Editing Open Kidney Surgery (section)

=== Radical nephrectomy ===

* '''Definition: removal of kidney outside of Gerota fascia'''
** '''Important to stay outside Gerota’s (perifascial) to prevent postoperative local tumor recurrence because ≈25% of clinical T1b/T2 RCCs demonstrate perinephric fat involvement'''

==== Indications ====

* '''Tumors in non-functional kidneys'''
* '''Large tumors replacing the majority of renal parenchyma'''
* '''Tumors associated with detectable regional lymphadenopathy'''
* '''Tumors associated with renal vein thrombus'''

'''Radical nephrectomy with adrenalectomy'''

* '''See Management of Localized and Locally Advanced Kidney Cancer Chapter Notes'''

'''Radical nephrectomy with lymphadenectomy'''

* '''See Management of Localized and Locally Advanced Kidney Cancer Chapter Notes'''
* '''Regional lymphadenectomy'''
** '''Includes ipsilateral great vessel and interaortocaval regions, extending from the crus of the diaphragm to the common iliac artery'''
*** For right-sided renal masses when lymphadenectomy is considered, the paracaval, precaval, retrocaval, and interaortocaval nodes from the right crus of the diaphragm to the bifurcation of the IVC are sampled.
** '''Employed in select cases of advanced local disease and when technically feasible'''
* '''Surgical description (for right-sided lymphadenectomy)'''
** Right-side lymphadenectomy
*** A right-angle clamp and electrocautery are used to split the lymphatic tissue from the anterior surface of the IVC. The lymphatic tissue is cleared cranially from the right crus of the diaphragm (located 3 to 4 cm above the right renal vein) and caudally until the bifurcation of the IVC.
*** The right gonadal vein is ligated at its insertion into the IVC with 2-0 silk suture, in order to avoid avulsion of the vein. Next the lymphatic tissue is cleared off the lateral aspect of the IVC (paracaval nodes).
*** The IVC is gently elevated with a vein retractor to expose the lumbar branches. The lumbar veins (typically four or five branches on either side of the IVC) are carefully ligated with 3-0 silk ties and transected.
*** '''The lymphatic trunks located above the renal vein are ligated with surgical clips.'''
**** '''Care to adequately ligate the lymphatic trunks is essential since large quantities of lymph and chyle drain through the cisterna chyli and thoracic duct, and failure to appropriately control them can result in chylous ascites''' .
*** Once the lumbar veins are secured and the superior aspect of the lymphatic trunk above the renal vein is secured, the assistant rolls the IVC medially with gentle pressure using two sponge sticks. Next the lymphatic tissue is cleared off the retrocaval region. The nodal tissue overlying the anterior surface of the aorta is then split and divided to the superior border of the left renal vein. Division of the nodal packet is followed to the medial border of the IVC and the aortocaval nodal packet is cleared to the level of the common iliac vessels.
** Left-side lymphadenectomy
*** For left-sided renal masses, the lymphatic tissue on the anteromedial surface of the aorta is clipped and divided and rolled laterally. The split is continued cranially along the aorta to the level of the superior mesenteric artery (SMA) and caudally past the inferior mesenteric artery (IMA) to the bifurcation of the aorta.
**** While the SMA and the celiac trunk have to be preserved, the IMA can be tied and divided in case of involved lymphadenopathy.
*** Once the lymphatics are dissected off the anterior and lateral surface of the aorta, the assistant gently elevates the aorta on either side to expose, secure, and divide the lumbar arteries. Once the lumbar arteries are properly secured, the aorta is rolled medially and the tissue between the anterior longitudinal vertebral ligament and the aorta (retroaortic lymph nodes) is resected.
*** The interaortocaval nodes are resected only if they are palpable or visualized on preoperative imaging, or if there is extensive nodal involvement around the aorta.

==== Surgical description ====

* Important to keep the renal fascia intact to ensure complete resection and to avoid tumor spillage
*'''The most commonly used incision for radical nephrectomy is the subcostal flank incision'''
* '''Incise through the skin and muscular layers. Setup Bookwalter retractor.''' If right-sided, the liver and gallbladder are packed away superiorly. When additional mobilization of the liver is required, the avascular right triangular ligament is incised.
* '''Incise the posterior parietal peritoneum on the white line of Toldt from the pelvis (region of the iliac artery) to the upper quadrant (region of hepatic/splenic flexure).'''
* '''Develop the anterior pararenal space by dissecting in the plane between the anterior renal fascia and the mesentery of the ascending/descending colon.'''
** Important to avoid injury to the ascending mesocolon, since injury to the right colic and ileocolic arteries may devitalize this segment of colon.
** Important to resect the renal fascia in its entirety for the best chance of surgical cure and to avoid any intra-abdominal tumor spillage.
* '''Mobilize the hepatic/splenic flexure of the colon''' using sharp and blunt dissection
* '''Mobilize the duodenum/tail of pancreas medially with extreme care.'''
** With medially located tumors, mobilization of the duodenum should be performed with extreme care.
* '''Identify the IVC/aorta posteriorly.'''
* '''Identify the renal vein. Dissect along the anterior surface of the IVC/aorta to identfy the renal vein (and gonadal vein if right-sided)'''
** On the right side, gonadal vein drains into IVC just below renal vein. On left side, gonadal vein drains into left renal vein.
** '''Placement of a vessel loop will enable gentle traction of the renal vein.'''
** '''The renal vein is palpated for any tumor thrombus.'''
** Surgical clips do not provide adequate hemostasis for the lumbar veins.
* '''Identify the renal artery, posterior to the renal vein.'''
** '''The origin of both renal arteries are generally found posterior to the left renal vein after it is mobilized after the aorta'''
***'''The origin of the right renal artery is posterior to the left renal vein and IVC.'''
*** '''The left renal artery is usually located cranial and posterior to the left renal vein.'''
** '''If identification of the renal artery is difficult, attention is turned to the lower pole of the kidney to identify the ureter''' '''and gonadal vein'''.
*** '''The left gonadal vein can be traced to its insertion to help identify the left renal vein.'''
*** Depending on the size and location of the tumor, determine whether the left gonadal vein should be left intact or tied off and transected to help with mobilization of the kidney. If technically feasible, the gonadal vein is spared. However, often because of the large size of the renal tumor, the gonadal vein cannot be safely left intact without the risk of avulsion from the IVC (right side) or left renal vein.
*** '''With ligation of the ureter, the kidney is lifted from a posterior to an anterior position in order to aid in identification of the renal artery posterior to the kidney.'''
** '''Another option for identifying the right renal artery in difficult hilar dissections is to dissect in the interaortocaval region at its takeoff from the aorta'''
** '''For left radical nephrectomy, particularly for upper pole renal masses, identification of the left renal artery from the posterior approach is recommended to avoid inadvertent ligation of the superior mesenteric artery, which is on the anterior surface of the aorta 1 to 2 cm cephalad to the left renal vein.'''
* '''Divide hilar vessels.''' Once the renal artery and vein are identified, the renal artery is ligated with two right-angle clamps and divided. Preferably, the proximal end of the renal artery is clamped with two right-angle clamps and the distal end with one right-angle clamp. The renal artery is divided using a fine scalpel. The proximal end is ligated with 0 silk suture and further secured with 2-0 silk suture ligature; the distal end is tied with 0 silk tie. With the renal artery secured and divided, the renal vein is secured and divided in a similar fashion.
** '''The most common source of bleeding after division of the renal hilum on the left is a lumbar vein.'''
** '''Hem-o-locks are contraindicated for arteries'''
** '''Whole-pedicle clamp'''
*** '''May be utilized to control the hilar vessels''' at times when the renal artery and vein may not be able to be separated individually because of significant hilar lymphadenopathy.
*** En bloc ligation of the whole renal pedicle may be associated with with a risk of arteriovenous fistula
**** Some small clinical series have not found any evidence of such fistulas in patients undergoing nephrectomy who have been managed by en bloc stapling of the renal hilum.
** '''Emergent condition of loss of control of the renal hilar vascular pedicle'''
*** Important to stay calm. Inform the anesthesiologist and all operating room personnel of major bleeding and request aggressive hydration and availability of blood products.
*** Compression can be applied using a fingertip or sponge stick to achieve hemostasis as best as possible so that the rest of the operating room staff can prepare. Compression can also be applied on the IVC and/or aorta to control bleeding.
*** Two Yankauer suction tubes can be used to clear the surgical wound.
*** '''Vascular occlusion clamps are used to clamp and ligate actively bleeding vessels.''' Clamping should not be done blindly; rather, one should suction, pack, retract, and dissect to get better exposure.
*** '''If the bleeding is occurring from the renal artery, compress the aorta above the renal artery, clamp the arterial stump with a vascular clamp, and repair the defect with two layered running vascular sutures.'''
*** '''If the bleeding is occurring from the IVC because of an avulsed or lacerated renal vein, or avulsed gonadal or lumbar vein, place a finger on the hole until the hole can be grasped with an Allis clamp.''' Pulling up on the clamp will normally stop the bleeding, allowing the defect to be visualized for repair.
* '''Wound closure'''
** Investigate for hemostasis and evaluate adjacent organs for any signs of injury.
*** '''The diaphragm and pleura are tissues that can be inadvertently injured secondary to retraction during radical open renal surgery.'''
*** '''To test for pleural injury,''' the retroperitoneum is filled to the level of the flank incision with saline. The anesthesiologist then inflates the lungs with high inspiratory volumes. Bubbling of saline irrigation in the retroperitoneum with deep inspiration would suggest a pneumothorax.
**** '''In case of a small pleural injury, the pleural cavity can be closed with running nonabsorbable sutures. Prior to complete closure of the pleura, the tip of a 14-Fr red rubber catheter is placed in the pleural cavity. The end of the catheter is placed in a saline-filled bowl. The anesthesiologist provides a deep inspiratory breath to evacuate any air from the pleural cavity through the red rubber catheter and into the saline bowl. Once the air is evacuated from the pleural cavity as evidenced by bubbles in the saline bowl, the red rubber catheter is removed and the assistant cinches the pleural incision tight for an airtight closure. A postoperative chest radiograph is essential to assess for any significant pneumothorax, even in cases when pneumothorax is not suspected.'''
** '''Fascial closure'''
** '''For subcostal incision, the fascial layers are approximated typically in two layers—the transversus abdominis and internal oblique fasciae are approximated together, and the external oblique fascia is approximated as a separate layer.'''
** The subcutaneous tissue is approximated using 3-0 absorbable sutures. The skin is approximated with skin staples or subcuticular 4-0 poliglecaprone 25 (Monocryl) suture

==== Complications ====

* '''Injury to the GI vasculature'''
** The celiac trunk supplies the esophagus, stomach, pancreas, liver, spleen, and part of the duodenum
** '''The superior mesenteric artery supplies the small bowel, cecum, ascending and transverse colon'''
** '''The inferior mesenteric artery supplies the transverse, descending, and sigmoid colon'''
** '''The inferior mesenteric artery can be safely ligated as long as the marginal artery of the colon is patent and can supply blood from the SMA to the left colonic arcades'''
** '''Ligation of either the SMA or the celiac trunk is a catastrophic event that occurs predominantly with left-sided nephrectomy and that must be rapidly reversed if the patient is to survive.'''
** '''The inferior mesenteric vein''' (IMV) is found in the mesentery of the descending colon, immediately lateral to the ligament of Treitz. The IMV '''can be safely ligated during surgery without consequence. In contrast, the superior mesenteric vein (SMV) should not be ligated unless that is the only surgical option.''' '''The abdomen should not be closed primarily in cases of SMV injury because abdominal compartment syndrome will occur.'''
* '''Injury to the liver and spleen:'''
** '''Small splenic or hepatic injuries''' (capsular tears and minor lacerations) '''can usually be managed effectively by''' '''electrocautery''' or argon beam coagulation. '''Fibrin glue and topical hemostatic meshes (e.g., Surgicel) are useful adjuncts.'''
** '''More serious splenic injuries can be managed by splenorrhaphy or splenectomy'''
** Minor hepatic lacerations can be repaired using the same basic principles as for a partial nephrectomy closure.
* '''Injury to bowel'''
** Minor electrocautery or laceration injuries should be managed by careful debridement of the nonviable tissue and closure in two layers, the mucosal layer with continuous 4-0 chromic or Vicryl suture on a 1 2 circle tapered needle, and the serosa and muscularis layer with 3-0 silk interrupted suture on a 1 2 circle tapered needle. An omental flap is placed over the injury and a closed suction drain is inserted
* '''Injury to the pancreas:'''
** First step is a thorough inspection of the pancreas
** '''Superficial lacerations and contusions can usually be managed by applying fibrin glue and inserting a closed suction drain. The drain is monitored for an alkaline pH and lipase/amylase levels to determine whether a pancreatic fistula is developing.'''
** If the injury to the pancreas is deep and/or involves the pancreatic duct, consultation with a gastrointestinal surgeon is essential for appropriate repair and management.
* '''Pulmonary complications:'''
** Large postoperative pleural effusions can be managed by aspiration initially, followed by chest tube drainage if necessary
* '''Chylous ascites'''
** '''Results from disruption of the major para-aortic lymphatic channels leading to the cisterna chyli and is predominantely noted in left-sided procedures (radical or donor nephrectomy) or RPLND'''
** '''Patients classically have abdominal distention without significant pain or fevers and will have normal bowel habits.''' 
** '''Diagnosed by paracentesis''' with ascitic fluid found to have classically white and turbid appearance with fluid analysis showing elevated lymphocytes, associated with a high cholesterol and triglyceride content.
** '''Initial treatment is to reduce the flow of chyle into the lymphatics by a low-fat medium-chain triglyceride diet'''
** '''If chylous ascites persists despite dietary management, the next step should involve bowel rest and TPN with the concurrent use of octreotide, a somatostatin analog'''.
*** Somatostatin has been documented to significantly decrease postprandial increase in TG levels by inhibiting lymphatic flow
** '''Open or laparoscopic treatment using suture ligation and fibrin glue to control the leak can be pursued if conservative management fails'''.
*** Intraoperatie location of the lymphatic leakage can be challenging and the combined use of preoperative lymphangiography and consumption of “fatty” meal immediately before surgery has been documented to be beneficial in helping the surgeon locate the site of the leak