**4.3 Retroperitoneoscopic LRN**

Retroperitoneoscopic radical nephrectomy may be considered in selected patients – history of multiple transperitoneal open surgical procedures, peritoneal dialysis, pregnancy and morbid obesity. In pregnancy, a retroperitoneoscopic surgery may minimize peritoneal and uterine irritation and the risk of preterm labour [7]. In morbidly obese patients, the retroperitoneoscopic approach may help by avoiding abdominal pannus and voluminous visceral fat encountered during transperitoneal approach [8].

Under general anesthesia with end tidal CO2 monitoring under cover of prophylactic antibiotics, the patient is positioned in the same way as above. The surgeon and camera person stand on ipsilateral side of the patient while the assistant on opposite side of the patient. Initial access is obtained by open (Hasson's technique). A 10–12 mm incision is made in the lumbar (Petit's) triangle below the 12th rib

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

at the lateral border of paraspinal muscle [9]. The muscle fibers are carefully separated and retroperitoneum is entered by gently piercing the thoracolumbar fascia with tip of an artery forceps. A balloon dilator is then inserted into the opening. Distention of the balloon with air rapidly and atraumatically displaces the adjacent fat and peritoneum, thereby creating an adequate working space for retroperitoneoscopic surgery within that area. A 10 mm port is then placed in this opening and used as camera port. The 2nd and 3rd ports were then inserted under direct vision. The psoas muscle acts as a landmark and the posterior aspect of the kidney is reached first and the pulsating renal artery is identified at the hilum. The renal hilum is dissected, the renal vein and renal artery cleared of fat and clipped using haem-o-lok clips and vessels divided. Further dissection of kidney is then continued separating it from the surrounding fat. The ureter is then clipped and divided; the specimen is retrieved by incising one of the port sites and increasing it to 2.5–3 cm. A drain is left in the retroperitoneum.
