Editing Laparoscopic Radical Nephrectomy (section)

=== Transperitoneal approach ===
*'''Position:''' Ipsilateral (tumor side up), modified flank/lateral decubitus at ≈60-90° (if left sided, 90° so that spleen can fall; if right-sided, less than 90°). Gel roll supporting the lower back. Bottom leg flexed. Top leg straight. Pillows between legs. Ipsilateral arm on side of body, contralateral arm out on arm board. 
**Some surgeons prefer to flex operating table. If flexing table, position patient so that ASIS is at/below break. Then slight head-down (Trendelenburg) to level patient parallel to floor.
*'''Surgical plan:'''
** '''Number of ports: 3-4 (4-5 if right-sided)''' (variations possible, depending on patient characteristics, surgeon preference, and institution equipment)
***1 camera port + 3 laparoscopic ports +/- 1 liver retractor for right-sided tumors
***#Superior working port (12 mm fascial dilating trocar or 10 mm reusable)
***#Camera port (12 mm fascial dilating trocar or 10 mm reusable)
***#*Ideally, camera is facing action
***#**In radical/donor nephrectomy, this is at the hilum (≈at level of 10th rib)
***#**In partial nephrectomy, this is at the tumour
***#Inferior working port (12 mm fascial dilating trocar).
***# Optional: 2-5-mm assistant port (or larger if going to be used as extraction site)
***#*Used to retract kidney laterally. 
***#*Can be extended as Gibson incision (parallel line, 2 cm from inguinal ligament) towards pubis to become an extraction site
***#*Some surgeons do not use this port
** '''Location of ports:'''
*** General considerations for laparoscopic port placement
****Ports should be placed a minimum of 5[https://www.laparoscopyhospital.com/fewbookpdf/laparoscopic-port-position.pdf]-10cm apart.[https://www.auanet.org/documents/education/blus-handbook.pdf]
****The optimal pattern of port placement should form an equilateral triangle or a diamond array around the operative field.[https://accesssurgery.mhmedical.com/content.aspx?sectionid=41808779&bookid=531]
*****A similar separation of the two working ports (surgeon's left and right hands) ensures that these two instruments will not be involved in “sword fighting” and that the angle between the two instruments at the target will be optimal (between 60 and 90 degrees).[https://accesssurgery.mhmedical.com/content.aspx?sectionid=41808779&bookid=531]
****Standard laparoscopic instrument length is 30 cm.
*****To produce a 1:1 translation and movement from the surgeon's hands to the operative field, the fulcrum of the instrument should be half the distance (15 cm for standard 30 cm instrument) from the target.[https://accesssurgery.mhmedical.com/content.aspx?sectionid=41808779&bookid=531][https://www.laparoscopyhospital.com/laparoscopic_equipments_detail_4.htm]
****Port placement through the rectus muscle risks damage to the epigastric vessels.[https://www.auanet.org/documents/education/blus-handbook.pdf]
*****The epigastric vessels travel near the lateral edge of the rectus muscles in the lower abdomen and travel closer to the midline in the upper abdomen where they join the internal mammary arteries.[https://www.auanet.org/documents/education/blus-handbook.pdf] 
*****Generally if trocars are not placed in the midline, they should be placed at least 6cm lateral to the midline to prevent epigastric injury.[https://www.auanet.org/documents/education/blus-handbook.pdf]
***Considerations for laparoscopic port placement in kidney surgery
****Want to be as superior as possible and are therefore always limited by ribs. 
****Consider translating ports laterally (obese patient, lateral tumor) or medially (skinny patient, medial tumor), depending on patient and tumour characteristics
***Configuration options
****Configuration 1 (straight line):
*****Superior port: lateral to rectus muscle, 2 finger-breadths below the costal margin
*****Camera port: lateral to rectus muscle, at level of 10th rib
*****Inferior port: lateral to rectus muscle, one handbreadth inferior to camera port
*****Assistant port: anterior axillary line
****Configuration 2:[https://www.auanet.org/documents/education/blus-handbook.pdf]
*****Superior port: lateral to rectus muscle, in same sagittal line as inferior port
*****Camera port: midway between the superior and inferior port, in the midline
*****Inferior port: midpoint on the line between umbilicus and ASIS
******In obese patients, the umbilicus is not a reliable landmark because it moves dependently with the panniculus. Therefore, in the obese patient, the primary access site and all other access sites should be moved laterally.
****Configuration 3:[https://ether.stanford.edu/urology/nephrectomy.pdf]
*****Superior port:
******For right side, 2-3 finger-breadths lateral to the rectus muscle at the costal margin [after inflation].
****** For left side, at the lateral border of the rectus muscle near the costal margin
*****Camera port: 2-3 finger-breadths below the costal margin at the lateral border of the rectus
*****Inferior port: at the level of the umbilicus at the lateral border of the rectus
*****Assistant port: anterior axillary line.
****Configuration 4:[https://pubmed.ncbi.nlm.nih.gov/34345564/]
*****Superior port: sub-costal area, in same sagittal line as camera port
*****Camera port: near midline, to triangulate between superior and inferior ports
*****Inferior port: on the line between umbilicus and ASIS, slightly lateral to the midpoint on the line
*****Assistant port: 2 cm (2 finger breadths) above ASIS
****Configuration 5:
*****Superior port: 1 finger-breadth below the costal margin at the lateral border of the rectus
*****Camera port: 3 fingers above and lateral to the umbilicus
*****Inferior port: at the level of the umbilicus at the lateral border of the rectus
*****Assistant port: 2 cm (2 finger breadths) above ASIS
***'''If right-sided, additional 5 mm trocar placed just inferior +/- lateral (depending on anatomy) to xiphoid process to retract liver.''' Use laparoscopic locking clamp to hold on abdominal wall/diaphragm and retract liver away from surgical field.
*** Additional 5-mm assistant ports may be placed, as needed; considered "free" ports
** '''Step by step:'''
*** '''Patient positioning, antiseptic preparation, draping.''' 
****After induction of general anesthesia...
****Trim hair overlying operative site, if needed
****Insert foley catheter and have tubing go over contralateral leg. 
****Optional: Slide patient up/down table so that ASIS is at/below the break.
****Slide patient laterally to tumor side of table and roll patient so that the anterior abdomen is placed on the contralateral edge of the table. Position patient in ipsilateral (tumor side up), modified flank/lateral decubitus.
****Axillary roll should be placed (under the upper chest, at a level inferior to the tip of the scapula, rather than under the axillary region[8]) to prevent neuropraxia. 
*****An axillary roll is not required if the patient is tilted at the 45° angle and not lying directly on his or her axilla[9].
****Use gel rolls, rolled blankets, or a bean bag to support the back.
****Bottom leg flexed. Top leg straight. Pillows between legs.
****Secure the patient to the table with wide cloth tape.
****Optional: Flex table slightly. Slight Trendelenburg to level table parallel to floor.
**** Lower arm is placed on a padded arm rest, and the other arm is flexed at the elbow and rested over the chest over pillows.
**** Meticulous foam pad soft tissue and bony sites, including the head and neck, axilla, hip, knee, and ankle, along with careful ergonomically neutral positioning of the neck, arms, and legs
****Adjust height of bed to optimize ergonomics
****Prepare surgical area and drape to expose umbilicus, xiphoid, costal margin, and ASIS.
*** '''Abdominal access with transumbilical Veress needle.''' Apply penetrating towel clamps superior and inferior of umbilicus. With fingers under clamp, gently lift (as excessive elevation can cause separation of the abdominal layers and increase risk of pre-peritoneal placement). Insert Veress needle at 90 degrees. Feel or hear (usually) 2 (corresponding to the penetration of the abdominal fascia and parietal peritoneum) clicks/pops (the protective sheath clicking when it recoils), indicating that the abdominal cavity has been entered.
**** If transumbilical unsuccessful (3 attempts) or contraindicated (presence of umbilical pathology such as adhesions or herniations, peri-umbilical scars, aortic pulsations, thin patient), consider 
*****In middle of ASIS and umbilicus and translate this point superiorly to the level of the umbilicus
*****In middle of ASIS and umbilicus and translate this point slightly laterally[https://pubmed.ncbi.nlm.nih.gov/34345564/]
******If not transumbilical entry, consider: use cautery/knife to make incision at planned entry point. Dissect down through fat to expose fascia. Use Kocher clamp to lift up on fascia. Insert Veress needle.
*****In patients with potential of significant abdominal adhesions, consider open (Hassan) entry
*** '''Test Veress needle and insufflate, if appropriate.''' Aspirate and inspect for blood or fecal content. If negative, inject saline for drop test (though not reliable). Aspirate the needle again. If successful on initial testing, gently advance the needle 0.5cm. Turn on insufflation to high flow (no need to begin at low flow because the size of the Veress needle limits flow to 1.5-2L/min) and evacuate initial air in tubing that is not CO2. Connect gas tubing to needle. Check for 3 consecutive pressure readings below 10mmHg. If pressure >10 mm, withdraw needle slightly. If pressure decreases <10 mm, this indicates that needle tip was against an intra-abdominal structure such as the intestine or omentum. If the pressure remains ≥10 mm Hg, the needle is not properly placed. Achieve pneumoperitoneum to 15 (or 20; 20 facilitates port placement by increasing abdominal resistance, but have to remember to decrease after ports inserted) mm Hg. 
*** '''Outline landmarks:''' Use marking pen to outline lateral border of rectus, costal margin, 10th rib, ASIS, (+/- xiphoid if right-sided)
***'''Outline port sites.''' Use marking pen to denote transverse (longitudinal for midline) incisions for ports based on chosen configuration. Start by marking superior port[https://accesssurgery.mhmedical.com/content.aspx?sectionid=41808779&bookid=531#57005845]. 
*** '''Insert first port.''' The visual trocar is used to insert the safest location of entry, which is the inferior working port. Use knife to make a 12 mm transverse incision at the site of the inferior working port. With the camera inside the visual trocar, carefully advance the trocar. Twisting is more important than pushing. Once inside the abdomen, remove canula and open valve (should hear air coming out when opening valve on port). Switch gas to this port. Insert camera (30 degrees).
*** '''Inspect abdomen.''' Check that no injury made during insertion of Veress needle. Check for adhesions that may interfere with port placement.
*** '''Insert remaining ports.''' Transilluminate abdominal wall to avoid large abdominal wall vessels. Begin insertion of most superior port (facilitates visualization). Use knife to make transverse incision. Twist port into incision under vision. Repeat steps for other ports. On right side, setup liver retractor with laparoscopic locking Allis grasper through 5-mm subxiphoid port. Once all ports are positioned, the pneumoperitoneum is reduced to 12-15 mm Hg for the procedure.
*** '''Lysis of adhesions, if needed.''' Check for adhesions and take any down if needed.
*** '''Medialize bowel to expose retroperitoneum.''' Incise peritoneum lateral to the white line of Toldt. The bowel mesentery is bright yellow in color while the retroperitoneal fat is dull yellow. Use blunt and sharp dissection to develop avascular plane anterior to Gerota fascia and posterior to the mesocolon. Release attachments to the spleen and liver as needed.
****Medial retraction by the assistant facilitates this step.
****Line of Toldt should be divided at the junction between mesocolon and Gerota's fascia.
*****If hole made in mesocolon, repair with absorbable suture.
****Thin pulsatile vessels belong to the mesentery and should not be divided. If there is undue bleeding, the plane is most likely wrong and needs revision
****'''On the right side, goal is to identify the IVC;''' there is no need for extensive mobilization of the bowel to expose the renal hilum.
***** '''Caution: To avoid duodenal injury, use minimal cautery during the medialization of the duodenum.'''
****Take care to leave the kidney attached laterally to avoid unnecessary mobilization into the operative field.
*** '''Mobilize upper pole.''' 
****'''On the left side, mobilize the spleen completely to avoid potential splenic injury.''' Be careful of splenic artery and pancreas. When developing space between spleen and kidney, use left hand under spleen to protect spleen. Use hand over hand motion. For efficiency, develop this space completely, before continuing to mobilize the colon.
****'''On the right side, the right triangular ligament may be divided to lift the liver off the upper pole.'''
*****On the right lobe of the liver, the anterior and posterior layers of the coronary ligament of the liver join to form the right triangular ligament.[https://www.kenhub.com/en/library/anatomy/liver-ligaments]
*****The falciform ligament runs along the anterior surface of the liver. Superiorly, the falciform ligament is attached to the visceral aspect of the anterior abdominal wall.[https://www.kenhub.com/en/library/anatomy/liver-ligaments]
*** '''Identify ureter and gonadal vein'''. Retract Gerota's fascia and lower pole tissues anteriorly to allow identification of the gonadal vein, ureter and psoas muscle. The mid-ureter is identified along the anterior aspect of the psoas, just inferior to the lower pole of the kidney. If too inferior, ureter will be medial and goal is to get under it so better to approach closer to lower pole. Once the ureter is identified, dissect a plane medial and parallel to the ureter +/- gonadal vein.
****At times, especially early in the experience, the psoas tendon or the iliac artery may be confused with the ureter. It is important to look for the peristalsis of the ureter in case of confusion.
****'''The gonadal vein is an important anatomic landmark when proceeding toward the renal hilum;''' the renal vein can be identified by tracing the gonadal vein proximally to its insertion in the
***** Renal vein, on the left side
***** Inferior vena cava just caudal to the hilum, on the right side
**** '''On the right side, the gonadal vein is kept medially toward the vena cava, whereas on the left side, the gonadal vein is lifted along with the left ureter to expose the lower margin of the left renal hilum.'''
**** '''Proximally, the gonadal vessels are medial to the ureter. The gonadal vessels descend laterally and cross anterior to the ureter, “water under the bridge”''', '''a third of the way to the bladder.'''
*****'''On the left side, the gonadal vessels cross the left ureter after running parallel to it for a small distance'''
*****On the left side, be careful not to confuse the IMV for the gonadal vein. The IMV will be in the mesocolon, the gonadal vein will be in the retroperitoneal space
****The gonadal artery is usually found just below the lower pole and if needed, can be ligated and divided.
***'''Dissect along psoas towards renal hilum.''' Use the 4th arm to elevate the ureter +/- gonadal vein. Develop the plane superiorly towards the renal hilum,  anterior to the psoas muscle. A few small ureteric vessels may be encountered which can be divided by the use of energy devices. The traction on the ureter is constantly re-positioned as one works towards the hilum.
*** '''Identify and dissect renal hilum'''. Dissect the renal hilum meticulously to clearly delineate the vascular structures. During hilar dissection it is important to place the kidney on stretch, to improve identification and to facilitate dissection of the hilar vessels. 
**** '''Caution: be careful not to miss early arterial branching''' that is more common on the right side, especially if a venous occlusion is planned, as this may lead to kidney congestion and may result in more bleeding.
**** If needed, the left gonadal vein can be ligated and divided to increase mobility of the renal vein and potentially improve exposure of the renal artery.
****If left side, lumbar veins may be seen and these should be preserved, if possible.
***'''Ligate and divide renal vessels'''. After dissection of hilar vessels complete, ligate vessels with 10 mm Hem-o-Lok clips (2 on the stay side, 1 on the go side) or vascular staples (open staple height of 2.5mm, either 45mm or 60 mm length). Ligate/divide the artery/arteries first, and then the vein.
**** If multiple veins, can ligate some to clear space even if all arteries not ligated as long as there is some collateral venous outflow
****'''Caution: ensure that artery is renal artery, NOT superior mesenteric artery'''
****If vessels are difficult to isolate, consider en bloc stapling.
*****A meta-analysis of 595 patients who underwent en bloc ligation during nephrectomy found that[https://pubmed.ncbi.nlm.nih.gov/27457261/] 
******No patients developed an arteriovenous fistula with an average postoperative follow-up of 26 months.
******Procedure duration reduced with en bloc nephrectomy
******No difference in blood loos or complications
*** '''Complete kidney dissection.''' Any remaining attachments of the upper pole of the kidney are completely dissected with a combination of cautery and blunt dissection. Adrenal sparing surgery is recommended, when feasible. The plane is carried laterally to completely free the kidney; first complete peritoneal incision and then blunt dissection can be used to free most of the remaining attachments. Be careful of diaphragm at superior lateral part of kidney.
*** '''Ligate and divide ureter.'''
*** '''Delver specimen.''' A laparoscopic entrapment sac is introduced and the specimen is placed in the sac.
***'''Obtain hemostasis.'''
***'''Remove specimen.''' Use laparoscope to assess anterior abdominal wall for potential superficial blood vessels that may interfere with extraction site. Use a marking pen to denote extraction site using either a Gibson or Pfannensteil incision (more cosmetic). Care must be taken to make the extraction incision large enough to avoid fracturing the specimen, possibly preventing accurate histopathologic examination for margin status and staging. Turn gas off. Use knife to make incision. Use cautery to enter abdomen, taking care to obtain careful hemostasis as anterior abdominal wall muscles are divided.
**** Gibson: 3 cm above and parallel to the inguinal ligament.§
**** Pfannenstiel: transverse lower abdominal incision, superior to the pubic ridge. Dissection is made through the skin and subcutaneous fat; the anterior rectus sheath is divided transversely. The rectus muscle is open vertically in the midline sparing the muscle fibers from being divided. The peritoneum is then entered through a vertical incision. Be careful of branches from the inferior epigastric branches as well as the superficial epigastric.§
****Care must be taken to make a large enough incision to prevent disruption of the specimen; this enables proper histopathological examination.
*** '''First layer closure of extraction site.''' Use 3-0 Vicryl to reapproximate peritoneum (second layer is closed after re-insufflation and ensuring no bowel taken with first layer).
***'''Re-insufflate abdomen to verify hemostasis and extraction site closure.''' Ensure no bowel taken with abdominal closure.
***'''Closure'''. Use 0 Vicryl to reapproximate fascia at extraction site to complete second layer closure. All 12-mm incisions are closed with 0-Vicryl suture by using the Carter-Thomason device (Inlet Medical Inc., Eden Prairie, MN, USA).