Radially expanding laparoscopic access for renal/adrenal surgery.

Abstract Objectives. To use a radially expanding system (Step) and a modified port location for intra-abdominal access to decrease the access-related complications in renal and adrenal surgery. Access-related complications during laparoscopic renal surgery are frustrating and are more common in patients with previous abdominal surgery and associated adhesions. Methods. Laparoscopic upper tract procedures were performed in 62 patients using radially expanding trocars, and the results were reviewed with regard to access, port placement, and associated complications. For initial access, a Veress needle was placed subcostally in the midclavicular line. An expandable mesh sleeve trocar was used for trocar insertion after a pneumoperitoneum was established. A blunt-tipped fascial dilator was used to dilate to 10 or 12 mm. Additional ports were placed in an L shape (nephrectomy) or a subcostal configuration (adrenalectomy) under direct vision using the Step ports. Results. Of 62 patients, 24 had had prior abdominal surgery. Open insertion of the mesh sleeve was necessary in 20%, of whom 60% had had prior abdominal surgery. In 9% of cases, the liver was punctured with the initial pass of the Veress needle. Only minimal bleeding from the injury site was noticed. The liver punctures did not require cauterization and did not result in conversion to an open procedure. At a mean follow-up of 12 months, no access-related complications or port-site hernias were noted. Conclusions. Placement of the initial access subcostally at the level of the midclavicular line helps to prevent visceral injury, especially in patients with previous abdominal surgery. The use of the radially expanding access system with the modification of port location allows safe and rapid laparoscopic access for upper urinary tract surgery. This trocar system is an excellent alternative to the standard laparoscopic trocars.