Standardized Linear Port Configuration to Improve Operative Ergonomics in Laparoscopic Renal and Adrenal Surgery: Experience with 1264 cases

Abstract

Traditional laparoscopic port placement for upper urinary tract surgery involves camera access via the umbilicus with working ports placed on either side of the camera at various locations. This diamond configuration requires the camera operator to cross hands with the surgeon, resulting in poor ergonomics. A standardized linear port configuration has been used for nearly all transperitoneal urologic surgery at our institution. The purpose of this article is to describe our experience with this simplified approach and its advantages. A retrospective review was conducted of all laparoscopic cases by a single surgeon from 2000 to June 2009. The linear port configuration includes three ports placed along the ipsilateral pararectal line with the most superior port one fingerbreadth below the costal margin and the inferior port at the level of the umbilicus. A 5-mm camera is used through the most superior port. A low transverse extraction site is typically used, if necessary. There were 1264 laparoscopic cases performed using the linear port configuration. Of these, there were 1038 donor/radical/simple and 60 partial nephrectomies, 35 nephroureterectomies, 49 adrenalectomies, 50 pyeloplasties, 20 renal cryoablations, and 12 miscellaneous renal procedures. Of these, 98.2% were performed successfully via this port configuration. Three cases needed an additional port. The intraoperative complication rate was 0.9%, and mean estimated blood loss was 60 mL. There were 20 (1.6%) open conversions: 16 were elective and 4 secondary to complications. Simplifying port placement via a linear configuration for both right and left renal and adrenal surgery is feasible, easy to learn, simplifies strategic planning preoperatively, and provides excellent exposure. Using camera access through the superior port allows for direct visualization and minimizes interaction between the camera holder and surgeon's working envelope.