Laparoscopic Radical Nephrectomy

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Contraindications

  1. Contraindications to laparoscopic surgery
  2. History of extensive abdominal or pelvic surgery
  3. Morbid obesity
  4. Extremely large tumor

Advantages to Laparoscopic vs. Open Approach

  • Reduced blood loss, less pain, and shorter hospital stays with laparoscopic approach

Pre-operative Preparation

  • Pre-operative imaging
    • Primary tumor
      • Proximity to collecting system
      • Vasculature
    • Staging
  • Hold/bridge anticoagulation medications prior to surgery
    • ASA 7 days
    • Clopidogrel 5 days
    • Apixaban 2 days
  • Pre-operative testing
    • Urinalysis +/- culture
    • CBC
    • Serum creatinine/GFR

Steps of procedure

Equipment

  • Specimen Retrieval Pouch
  • Sutures
    • Rescue stitches
      • 4-0 Prolene on RB1 (in case of vascular injury), cut to 10cm

Venous thromboembolism prophylaxis

  • Compression stockings
  • Heparin

Antibiotics

  • 2g cefazolin (900 mg clindamycin, if penicillin allergic)[1]

Transperitoneal approach

  • Position: Ipsilateral (tumor side up), modified flank/lateral decubitus at approximately 60-90° (if left sided, 90° so that spleen can fall; if right-sided, less than 90°).
    • 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)
      • 1 camera port + 3 laparoscopic ports +/- 1 liver retractor for right-sided tumors
    • Location of ports:
      • 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 medial to the rectus border risks injury to the epigastric vessels.
      1. Camera (12 mm)
      2. Working port (10-12 mm) for dominant hand (12 mm fascial dilating trocar or 10 mm reusable)
      3. Port for non-dominant hand
      4. 2-5-mm port to retract kidney laterally
      • 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.
      • Additional 5-mm assistant ports may be placed, as needed; considered "free" ports
      • Mark the site of the 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
        • On the right side, this is the working port (10-12mm). On the left side, this is for the non-dominant hand (5 mm).
        • Alternative: 1 finger-breadth below the costal margin at the lateral border of the rectus
      • Camera port site 2-3 finger-breadths below the costal margin at the lateral border of the rectus
        • Approximately at level of 10 rib (ideally, camera is facing action so in radical/donor nephrectomy, this is at the hilum; in partial action is the at the tumour).
        • Alternative (Dahl): 3 fingers above and lateral to the umbilicus
      • Inferior port at the level of the umbilicus at the lateral border of the rectus
        • On the right side, this is for the non-dominant hand (5 mm). On the left side, this is the working port (10-12mm).
      • 2-5mm port is 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
        • Alternative: 2 finger breadths above ASIS
        • Incision is limited medially by the inferior epigastric vessels/rectus.
    • Step by step:
      • Patient positioning, antiseptic preparation, draping.
        • Insert foley catheter and have tubing go over contralateral leg.
        • Slide table up/down table so that ASIS is at/below the break.
        • Slide patient laterally to tumor side of table. 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 a gel roll, a rolled blanket, or a bean bag to support the back.
        • Bottom leg flexed. Top leg straight. Pillows between legs.
        • 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.
        • Wide cloth tape is used to secure the patient to the operating table to allow for table rotation during the surgery.
        • Meticulous foam padding of 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
        • Prepare surgical area and drape to expose umbilicus, xiphoid, costal margin, and ASIS.
      • Outline landmarks. Use a marking pen to outline costal margin, iliac crest, and lateral border of rectus.
      • Veress needle access. Commonly where camera port will be. Palmer's point (3 cm below the left costal margin and in the midclavicular line) is another option. Make an incision through skin and dermis. Use Kocher to lift up on fascia. Insert Varess needle. Confirm appropriate placement with saline test.
      • Achieve pneumoperitoneum. Evacuate initial air in tubing that is not CO2. Have gas on low flow and determine opening pressure. If pressures are low (< 10 mmg Hg), increase to high flow. As the pressure slowly rises to 20, the port sites are prepared.
      • Insert ports. Once at 20mm Hg, the first port, the camera port is placed through a 12 mm transverse incision followed by the remaining ports all under direct vision. Once all ports are positioned, the pneumoperitoneum is reduced to 12-15 mm Hg for the procedure.
      • Medialize bowel to expose retroperitoneum. Incise peritoneum lateral to the white line of Toldt. 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. Assistant retracts bowel medially.
        • On the right side
          • No need for extensive mobilization of the bowel to expose the renal hilum.
          • During the mobilization of the duodenum medially, the use of cautery is minimized.
        • On the left side
          • Mobilize spleen completely. Be careful of splenic hilum
      • Identify ureter. The mid-ureter is identified along the anterior aspect of the psoas, just inferior to the lower pole of the kidney. If you are too low, ureter will be medial and goal is to get under it so better to approach closer to lower pole. Once identified, dissect a plane medial to the ureter, with careful identication of the gonadal vein. The plane is developed superiorly along the psoas muscle with anterior elevation of the ureter and/or gonadal vein to identify the renal hilum. The assistant lifts the kidney up.
        • 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 or to its insertion in the 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.
        • 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
        • 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.
          • The gonadal vessels cross the left ureter after running parallel to it for a small distance
      • Dissect hilum. Dissect the renal hilum meticulously to clearly delineate the vascular structures prior to their ligation. After dissection complete, ligate vessels with 10 mm Hem-o-Lok clips (2 on the stay side, 1 on the go side) or vascular staples (30mm or 45mm depending on vessel length). Ligate/divide the artery/artieres 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
      • Complete kidney dissection. The superior pole of the kidney is disected with a combination of cautery and blunt dissection. Adernal sparing surgery is recommended, when feasible. The plane is carried laterally to completely free the superior pole of the kidney. Be careful of diaphragm at superior lateral part of kidney.
      • Transect ureter. Apply clips to ureter and then transect the ureter.
      • Delver specimen. A laparoscopic entrapment sac is introduced by the assistant through the 12 mm assistant trocar; the specimen is placed in the sac and removed from an incision extended medially (to avoid injury to the inferior epigastric vessels) from the 5mm trocar site to form either a Gibson or Pfannensteil incision (more cosmetic).
        • 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.
        • Incision is ideally closed in 2 layers.
      • Closure. All 12-mm incisions are closed with 0-Vicryl suture by using the Carter-Thomason device (Inlet Medical Inc., Eden Prairie, MN, USA).

Complications

  • Intra-operative
    • Bleeding
    • Injury to adjacent organ (bowel, diaphragm, liver, spleen, pancreas)
  • Early post-operative
    • Infection
    • Re-operation due to
      • Bleeding
      • Wound dehiscence
    • Renal dysfunction, depending on baseline renal function
  • Late post-operative
    • Incisional hernia

References

  • Novick, Andrew C., et al., eds. Operative Urology. Springer Science & Business Media, 2007.
  • Deo, Sadhana V., and Dhananjay S. Kelkar."Laparoscopic right radical nephrectomy." Journal of surgical technique and case report 3.2 (2011): 106.
  • Collins, Sean, et al. "AUA BLUS handbook of laparoscopic and robotic fundamentals." Linthicum: American Urological Association 100 (2015): 200-300.
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