is due, in part, to the increased detection of incidental small renal masses (SRM’s) on routine diagnostic imaging.(3)

    Over 40 years ago, Robson established the basic surgical oncologic principles of the open radical nephrectomy (ORN), which was adopted as the gold standard for the management of all renal masses.(4) With the advent of minimally invasive and nephron-sparing approaches, the indications for ORN are diminishing. Driven by technological advances and the increased detection of SRM’s, the surgical management of RCC continues to evolve. In the last 20 years since Clayman described the first laparoscopic radical nephrectomy (LRN), improvements in instrumentation and surgeon experience have cemented LRN as an equally efficacious and minimally invasive alternative to ORN for selected kidney tumors.(5,6) Supported by long-term outcomes data, LRN has proven to be oncologically equivalent to the open approach, while offering the advantages of improved postoperative pain, decreased hospital stay, and shortened convalescence.(7-15)

    Currently, five laparoscopic approaches to renal surgery may be employed: transperitoneal, retroperitoneal, hand-assisted, robotic, laparo-endoscopic single-site surgery (LESS), and natural orifice transluminal endoscopic surgery (NOTES). Selecting the appropriate approach depends on a variety of factors: patient characteristics (e.g. obesity, prior abdominal surgery), patient preferences (e.g. cosmesis), equipment availability (e.g. da Vinci Surgical System [Intuitive Surgical, Sunnyvale, CA]), and the training and expertise of the laparoscopic surgeon. None of these approaches have shown a superior recovery advantage, though differences in cost and cosmesis may exist. A modified approach to the traditional transperitoneal LRN reported by Clayman is described and displayed here.


    Surgical resection in the form of either partial or radical nephrectomy (RN) is the current standard of care for the curative management of renal masses. The indications for LRN are similar to those for the open approach, that is, to diagnose and treat RCC in patients with tumors that are not amenable to nephron-sparing surgery (NSS). LRN has been shown to achieve equivalent short- and long-term oncologic efficacy while limiting perioperative and postoperative morbidity compared to ORN.(8,10,15) While LRN is an established treatment for clinical T1 RCC, renal tumors of almost any size and complexity have been successfully managed laparascopically, depending mostly only on the comfort level of the laparoscopic surgeon. Expanding indications for LRN include: large tumors (tumors >20 cm have been reported), tumors with renal vein or low-level vena caval thrombi, and cytoreductive surgery.(16-20)


    Historically, absolute contraindications to laparoscopic surgery have included: uncorrected coagulopathy, intestinal obstruction, untreated infection, massive internal hemorrhage, and suspected malignant ascites. Contraindications specific to LRN include: high-level vena caval thrombi, bulky lymphadenopathy, and locally invasive tumors. Challenging tumor and patient characteristics, such as large tumor size, venous tumor thrombi, prominent peritumoral vessel collateralization, extensive peritumoral desmoplastic reaction, significant prior surgery in the operative field, compromised pulmonary function that may limit the insufflation required for laparoscopy, and morbid obesity, may increase the operative difficulty but are only relative contraindications to LRN that depend on the laparoscopic surgeon’s ability and clinical judgment.

    In recent years, with a better understanding of the adverse effects of chronic renal insufficiency on cardiovascular health and of the potential increased risk of chronic renal insufficiency (CRI) after RN, renal preservation has become a necessary consideration in oncologic renal surgical planning.(21,22) Accordingly, RN is contraindicated in situations amenable to NSS wherein the patient would be rendered functionally or anatomically anephric following RN, including cases of synchronous bilateral renal tumors in which NSS is mandated in 1 or both kidneys.(23) Based on its superior preservation of renal function and equivalent long-term oncologic efficacy for T1 tumors, NSS has become the treatment of choice for small, localized renal masses.(22,24) Some experts argue that even in the absence of CRI or identifiable risk factors, RN is potentially harmful to the health of the patient with a SRM and should be relatively contraindicated when NSS is technically feasible.(25)

    Special anatomy considerations

    Obesity is not a contraindication to LRN; however, it poses unique anatomic and technical challenges for the laparoscopic surgeon.(26) The key technical considerations specific to laparoscopy in the obese patient include: adjustment of trocar positioning and maintenance of adequate intraperitoneal exposure. When obese patients are placed in modified flank position, the pannus shifts disproportionately relative to midline with associated displacement of external anatomic landmarks (i.e., the umbilicus). Failure to account for the body habitus can lead to an increased port-to-kidney working distance and impaired visualization due to intra-abdominal contents. Shifting the trocars laterally in the obese patient, such that the trocars are repositioned lateral to the rectus abdominis and the pannus, compensates for this displacement and allows for similar intra-abdominal visualization as to that achieved in nonobese patients. In obese patients, a slightly higher insufflation pressure (up to 20 mm Hg) helps maintain an adequate working space. Extra-long equipment, including Veress needle (150 mm versus 120 mm), trocars (150 mm versus 100 mm), and laparoscopic instruments, also may be required depending on the thickness of the abdominal wall. The increased risk for rhabdomyolysis and tissue necrosis in obese patients necessitates the judicious padding of all pressure points and the limiting of operative time as much as possible. Obese patients are at risk for compromised ventilation during laparoscopy secondary to high intra-abdominal pressures restricting lung compliance, a problem that should prompt an ongoing dialogue between the surgeon and anesthesiologist, and elective open conversion when appropriate.

    Similarly, prior abdominal surgery is not a contraindication to LRN, but it should raise the suspicion of intra-abdominal adhesions and the potential for bowel being in close proximity to the abdominal wall. Given the increased risk of injury to bowel during trocar placement, the initial Veress needle entry site should be away from the prior surgical field or any visible incisional scars. With proper port planning, the Veress entry site usually can be positioned to serve as one of the working ports or as extra assistant port for retraction. Veress needle safety tests, including the aspiration/irrigation, “drop”, and advancement tests, may provide useful information regarding proper Veress placement; however, an initial intraperitoneal insufflation pressure less than or equal to 10 mm Hg and symmetric expansion of the abdominal wall are two of the most reliable indicators of correct intraperitoneal placement and are recommended.(27) Elevation of the anterior abdominal wall at the time of Veress needle placement has not been shown to avoid visceral or vessel injuries and actually may increase the incidence of failed entry; therefore, it is not routinely recommended.(27,28) Open trocar placement using the Hasson technique has been shown to reduce the incidence of failed entry and may minimize vascular access injuries; however, in the authors’ experience, it is generally unnecessary.(28,29) Alternatively, the peritoneal cavity may be avoided entirely by using a retroperitoneal approach.

    In the setting of bulky or unfamiliar pathology, prior surgery, or other cases of aberrant anatomy, careful review of preoperative imaging studies, continuous anatomic re-orientation, and vigilant self-questioning are recommended prior to intra-peritoneal access and throughout the case.

    Patient positioning / Special instrumentation

    Transperitoneal, the traditional and most widely used approach for tackling renal pathology, is described. The patient is initially laid supine for the induction of general anesthesia and endotracheal intubation. An indwelling bladder catheter is inserted and connected to gravity drainage. The patient is re-positioned in a lateral decubitus position with the operative flank facing the ceiling. The top of the patient’s iliac crest is positioned over the bottom of the kidney rest. The hip and knee of the lower leg are flexed at 45 degrees and 90 degrees, respectively. The upper leg is maintained straightened in neutral position, supported by pillows placed between the legs. The hip, knee, and ankle of the dependent leg are padded thoroughly. The lower arm is outstretched on an arm board with 90 degrees of shoulder flexion, full elbow extension, and 90 degrees of forearm pronation. At this point, the table is fully flexed, opening the space between the iliac crest and the rib cage, and placed in slight Trendelenburg until the flank is parallel to the floor. An axillary roll is inserted underneath the dependent axilla to prevent undo pressure on the brachial plexus. The upper arm is secured to a floating arm board in 90 degrees of shoulder and elbow flexion with 90 degrees of forearm pronation. Care is taken to ensure that the upper arm does not encroach on the operative field. Finally, the patient’s body is rotated slightly posterior, approximately 60 degrees. A rolled towel is placed behind the back to maintain this position. The patient is secured to the operating table with heavy tape, applied to the patient’s skin at the greater trochanter of the upper hip and approximately at the nipple line across the chest (a towel can be used to protect the nipples from tape injury). The tape is passed several times around the operating table to prevent inadvertent movement during the surgery. An extraction site, usually a Pfannenstiel or Gibson incision, is marked out on the skin prior to prepping and draping the patient.

    A basic laparoscopic instrument set is opened. An endovascular gastrointestinal anastomosis (GIA) stapler with vascular loads as well as polymer and metal clips can be used for vascular control. Specialized electrosurgical hemostatic instruments, i.e. the LigaSure™ vessel sealing system and the Harmonic Scalpel™ (Ethicon Endo-Surgery, Cincinnati, OH), are not routinely needed. A nonpermeable endoscopic specimen retrieval pouch is important for preventing tumor spillage during specimen extraction. Extra long instruments may be required for obese patients.


    Trocar Placement

    A laparoscopic radical nephrectomy typically can be accomplished through three to four ports. For a left-sided nephrectomy, the right-handed most inferior port (10/12 mm) is placed lateral to the rectus muscle at a distance halfway between the anterior superior iliac spine and the umbilicus at the level of the umbilicus. Approximate locations of the remaining ports can be planned prior to insufflation but will often shift after insufflation. The middle camera port (10/12 mm) is marked just lateral to the rectus muscle at the level of the tip of the twelfth rib. The left-handed port (5 mm) is marked at the intersection of lateral aspect of the rectus muscle and the costal margin, approximately two fingerbreadths inferior to the rib.  Peritoneal access and insufflation of the abdomen are achieved through the first port (most caudal port), and locations of the remaining ports are adjusted accordingly to achieve appropriate triangulation around the kidney. For a right-sided nephrectomy, port positioning is similar except that the left-handed most inferior port through which access is achieved is 5 mm, while the right-handed most superior port is 10/12 mm.  For simplicity, the right-handed port is always 10/12 mm. An optional subxiphoid port (5 mm) may be placed for liver retraction (in a right-sided nephrectomy).


    Reflection of the colon:

    Following intraperitoneal entry and a brief inspection of the abdomen, attention is focused to reflection of the colon. Any adhesions limiting the operative exposure are divided prior to proceeding.

    The peritoneum is incised lateral to the colon. Although the incision traditionally is described along the line of Toldt, it may not need to be that lateral, as long as the incision is lateral to the colon. For a left-sided nephrectomy, the incision is carried from just below the lower pole of the kidney inferiorly to the tip of the spleen superiorly. After incising the peritoneum, be very careful as dissection should NOT precede any further posteriorly. Dissection too far posteriorly will create a plane behind the kidney severing its lateral attachments and making the remainder of the operation more challenging. Preservation of the lateral renal attachments, until the hilum is controlled and divided, stabilizes the kidney and avoids the need for additional ports early on for kidney retraction. The lienocolic ligament is incised allowing the spleen and pancreas to fall medially with the colon. Once the colorenal interface is identified, blunt dissection in this plane should allow the colon to be swept medially, exposing Gerota’s fascia and the underlying renal silhouette. Take note that the peritoneal layer overlying the kidney (parietal peritoneum) is rather thin; dissection too deep may lead to entry into Gerota’s fascia while dissection too close to the colon may lead to entry into visceral peritoneum containing the nerves and blood vessels of the colon’s mesentery. Perirenal fat (contained within Gerota’s fascia) is pale yellow while the mesenteric fat (of the colon) is a brighter yellow. Identifying this correct plane between the colon and Gerota’s fascia is occasionally challenging for residents early in their training. However, it is critical to appropriately identify this plane to safely and effectively complete a laparoscopic nephrectomy. For a right-sided nephrectomy, mobilization of the colon is accomplished in a similar fashion except that the line of Toldt may be less clearly defined. The peritoneum is incised from just below the lower pole of the kidney inferiorly to the liver edge superiorly. An extra subxiphoid 5-mm port may be required for liver retraction, which is achieved by elevating the liver edge and grasping high on the lateral abdominal wall with a locking Allis clamp; however, care must be taken to ensure the locking clamp does not tear into the pleura. As alternatives, a self-retaining laparoscopic fan retractor or a laparoscopic snake retractor can be used. Furthermore, on the right, the peritoneum just lateral to the duodenum is sharply incised (Kocher maneuver), allowing medial reflection of the duodenum and exposure of the renal hilum.

    Dissection of ureter:

    After reflecting the colon, the psoas muscle is readily identifiable below the lower pole of the kidney. The psoas muscle serves as a landmark for the ureter and gonadal vessels, which run anterior and parallel to the muscle inferior to the kidney. For this portion of the procedure, the psoas muscle should be maintained in a horizontal orientation on the video display until the renal hilum is clearly identified. As dissection continues over the psoas muscle, the gonadal vein is encountered first and swept medially. The ureter, uniquely discernible by its peristaltic movements, lies just deep to the gonadal vein. Once the ureter is identified, it is elevated and followed superiorly to the renal hilum.

    Dissection of renal hilum:

    Gentle anterior retraction on the inferior pole of the kidney will place the renal hilum on stretch, more clearly delineating its course. Once identified, the hilum should be oriented vertically on the video display, preventing its confusion with the great vessels. A combination of blunt aspirator dissection and piecemeal hook electrode dissection over the inferior-most portion of the hilum will expose the renal vein. The renal vein typically runs anterior to the renal artery, which usually lies directly posterior, but may be slightly superior or inferior to the renal vein. Following adequate identification and exposure of the renal vessels and control of any accessory or lumbar vessels, the hilum is taken. A right-angle clamp is passed behind the renal vessels individually and spread open to ensure adequate space for circumferential control. The renal artery is controlled and divided first before dividing the renal vein. The renal artery is controlled with polymer clips, with at least 2 clips preferred on the patient (stay) side, and then divided. Great care should be taken for appropriate use and application of these clips as previously described.(30) The vein is divided with an endovascular GIA stapler. For adrenal-sparing left-sided nephrectomies, the renal vein should be divided distal to the adrenal vein’s insertion into the renal vein, thus preserving its primary venous outflow.  Pre-operative imaging is a useful tool that may forewarn the surgeon of accessory vasculature or aberrant vascular anatomy and should supplement careful intra-operative dissection of the renal hilum.

    The upper pole and adrenal gland:

    While traditionally removed in Robson’s original description of the radical nephrectomy, the adrenal gland often can be preserved in contemporary radical nephrectomies, unless there is suspicion of direct tumor involvement. Before proceeding with dissection of the superior renal attachments and adrenal gland, the ureter is divided between clips, allowing anterior mobilization of the upper pole. For adrenal preservation, Gerota’s fascia is incised above the divided renal hilum, and dissection is carried superiorly and posteriorly along the border of the upper pole of the kidney. The adrenal gland with its golden yellow globular fatty appearance is excluded from the dissection and bluntly mobilized off the kidney. For right-sided nephrectomies, care must be taken during mobilization of the adrenal gland, as the right adrenal vein is very short and easily avulsed as it drains directly into the inferior vena cava.

    Division of the remaining (lateral) attachments:

    After division of the hilum, ureter, and superior attachments of kidney, only the lateral attachments remain. These attachments are divided, staying in the plane of para-renal fat between Gerota’s fascia and the abdominal sidewall.

    Specimen extraction:

    Once freed of all its attachments, the kidney is placed in specimen retrieval pouch. The area of dissection is carefully inspected for good vasculature control as well as overall hemostasis. The intended extraction site is inspected for adhesions, which if present, are divided sharply prior to proceeding. The kidney is removed through the pre-determined Pfannenstiel or Gibson incision, ideally in muscle-splitting (non-muscle cutting) fashion.


    After closing the extraction site, pneumoperitoneum is re-established, and the abdomen is re-inspected for good hemostasis after at least 10 minutes of desufflation. The fascia of the any trocar sites greater than 5 mm is closed with the assistance of a Carter-Thomason suture passer device. Finally, the skin is re-approximated.


    While complications are sometimes unavoidable in surgery, a thorough understanding of the procedure and its potential risks can minimize their morbidity. Awareness of potential complications may prevent them entirely, or allow for early recognition and timely intervention when they occur. An open, honest discussion of potential complications is also essential to the informed consent process.

    Based on a large contemporary meta-analysis, urological laparoscopic procedures as a whole are associated with a 22% overall complication rate, a 0.07% mortality rate, and a 2.7% open conversion rate.(31) Adverse events associated with laparoscopic surgery can be broadly divided into four categories based on their usual time of presentation: complications related to gaining access and establishing pneumoperitoneum, complications related to the surgical procedure, post-operative complications, and complications related to general anesthesia. These complications include: adjacent organ injury (bowel, diaphragm, gall bladder, liver, nerves, pancreas, spleen, stomach, ureter, urinary bladder); bleeding; cardiovascular events (arrhythmia, cardiovascular collapse, myocardial infarction); genitourinary events (transient elevation in serum creatinine, ureteral obstruction, urinary retention, urinary tract infection); lymphatic events (chylous ascites, lymphocele); neuromuscular events (pain, paresis, paresthesia, rhabdomyolysis); prolonged ileus; pulmonary events (aspiration of gastric contents, atelectasis, gas embolism, pneumonia, pneumothorax, pulmonary edema); thromboembolic events (deep venous thrombosis, pulmonary embolism); vascular injury; and wound events (infection, internal hernia, hematoma, port-site hernia, seroma, wound dehiscence).

    Compared to other urological laparoscopic procedures, the overall complication for LRN is much lower at approximately 4% and does not differ significantly from that of ORN.(31,32) The most common perioperative complications during transperitoneal LRN are: adjacent organ injury, which occurs in up to 4% of cases, and vascular injury, which occurs in up to 2% of cases.(32) By organ, the incidence of injury is: bowel (0.8%), diaphragm (0.6%), pancreas (2.1%), and spleen (1.4%).(32) Post-operative bleeding requiring blood transfusion occurs in up to 1% of cases.(31,32) Post-operative ileus occurs in 1-2% of cases but may be as high as 10% in some series.(31-33) Port-site metastases are extremely rare with only six cases reported in the literature.(32)

    In recent years, new onset CRI has been ascribed to RN as a potential complication based on evidence that patients with a normal preoperative creatinine are at a higher risk of developing CRI after RN than after NSS.(34) Considering long-term data from living kidney donors suggesting that a healthy solitary kidney can maintain normal function, it is unlikely that RN causes de novo renal injury; however, it may unmask occult CRI in the apparently normal (spared) contralateral kidney in patients with co-morbidities known to be associated with CRI.(35,36)

    Outcomes Data

    When comparing LRN and ORN, no randomized controlled trials have assessed oncological outcomes to date. Based on one prospective cohort study and several retrospective studies with up to 10 years followup, LRN appears to be oncologically equivalent to ORN in terms of overall (OS), cancer-specific (CSS), and disease-free (DSS) survival rates with regard to local tumor control.


    ORN in terms of overall (OS), cancer-specific (CSS), and disease-free (DSS)

    Final thoughts

    The key to accomplishing this procedure laparascopically through no more than 3 (left-sided) or 4 (right-sided) ports lies in maintaining the lateral sidewall attachments to the kidney as a source of natural upward suspension/retraction on the kidney until after the division of the renal hilum and ureter. To achieve this, care is taken not to dissect too deeply lateral to the kidney. After superficially incising the lateral colonic attachments, the colon is swept medially exposing the underlying contour of the kidney. Any further dissection lateral to the kidney after reflection of the colon can release the lateral attachments and lead to falling of the kidney medially, which may require the insertion of additional ports for retraction, or lead to unnecessary bleeding from the abdominal sidewall.

    As in the open approach, a good operation relies on a good working knowledge of anatomy. With increasing emphasis placed on the importance of nephron preservation, partial nephrectomy is being utilized more frequently for the treatment of small renal masses with comparable oncologic control as the open approach. As a result, laparoscopic radical nephrectomy is being reserved increasingly for large renal masses that are not amenable to partial nephrectomy or ablative procedures. Large renal tumors are more likely to distort surrounding anatomy, making one’s understanding of the normal anatomy all the more important.

    An understanding of the renal anatomy is most important during identification of the ureter and transection of the renal vessels. Once the inferior pole of the kidney is identified, dissection caudally typically will encounter first the gonadal vein (superficial) followed by the ureter (deep). After the ureter is isolated, tracing it superiorly will lead to the renal hilum. At the hilum, the renal vein is typically anterior to the renal artery, which is anterior to the renal pelvis and ureter. On the left side, the renal vein is longer but receives multiple branches: the left adrenal vein superiorly, the lumbar vein posteriorly, and the left gonadal vein inferiorly. On the right side, the renal vein is much shorter and enters the inferior vena cava directly on its posterolateral aspect, but it typically does not receive any branches. These relationships are important during management of the adrenal gland. Both adrenal glands are enclosed within Gerota’s fascia and are separated from the upper pole of the kidneys by a thin layer of connective tissue. The right adrenal gland is directly superior to the kidney, while the left adrenal gland is slightly medial and superior to the kidney’s upper pole.  On the left side, the renal vein should be divided distal to the insertion of the adrenal vein for adrenal-sparing procedures. On the right side, care should be taken when mobilizing the posteromedial aspect of the adrenal gland to avoid avulsion of the adrenal vein when removing the adrenal gland.

    Finally, a few points are worth mentioning regarding obtaining hilar control. When approaching the hilum, it is helpful to place anterior traction on the lower pole of the kidney providing gentle traction on the hilar vessels, which aides in the identification of the renal vein, and ultimately, the renal artery. During transection of the renal vessels, it is a good habit to leave a reasonable vascular stump on the stay side for easy proximal control in emergency cases of stapler or clip misfire. When large vessels are controlled between vascular clips, it is best to not transect the vessels with one cut, but rather at least two cuts to completely divide the vessel. This allows confirmation that your proximal clips are appropriately placed and the vessel is controlled. If after an initial cut bleeding is encountered the remaining uncut portion of the vessel will allow for traction of the stump and allow the placement of additional clips in a controlled fashion of the incompletely occluded vessel.

    Additional Surgical Pearls

    • Confirm the correct side (radiographically, if possible) before making incision.
    • Position the patient to take advantage of gravity.
    • Pad the patient well to avoid pressure wounds.
    • Know the equipment; don’t expect the operative team to know it.
    • Communicate with the anesthesia team.
    • Place trocars in standard triangulation (just like open surgery – keep the eyes/scope in the middle and the hands/laparoscopic instruments at 45 degree angles to the focal point).
    • Don’t forget to use both hands! Trainees often forget to use the non-dominant hand.
    • Retraction is an active maneuver that requires continual repositioning.
    • Anatomy doesn’t always follow the textbook or the pre-operative imaging.
    • Don’t rush the dissection.
    • Find the correct planes. This (and good judgment) is what separates good surgeons from great surgeons.
    • Consider what else that obvious structure could be, before cutting it!
    • If using locking clips, use them correctly!(30)
    • Always plan for trouble before encountering it, for every single step of the case (i.e. anticipate a stapler misfire before it happens).
    • Don’t panic; keep cool! This attitude sets the tone for the entire operating room. Even if there is a problem, act quickly, decisively and calmly, and everyone else will follow.
    • If significant bleeding is encountered, quickly assess whether it can be controlled laparascopically (i.e. with an atraumatic bowel grasper, increased pneumoperitoneum, or a 4”x18” sponge which fits through a 12 mm port).  Once the bleeding is controlled laparascopically, the decision can be made to open in a more controlled fashion.
    • If urgent open conversion is necessary, do so calmly and expeditiously. Maintain pneumoperitoneum as long as possible. A subcostal incision is usually safe for most approaches. Use the laparoscopic intraperitoneal view to help facilitate a quick laparotomy. Communicate with the operative and anesthesia teams the entire time; they can really help!
    • Wait at least 10 minutes at the end of the case without pneumoperitoneum before re-inspecting for bleeding.
    • Don’t become too comfortable or too confident; that is when mistakes are made.
    • Expect the unexpected.


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