**4.1 Patient positioning and port placement**

The patient is kept nil by mouth for 8 hours before the scheduled surgery. Under General Anesthesia, nasogastric tube is placed and the bladder is catheterized. Preoperative injectable antibiotics, preferably third generation Cephalosporins are given.

The patient is placed in ipsilateral kidney position at an angle of 45 degrees and the kidney bridge of the operating table is raised. The patient is secured to the table with upper leg kept extended while lower leg flexed with a pillow between the legs. The arms rest comfortably with padding. The operating surgeon and camera person are on the left side of the patient and the monitor is kept on the right side of the patient at the level of eyes of the surgeons.

Following ports are placed as shown in **Figure 1** for right side and in **Figure 2** for left side LRN:


*Operative Techniques and Outcomes in Laparoscopic Radical Nephrectomy DOI: http://dx.doi.org/10.5772/intechopen.106475*

#### **Figure 1.**

*Port placement for right side laparoscopic radical nephrectomy (Hollow circles: 10 mm ports and Solid circles: 5 mm ports).*

#### **Figure 2.**

*Port placement for left side laparoscopic radical nephrectomy (Hollow circles: 10 mm ports and Solid circles: 5 mm ports).*

#### **4.2 Transperitoneal approach**

	- a.Right side: Liver is retracted by atraumatic grasper placed through an extra 5-mm port distal to xiphisternum followed by isolation and dissection of lower pole of kidney with ureter. This is followed by creation of plane between upper pole of

#### **Figure 3.**

*Intra-operative image depicting mobilization of colon on left side.*

#### **Figure 4.** *Intra-operative image depicting the Gerota's fascia on left side.*

#### **Figure 5.**

*Intra-operative image depicting the dissection of right renal superior pole from liver.*

kidney and adrenal gland thereby creating an upper window proximal to renal vein (**Figure 5**). Dissection of right renal vein in relation to IVC is then done by blunt and share dissection using energy source (**Figure 6**). Thus the right renal vein is dissected circumferentially. The right renal artery which lies inferior and posterior to the right renal vein is then dissected (**Figure 7**) and clipped with two haem-o-lok clips proximally and two distally. After clipping of renal artery, renal vein is clipped with two haem-o-lok clips proximally and two distally.

*Operative Techniques and Outcomes in Laparoscopic Radical Nephrectomy DOI: http://dx.doi.org/10.5772/intechopen.106475*

#### **Figure 6.**

*Intra-operative image depicting dissection of right renal vein from IVC.*

#### **Figure 7.** *Intra-operative image depicting right hilar dissection.*

#### **Figure 8.**

*Intra-operative image depicting dissection of left renal vein and its branches.*

b.On the Left side: On left side, after the lower pole is isolated gonadal vein is identified and dissected cranially to find the left renal vein (**Figure 8**). After the renal vein is seen, lumbar vein is identified and clipped for identification renal artery which lies posterior to it. This is followed by creation of upper window proximal to renal vein by clipping of adrenal vein. The right renal artery which lies inferior and posterior to the right renal vein is dissected (**Figure 9**) and clipped with two haem-o-lok clips proximally and with two

**Figure 9.** *Intra-operative image depicting left renal artery with psoas window.*

distally. After clipping of renal artery, renal vein is clipped with two haem-olok clips proximally and two distally.

