What is the anatomy of the kidney relevant to extraperitoneal nephrectomy?

Updated: Sep 24, 2019
  • Author: Michael Grasso, III, MD; Chief Editor: Bradley Fields Schwartz, DO, FACS  more...
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Answer

Answer

Laparoscopic port positioning is subcostal, with the posterior port placed below the junction of the 12th rib and the paraspinous musculature. The middle endoscopic port is positioned just medial and below the tip of the 11th or 12th rib. From this position, after development of the retroperitoneal potential space, immediate endoscopic landmarks include the horizontally oriented psoas muscle and Gerota fascia. Anteriorly, the peritoneal reflection is identified and teased medially to allow for placement of the third laparoscopic port under direct vision. This prevents accident entry into the peritoneal cavity.

After opening Gerota fascia posteriorly, the great vessels are noted medially, and the renal hilum is typically located at the junction of the inserting diaphragmatic muscle fibers with the psoas muscle. Early identification of the inferior vena cava (IVC) on the right, and the pulsating aorta on the left, is helpful to maintain correct orientation. The relationship between the great vessels and accessory vasculature, such as gonadal, adrenal, and lumbar vessels, is also routinely noted during dissection. The renal artery is identified as a pulsating, vertically oriented structure, with the renal vein often lying anterior to the artery. Lumbar vessels directly entering the renal vein are commonly encountered, frequently draping around the renal artery during left renal dissection.

Landmarks noted during renal dissection include the extraperitoneal surfaces of the liver (right side) and spleen (left side). Complete dissection of the suprarenal IVC often defines not only the adrenal vasculature but also frequently the right hepatic vein. Meticulous dissection of the left renal vein before division with an endovascular stapling devise is key to preserving the superior mesenteric artery, which resides directly anterior. During right nephrectomy, the duodenum is also readily identified medially, and in most cases can be gently retracted anteriorly when developing the specimen.


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