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Bashir Yunusa et al

5 mm trocars are placed through the anterior abdominal costal margin, third port is placed posteriorly between the
fascia in a triangular configuration. A 5 mm 45º laparoscope 12th rib and iliac crest along the lateral border of sacrospi­
is used along with articulating laparoscopic instruments. natus muscles and the fourth port for retraction is placed
The laparoscope is placed through the most medial trocar cephalad to the first port at anterior axillary line. The right
and positioned anteriorly in the abdomen so that the camera side is a mirror image of the left but the liver lobe is retracted
looks down onto the surgical field. The working instruments percutaneously reducing the ports number to three. 23
are placed through the two lateral trocar. 18 Retroperitoneal posterior approach described by Walz
et al, and thoracoscopic transdiaphragmatic approach
Laparoscopic Adrenalectomy described by Gill et al are not commonly used. 20

Laparoscopic adrenalectomy (LA) has become a gold stan­
dard in the management of most of the adrenal disorders, LESS Adrenalectomy
after it was described by Schuessler et al in 1993 and The approach is usually through transumbilical incision and
19
matched it success with open. Apart from advantages placement of multichannel single Gelport and 3.5 mm ports
like early recovery, reduced hospital stay and cosmesis, the for flexible laparoscope, SILS dissector and tissue sealing
main benefits of LA over open adrenalectomy are decreased device; and the adrenal gland approached anteriorly in cases
incidence of intraoperative and postoperative hemorrhage, of right side with no mobilization of the right lobe of the
23
decreased morbidity and mortality. liver, and the left is approached laterally. Retroperitoneal
LESS adrenalectomy has also been described.
Transperitoneal Laparoscopic Adrenalectomy

This involves putting 12 mm port in the umbilicus or at the Laparoscopic Approaches to the Ureter
lateral border of rectus abdominis muscle just above the A three­port approach with primary port at the umbilicus,
level of umbilicus. Two subcostal 5 mm ports at midclavi­ one 5 mm port midway between the umbilicus and the medial
cular line and in the lateral border of the rectus and another costal margin and a 5 mm port midway between the antero­
3.5 mm subcostal trocar­anterior axillary line, for the left superior iliac spine and the umbilicus, was described. 24
adrenals. The right is approached through a mirror image Umbilical port with, ipsilateral hypochondrium and iliac
and an additional epigastric port to the left of the liver for fossa as working ports have been described for approaches
its retraction. 20 to upper and mid ureter while ipsilateral paraumbilical and
Right adrenalectomy can also be performed with four suprapubic ports for lower ureter while maintaining the
ports. The primary camera port 10 mm to be placed at about umbilical port. 25
3 cm lateral and cephalad to the umbilicus. Two working In cases of retrocaval ureter, a three port approach with
ports, 5 and 10 mm are placed in the midclavicular position, a primary port at 2.5 cm to the right of umbilicus, a 5 mm
the upper one (5 mm) below the costal margin, and the lower port midway between the primary port and right costal
one (10 mm), 10 to 12 cm below the upper one. Another margin, and on right midclavicular line, and another 5 mm
5 mm port is to be placed in the sub­xiphisternal position port midway between the anterosuperior iliac spine and
for liver retraction. A fifth 5 mm port, if required, is placed the umbilicus was used while the patient is placed in the
in the right anterior axillary line, to facilitate retraction or left lateral position. Mobilization of the ureter in the inter­
suction. 20,21 aortocaval region require additional 5 mm port to be inserted
And another approach is to put the telescope’s trocar at at the flank. 17
the umbilicus while maintaining the positions of the other LESS approach to lower ureter through suprapubic
20
trocars. In the case of the left usually, the first three ports transvesical port has been described. 26
are placed in a mirror image of the right. A fourth 5 mm
port, if required, is placed in the left midaxillary line to Laparoscopic Prostatectomy
facilitate retraction. 20­22 Laparoscopic simple or radical prostatectomy has been per­
formed through almost the same approach. The commonly
Retroperitoneal Lateral Laparoscopic described conventional laparoscopy is through a primary
Adrenalectomy
port placed upper side of the umbilicus. Then secondary
Retroperitoneal lateral approach to the left adrenal gland ports at upper margin of the pubic bone and levels of the
is through an incision at the inferior edge of the 12th rib in anterior superior iliac spines bilaterally and the fifth port
which the camera port is placed, the second port 5 mm at at a point midline at about 15 cm from the pubic bone 27,28
anterior axillary line midway between the iliac crest and while others described both iliac fossae for the last two
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