Indication, instruments and patient position E. Liatsikos, Panagiotis Kallidonis

Step 1: Instruments and patient position

• The procedure is performed under general anesthesia.
• The patient is placed in lithotomy position
• The table is positioned 45° laterally setting the kidney to be removed on the upper side.
• Gelpoint (Applied Medical Resources Corporation, California, USA) or an Endocone (Karl Storz, Tuttlingen, Germany) is inserted for umbilical access.
• Specially designed flexible cannulas (Karl Storz, Tuttlingen, Germany) are inserted for the transvaginal access.
• A combination of pre-bent and straight laparoscopic instruments is used.
• Specially designed extra-long pre-bent and straight instrumentation (Karl Storz, Tuttlingen, Germany) is found particularly useful for manipulations performed through the vagina. The extra-long pre-bent instruments provide the desired angle of approach to the kidney.
• Conventional laparoscopic instruments does not offer adequate shaft length for dissection transvaginally.
• Combination of the access ports helps in using all possible instrument combinations, even large bore instruments. The use of staplers and clip applicators is performed through the umbilical port.
• The majority of the manipulations are performed transumbilically with extra-long instruments inserted through the vagina for tissue retraction.