Direct, Duodenum-Guided Access to the Renal Hilum During Laparoscopic Radical Nephrectomy

AIM: To provide a step-by-step description of the surgical technique that allows for a direct, duodenum-guided access to the renal hilar vessels during laparoscopic radical nephrectomy (LRN). MATERIALS AND METHODS: For a right-sided LRN, a Kocher maneuver exposes the underlying vena cava (VC). The cephalad dissection of its lateral margin leads to the right renal vein (RRV). The right renal artery is identified posteriorly between RRV and VC and clip-secured. The access to the left renal hilum is guided by the identification of the fourth portion of the duodenum and the inferior mesenteric vein. The Treitz ligament is incised. The duodenum is medialized exposing the aortic wall and the left renal vein. The lateral surface of the aorta is carefully dissected till the emergence of the left renal artery. CONCLUSIONS: The described approach, although technically challenging represents a feasible, safe and oncologically valid technique to perform LRN in the hands of an experienced laparoscopist.