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Monopolar diathermy, bipolar diathermy, Harmonic scalpel, and argon beam coagulator are some of the most commonly used energy sources during laparoscopic surgery, often all during the same case. This creates a clutter of foot pedals on the floor near the surgeon. One trick to reduce this clutter is to tape the smaller bipolar diathermy pedal securely onto the top of the monopolar diathermy pedal, which is taped to the floor. The current model of the Harmonic scalpel is entirely handactivated, eliminating the need for a foot pedal.

People tend to put in a minimum number of ports for simple nephrectomy, say, three ports, maybe because it’s sexy! Maybe you can even do it with two, but I think, when doing simple nephrectomy, one should not be afraid to put in an extra port, if you think that would help and you should not wait too long to do that. From the beginning, if you feel you have chosen the wrong port and need an additional port, just go ahead and put one in. The second tip is that when you go for the transperitoneal approach you often go for a zero-degree lens, but if you go in a retroperitoneal approach you absolutely need the 30-degree lens, because otherwise you will not have the optimal view. The third tip is that instead of using a GIA to control the renal vessels you can use the very nice Wecklock® clip. They are cheap, they are reliable, and they are easy to handle.

In earlier days, conventional arteriography was the standard procedure performed in every patient undergoing a donor nephrectomy. With advances in CT scanning techniques, currently we perform a 3D-CT scan with a video reconstruction as the only preoperative radiographic imaging. The 3D-CT scan provides superb visualization of the renal artery, renal vein, and the interrelationship of these extra-renal vessels. Further, it also evaluates the renal parenchyma for any abnormalities. Finally, the collecting system is imaged as well. I believe that the 3D-CT is the best test for renal vein anatomy. Currently, interventional angiography is performed in addition only in those patients who have multiple renal vessels on 3D-CT . In a recent study, in which 50 potential kidney donors underwent both the 3D-CT scan and conventional arteriography, in every patient that the 3D-CT confirmed a single renal artery and single renal vein bilaterally, arteriography confirmed these findings.[ 1 ]

Placement of the hand-assistance device depends on the device being used. As opposed to the original handassistance devices, the current ones are placed before creating the pneumoperitoneum. The manufacturer’s instructions are usually pretty clear, and they should be followed carefully. If you are cavalier about it and don’t learn the specifics for insertion of each device, you will struggle a lot. There are particular tricks for applying each individual device. For the Lap Disc®, placing two stay sutures helps considerably. For the Gelport®, rolling the wound protector edge to the right distance and getting the first “snap” of the cap on firmly are important. For the Omniport®, it is easier to place both rings into the abdomen, and then pull the outer one out, than it is to place the inner one inside the abdomen and the outer one outside initially.

For radical nephrectomy, it is extremely important to get onto the psoas muscle and then develop the plane immediately anterior to it. This leads to the aorta on the left and the IVC on the right. Stay on that great vessel to take the artery first and to take the vein second. You don’t always have to do it in that order but if you are going to take the vein first, you need to be prepared for venous hypertension, i.e., bleeding from the venous staple line or from capsular incisions. This is not relevant for radical nephrectomy but can be a problem during a simple nephrectomy of a stone-bearing kidney with a lot of perirenal fibrosis.

Our approach to renal cysts has evolved with the advent of laparoscopic partial nephrectomies. More and more often, we either excise the cyst if we are worried about it, or if not, we just leave it alone. This works well as long as the cysts are not endophytic and are amenable to resection; fortunately, most cysts are peripheral and are easily excised. For B osniak 3 cysts, we usually recommend excision. For B osniak 2 cysts, we will talk to the patient about the low incidence of malignancy, and help them decide between observation and excision, basing our decision on their age, co-morbidities, and preference. Typically, when a confident diagnosis of B osniak 2 cyst can be made on CT , surgical intervention is not warranted.

The most important thing is to have the requisite experience and confidence in time-sensitive and precise intracorporeal suturing. The second most important thing is to make sure everything is lined up before you clamp the renal hilum.

Patient selection is most important for RFA. Watch for surrounding landmarks. I have significant concerns for tumors that abut the collecting system, particularly tumors that abut the ureteropelvic junction.

As far as pyeloplasty is concerned, the best advice is to do it extraperitoneally. It is much more direct and it brings you, whether you are doing a left- or a right-sided case, really right up to the ureteropelvic junction (UPJ), since the collecting system is the most lateral structure. Compared to the transperitoneal approach, dissection of the crossing vessels is easier, but the anastomosis is a bit more difficult because you are sewing around the vessels. The rest of the operation is much easier.

An excellent preoperative medical preparation of the patient is the key. We typically optimize the patient with calcium channel blockers, with secondary use of alpha-1 blockers and beta blockers in select circumstances. Cardiovascular clearance is essential. Vigorous intravenous hydration, early control of the adrenal vein, and minimal handling of the tumor are essential aspects of surgery. If adequate experience with retroperitoneoscopy is not available, the transperitoneal approach should be preferred in that circumstance. At our institution, we would approach the adrenal pheochromocytoma either transperitoneally or retroperitoneally without any general preference for either approach. Another key approach to adrenal surgery is to stay outside the periadrenal fat, thereby minimizing or completely avoiding handling of the adrenal gland per se, which will uniformly lead to adrenal gland fracture with troublesome hemorrhage.