The Transabdominal Lumbar Approach (TALA) for Robotic Renal Surgery-A Retrospective Single-Center Comparative Study and Step-by-Step Description of a Novel Approach

Abstract

The transperitoneal approach (TP) and the retroperitoneal approach (RP) are two common methods for performing nephrectomy or partial nephrectomy. However, both approaches face difficulties, such as trocar placement and limited working space (RP). TP is impaired in the case of dorsal tumors and dissection of the renal artery can be challenging due to the anatomic localization dorsally to the renal vein. A hybrid approach that combines both methods has been previously reported in a case series, but not evaluated systematically. This study proposes a modified hybrid approach, which we call the transabdominal lumbar approach (TALA), involving late robotic docking after elaborating the retroperitoneum using conventional laparoscopy. The study compares the last 20 consecutive patients who underwent RP and the last 20 patients who underwent TALA at our institution. The investigated variables include operative time and amount of blood loss, hospitalization duration, postoperative analgesia requirement, and postoperative complications. The study found no significant difference in operative time, blood loss, ischemia time, or hospital stay between the two groups. The TALA group had fewer complications regarding Clavien-Dindo category 3, but one complication of category 4. In Conclusion, TALA is a safe and promising approach that combines the advantages of RP and TP.

Keywords: laparoscopy; nephrectomy; partial nephrectomy; robotic surgery; surgical technique.

Figure 1

Step-by-step description of the trocar placement for the transabdominal lumbar approach (TALA). (A) The first trocar (1) is placed at the crossing of the lumbar line (green line) oriented in direction towards the umbilicus and the lateral boarder of the rectus abdominis muscle (yellow line). After placement of the first trocar (trocar 1) and establishing the pneumoperitoneum two additional DaVinci-trocars are placed (trocars 2 and 3). One (trocar 2) on the lumbar line at a distance of approximately 8 cm and a second DaVinci trocar (trocar 3). It is important to achieve a slight triangulation and a distance of 6–8 cm between the other trocars. (B) Next, the retroperitoneum is opened by a conventional laparoscopic incision of the Toldt’s line and blunt dissection (B1). (C) The lateral abdominal wall is exposed (C1) in the retroperitoneum, one additional trocar (trocar 4) is placed under direct vision (C2). (D) The DaVinci trocar 3 is replaced by a 12 mm assistant trocar (trocar 12). (E) The last DaVinci trocar (trocar 3) is now placed between (trocar 2 and trocar 4) with a distance of approximately 6–8 cm in between. (Images (A,C–E) courtesy of magicposer).

Figure 2

Description of the procedure showing the intraoperative view of the operation (A) docked robot; (B) view of the anatomy after docking: Colon ascendens (beneath right instrument), kidney shape left to left instrument; (C) incision of the peritoneum between kidney and colon; (D) dissection of the lower pole adherences; (E) view of psoas muscle; (F) avascular plane between psoas muscle and kidney (holding up kidney); (G) Renal artery, (H) dissection of the renal vein after dissection of the renal artery and clamping of the renal vein; (I) final postoperative view after undocking of robot and wound closure.