Objectives. Large-sized upper pole renal or adrenal tumors are often excised by the open thoracoabdominal approach. As an adjunct to existing transperitoneal and retroperitoneal laparoscopic approaches, we explore a novel minimally invasive technique, the thoracoscopic transdiaphragmatic approach, for performing nephrectomy. Methods. Thoracoscopic transdiaphragmatic nephrectomy was performed bilaterally in 4 farm pigs (8 kidneys) using three ports placed intercostally.

Results. The mean surgical time was 69.3 minutes on the left side and 74.3 minutes on the right. Blood loss was 18.7 mL. The mean size of the diaphragmatic incision was 7.2 cm. Adequate retraction of the spleen and liver was feasible during left and right-sided nephrectomy, respectively. Excellent and expeditious access to the renal hilum was routinely obtained. In 5 of 8 procedures, the diaphragmatic incision was located peripherally along the posterior margin; difficulty in suture repair of the diaphragmatic incision was noted in each instance because of the thin diaphragm in this location. During porcine left nephrectomy with ipsilateral lung collapse (n = 4), arterial blood gases and end-tidal carbon dioxide remained normal.

Conclusions. Thoracoscopic transdiaphragmatic nephrectomy is feasible. This technique provides excellent and unique visualization of the renal vessels and the upper pole of the kidney and adrenal gland. When indicated, the thoracoscopic transdiaphragmatic approach, used in combination with current laparoscopic techniques, has the potential to provide the minimally invasive counterpart of the thoracoabdominal surgical approach in select patients with upper pole renal or adrenal pathologic findings.