Fig. 7.1
Patient position for posterior retroperitoneoscopic adrenalectomy
The patient is positioned prone with hips and knees flexed, with the side of surgery as near to the side of the operating table as can be achieved. Try to minimize the lumbar lordosis with the aid of a small amount of table break and/or an oval or rectangular support under the patients abdomen that allows the abdomen to fall freely onto the surface of the operating table (not essential but may help in obese patients).
Ensure that there is sufficient padding under the patient at the hips, upper thighs, and weight-bearing surface of the tibiae. The arms are placed on boards with the hands pointing towards the anesthetist; the face should be suitably protected from pressure damage.
Pearls
When the patient is correctly positioned, mark the tip of the 12th rib before you scrub – it may be more difficult to palpate with your gloves on.
Make a transverse incision onto the tip of the 12th rib, and from this point try to avoid stretching this incision any more than you need as a gas leak through the muscle incision makes the procedure much more tedious and increases the chance and extent of surgical emphysema. Just below the tip of the rib, push the scissors through the muscle (guarding against too deep penetration) – you will feel a “pop” as you do it. Spread the jaws at the muscle layer to enlarge this hole to a size to admit your index finger.
Sweep the fat and fascia off the anterior aspect of the muscle; medially your finger will palpate the paraspinal muscles, laterally the tip of the 11th rib. Insert the medial port (10 mm) obliquely, the lateral port (5 mm), and then the blocking port. On insertion of the medial and lateral ports, you must guard the port tip with your finger as it comes through the body wall.
Insufflate and insert the telescope (30°) turned to look upwards via the middle port.
Related posts:
Stay updated, free articles. Join our Telegram channel
Full access? Get Clinical Tree
