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.