Laparoscopic Radical Nephrectomy

Videos

• Laparoscopic transperitoneal left radical nephrectomy (Dr. Renaud Bollens)
• Laparoscopic transperitoneal left radical nephrectomy (Dr. Renaud Bollens, alternate)
• Laparoscopic transperitoneal left radical nephrectomy (not narrated)
• Laparoscopic transperitoneal right radical nephrectomy (Dr. Renaud Bollens)

Contraindications

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

Advantages to Laparoscopic Approach

• Compared to open approach:
  • Reduced blood loss, pain, and hospital stays
• Compared to robotic approach:
  • Reduced cost

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
• Laparoscopic lens: 30 degrees
• Vessel sealing device
• Laparoscopic staplers/Hem-o-Loks
  • If vascular stapler, open staple height of 2.5mm, either 45mm or 60 mm length depending on size of renal vessels
• Sutures
  • Closing
    • 0 Vicryl on UR6 x 2 (port site closure)
    • 1-0 Vicryl on UR6 x 2 (closure of extraction site)
    • 4-0 monocryl on PS-Z (skin closure)
  • 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: 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
      1. Superior port
         • On the right side, this is the working port (12 mm fascial dilating trocar or 10 mm reusable). On the left side, this is for the non-dominant hand (5 mm).
      2. Camera
         • 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).
      3. Inferior port
         • On the right side, this is for the non-dominant hand (5 mm). On the left side, this is the working port (10-12mm).
      4. 2-5-mm assistant port
         • Used 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
         • 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.[2]
      • In laparoscopy, the standard 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 15 cm from the target.[3]
      • 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).[4]
      • Trocars should be placed a minimum of 10cm apart.[5]
  • Location of ports:
    • 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.[6]
        • 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.[7]
        • Generally if trocars are not placed in the midline, they should be placed at least 6cm lateral to the midline to prevent epigastric injury.[8]
    • Configuration 1:[9]
      • 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:[10]
      • 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: inserted at the anterior axillary line.
    • Configuration 2:[11]
      • 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 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 5: See CW Figure 5.1
    • 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
  • 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.
    • Abdominal access with transumbilical Veress needle. Apply penetrating towel clamps superior and inferior to 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 left upper quadrant (also known as Palmer’s point) entry.
        • Palmer’s point: 3cm below the left subcostal border in the mid-clavicular line
          • Contraindications to Palmer’s entry include splenomegaly, hepatomegaly, portal hypertension, gastric or pancreatic masses, history of a splenic or gastric surgery and presence or suspicion of left upper quadrant adhesions.
          • If Palmer’s point contraindicated, consider a point that is
            • 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[12]
          • If not transumbilical entry, 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 port sites. Use marking pen to denote incisions for ports. Start by marking superior port. Laparoscopic ports should be at least 5cm[13] (approx. 4 fingerbreadths from each other and, within appropriate distance to target anatomy (15cm)[14]. Make sure assistant has good access to field from assistant port.
    • Insert ports. Once at 15 (or 20) mm Hg, the first port, the camera port is placed through a 12 mm transverse incision. Twisting is more important than pushing. Once in, remove trocar (should hear air coming out when opening valve on port), and insert camera (30 degrees). Switch gas to this port.
    • Inspect abdomen. Check that no injury made to the bowel during insertion of Veress needle. Check for adhesions that may interfere with port placement.
    • Insert remaining ports. Point camera towards patient’s head. Transiluminate abdominal wall to avoid large abdominal wall vessels. Begin insertion of most superior port (facilitates visualization of inserting other ports). Use knife to make an transverse incision in this area. Twist port into incision under vision. Take out obturator and advance trocar until black line. Repeat steps for other ports. On right side, setup liver retractor with Allis clamp 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. Use blunt and sharp dissection to develop avascular plane anterior to Gerota fascia and posterior to the mesocolon. The bowel mesentery is bright yellow in color while the retroperitoneal fat is dull yellow. Release attachments to the spleen and liver as needed. Assistant retracts bowel medially.
      • 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.
      • 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
      • A blunt instrument like suction is very useful at this step to swipe the mesentery away
    • 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 triangular ligament may be divided to lift the liver off the upper pole.
    • Identify ureter and gonadal vein. 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. 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. Once the ureter is identified, dissect a plane medial and parallel to the ureter, with careful identification of the gonadal vein. The plane is developed superiorly along the psoas muscle towards the renal hilum with anterior elevation of the ureter and/or gonadal vein. The assistant lifts the kidney up. 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 lower pole of the kidney. The gonadal artery is usually found just below the lower pole and can be either clipped or divided by the use of ultrasonic or bipolar energy devices
      • 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
        • 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.
      • 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
    • Identify and dissect renal hilum. Dissect the renal hilum meticulously to clearly delineate the vascular structures prior to their ligation. During hilar dissection it is important to place the kidney on stretch, to improve identification and to facilitate dissection of the hilar vessels. Identify renal artery. The renal artery is posterior to the renal vein.
      • Caution: do 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 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. 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
          • 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. The superior pole of the kidney is dissected 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 and the specimen is placed in the sac.
    • Obtain hemostasis.
    • Remove specimen. Extend incision medially (to avoid injury to the inferior epigastric vessels) from the 5mm trocar site to form 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.
      • 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.
    • Close abdominal incision.
    • Re-insufflate abdomen and verify hemostasis and no bowel taken with abdominal closure.
    • Closure. Remove all instruments and ports. 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.
• Jindal, Tarun, et al. "Simplifying Laparoscopic Nephrectomy for Beginners: Double Window Technique With En Bloc Hilar Stapling." Cureus 13.7 (2021).
• Collins, Sean, et al. "AUA BLUS handbook of laparoscopic and robotic fundamentals." Linthicum: American Urological Association 100 (2015): 200-300.