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The patient is placed in the lateral flank position with elevation of the kidney bridge. Further, the table may be tilted anteriorly to allow the peritoneum and bowel to fall away from the proposed port site. The primary port is placed using a 1.5-cm incision, 2 cm below and posterior to the tip of the 12th rib in the posterior axillary line, deepened down to the thoracolumbar fascia. A retroperitoneal space is created using a self made baloon. Two or three secondary ports are inserted under laparoscopic vision or finger guided to avoid transgression of the peritoneum. The hilar vessels are dissected first and divided. The ureter is dissected and divided. The kidney is mobilized all round and delivered intact by extending a port or by joining two ports. Alternatively, the specimen may be removed piecemeal after morcellation within a plastic bag. A 14-F tube drain is left behind in the retroperitoneal space through the 5-mm port site at the discretion of the surgeon.
The retroperitoneal approach mimics traditional open surgery in that kidney is approached without entry into the peritoneal cavity thereby providing an advantage in patients with a history of multiple abdominal surgical procedures or peritonitis. It is therefore imperative that the laparoscopic surgeon should be familiar with both transperitoneal and retroperitoneal approaches. Retroperitoneal approach also provides direct access to the hilum resulting in early vascular control and making the subsequent dissection easier.
The disadvantages of the retroperitoneal approach include a steeper learning curve in view of an absence of traditional landmarks and a limited working space that can result in difficulty with orientation, visualization, trocar spacing and organ entrapment. Even though this provides an extraperitoneal operation, injury can occur to intra-abdominal organs, and a hernia can be created during balloon dilatation of the extraperitoneal space. The retroperitoneal approach results in complication rates, pain medication requirements, length of hospital stay and times to return to normal activity after surgery similar to those of transperitoneal route
