Bệnh nhân béo phì vị trí cho nephrectomy triệt trái. Lưu ý đường phân ranh giới tốt bụng mỡ medially rơi gần biên giới bên của abdominis rectus. Sâu hàm ếch suprapubically làm cho một mỏm đá nhô của chất béo trên vết rạch. Một vết rạch khai thác theo chiều dọc là thích hợp hơn, | 240 p. Liao . Jacobs Fig. 5. Obese patient positioned for left radical nephrectomy. Note well-demarcated line where abdominal fat falls medially approximately at the lateral border of the rectus abdominis. The deep cleft suprapubically makes for an overhanging ledge of fat above the incision. A longitudinal extraction incision is preferable for example through this patient s previous lower midline scar but there is still a large amount of subcutaneous fat to traverse anterior but getting disoriented in the fat anterior to Gerota s fascia risks duodenal injury. The key to a smooth radical nephrectomy is neatly developing the plane between the colon mesentery and the anterior surface of Gerota s fascia. There is a qualitative difference in the character of the fat this should be learned on normal patients before taking on the obese while it is easier to get lost in the obese patient s mesentery it is more difficult to actually cause through-and-through mesenteric rents. These rents can be dangerous as internal herniation of bowel can occur through them. The total size of the contents of Gerota s fascia can vary enormously as shown in Fig. 6. In general women have less perinephric fat than men and that fat seems less dense and adherent. However the patient s BMI does not yield a good prediction as to the amount of perinephric fat. The radical nephrectomy or nephroureterectomy is performed in the standard fashion. Retraction of bowel or fat can be done with paddles or effective retraction can be done with an assistant hand through the extraction site incision. We prefer an entrapment bag for specimen extraction. On occasion the kidney and its perinephric fat are too large for entrapment and the specimen must be retrieved manually via the extraction site. Because the total surgical specimen is large the extraction sites need to be slightly larger. Attempts to pull a very large specimen through too small an extraction site risks specimen rupture and spillage. In obese
