Laparoscopic Radical Nephrectomy: Difference between revisions

Line 65:

**Some surgeons prefer to flex operating table. If flexing table, position patient so that ASIS is at/below break. Then slight Trendelenburg to level table parallel to floor.

*'''Surgical plan:'''

** '''Number of ports: 4 (5 if right-sided)''' (variations possible, depending on patient characteristics, surgeon preference, and institution equipment)

** '''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

****Camera (12mm)

****Working port (10-12 mm) for dominant hand (12 mm fascial dilating trocar or 10 mm reusable)

**** Port for non-dominant hand

**** 2-5-mm port to retract kidney laterally

**** 2-5-mm assistant port to retract kidney laterally

*****Some surgeons do not use an assistant port for retraction

***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]

****In laparoscopy, the standard instrument length is 30 cm.

Line 79:

Line 80:

*** See Figure 5.1

*** In kidney surgery, want to be as superior as possible and are therefore always limited by ribs. Ports may be translated laterally (obese patient, lateral tumor) or medially (skinny patient, medial tumor), depending on patient and tumour characteristics

**** Port placement through the rectus muscle risks damage to the epigastric vessels.

**** 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.

*****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.

*****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]

***Configuration 1:

***Configuration 1:[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 2:[https://pubmed.ncbi.nlm.nih.gov/34345564/]

****Superior port: sub-costal area, in same sagittal line as camera port

****Camera port:

****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 3:

****Superior port:

*****'''For right side,''' 2-3 finger-breadths lateral to the rectus muscle at the costal margin [after inflation].

Line 92:

Line 103:

*****On the right side, this is for the non-dominant hand (5 mm). On the left side, this is the working port (10-12mm).

****Assistant port: inserted at the anterior axillary line to retract kidney laterally. This can be extended as Gibson incision (parallel line, 2 cm from inguinal ligament) towards pubis to become an extraction site

***Configuration 2:

***Configuration 4:

****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

***Configuration 3:[https://pubmed.ncbi.nlm.nih.gov/34345564/]

****Superior port: sub-costal area, in same sagital line as camera port

****Camera port:

****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

*** If right-sided, additional 5 mm trocar placed just inferior +/- lateral to xiphoid process for liver traction. Use Allis clamp to hold on abdominal wall and retract liver away from surgical field.

@@ Line 65: / Line 65: @@
 **Some surgeons prefer to flex operating table. If flexing table, position patient so that ASIS is at/below break. Then slight Trendelenburg to level table parallel to floor.
 *'''Surgical plan:'''
-** '''Number of ports: 4 (5 if right-sided)''' (variations possible, depending on patient characteristics, surgeon preference, and institution equipment)
+** '''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
 ****Camera (12mm)
 ****Working port (10-12 mm) for dominant hand (12 mm fascial dilating trocar or 10 mm reusable)
 **** Port for non-dominant hand
-**** 2-5-mm port to retract kidney laterally
+**** 2-5-mm assistant port to retract kidney laterally
+*****Some surgeons do not use an assistant port for retraction
 ***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]
 ****In laparoscopy, the standard instrument length is 30 cm.
@@ Line 79: / Line 80: @@
 *** See Figure 5.1
 *** In kidney surgery, want to be as superior as possible and are therefore always limited by ribs. Ports may be translated laterally (obese patient, lateral tumor) or medially (skinny patient, medial tumor), depending on patient and tumour characteristics
-**** Port placement through the rectus muscle risks damage to the epigastric vessels.
+**** 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.
+*****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.
+*****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]
-***Configuration 1:
+***Configuration 1:[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 2:[https://pubmed.ncbi.nlm.nih.gov/34345564/]
+****Superior port: sub-costal area, in same sagittal line as camera port
+****Camera port:
+****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 3:
 ****Superior port:
 *****'''For right side,''' 2-3 finger-breadths lateral to the rectus muscle at the costal margin [after inflation].
@@ Line 92: / Line 103: @@
 *****On the right side, this is for the non-dominant hand (5 mm). On the left side, this is the working port (10-12mm).
 ****Assistant port: inserted at the anterior axillary line to retract kidney laterally. This can be extended as Gibson incision (parallel line, 2 cm from inguinal ligament) towards pubis to become an extraction site
-***Configuration 2:
+***Configuration 4:
 ****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
-***Configuration 3:[https://pubmed.ncbi.nlm.nih.gov/34345564/]
-****Superior port: sub-costal area, in same sagital line as camera port
-****Camera port:
-****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
 *** If right-sided, additional 5 mm trocar placed just inferior +/- lateral to xiphoid process for liver traction. Use Allis clamp to hold on abdominal wall and retract liver away from surgical field.