- The camera port is marked off the tip of the 12th rib. For lower pole tumors, the camera site is shifted inferiorly towards the ASIS.
- The retroperitoneum is entered at the marked camera port site, and the retroperitoneal space is developed first with one’s index finger and then using a retroperitoneal dilating balloon dissector.
- Once the 8 mm lateral port site is placed under digital guidance 6-8 mm lateral to the camera port, a balloon-tipped camera port is inserted.
- Retroperitoneum is insufflated to 15-18mm of Hg and a laparoscopic Kitner is used to sweep the peritoneum medically. Entry into the peritoneum should not fluster the surgeon, as the case can be completed with little difficulty if a 4th medial arm is utilized to lift the kidney medially.
- Remaining ports are then placed under direct vision 6-8mm apart from each other.
- Use of bariatric ports (especially for the lateral arm) can be of tremendous help when resecting upper pole tumors as the greater distance of the robotic arm from the body that is afforded by these longer ports helps prevent collision with the hip/body wall as the dissection proceeds cranially. We have now started routinely using bariatric ports for all cases.