Bilateral hand-assisted laparoscopic renal surgery in the supine position: the spleen at risk

We evaluated the safety of simultaneous bilateral renal procedures performed using hand-assisted laparoscopy (HAL) with the patient in the supine position.

After securely strapping the patient to the table, a hand-port device is placed via a 7-cm supraumbilical or peri-umbilical incision with two to four 5-mm to 12-mm trocars placed bilaterally. During a 3-year period, 8 bilateral HAL renal operations were initiated (upper pole partial nephrectomies, 3 nephroureterectomies, 3 bilateral nephrectomies, and right nephrectomy with left adrenalectomy).

Mean patient age was 41 years. One patient with ADPKD required conversion to open due to failure to progress secondary to excessive perirenal fat and 22-cm kidneys. The other 7 were completed successfully with a mean operative time of 417 minutes and mean EBL of 336cc. Two patients received transfusions. Two small splenic lacerations, managed conservatively, were the only complications.

Bilateral hand-assisted laparoscopic renal surgery with the patient in the supine position (rolling the table side to side) is feasible in the majority of patients. However, very large kidneys (eg, ADPKD) may be better approached with the patient in the lateral decubitus position or via an open subcostal incision. Importantly, the spleen appears to be at increased risk for capsular injury due to apparent increased difficulty of left colon mobilization in the "rolled" or "airplaned" supine position.