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Home » Oncology » Oncology – Renal » Laparoscopic nephrectomy

Laparoscopic nephrectomy

Summary, principles and goals

  • Removal of the entire kidney with control and ligation of the renal hilum, and on the left/right this is achieved by a dissection of the gonadal vein/vena cava
  • Traditionally radical nephrectomy involved ipsilateral adrenalectomy, regional lymph node dissection and removal of the entire contents of Gerota’s fascia

Indications

  • T1 renal mass where partial nephrectomy is not feasible
  • T2 + renal mass including locally advanced disease
  • Cytoreductive or palliative nephrectomy in metastatic disease
  • Benign nephrectomy – non functioning kidney causing problems, or lack of other treatment options

 

Technique

  • GA, IDC, antibiotics, side marked pre-operatively
  • Lateral flank position – between costal margin and iliac crest on break, 2 x back supports between scapula and buttocks/sacrum, axillary roll, pillow between legs, both arms cranially
  • Ports
    • 12 mm camera port – between the umbilicus and costal margin, about a palms breadth from costal margin, around lateral border of rectus
      • Hasson entry
    • Triangulate two working ports – 12 mm caudally for stapler, 5 mm cranially, caudal port a bit lateral
    • 5 mm liver retractor port just under xiphisternum for right side
  • Diagnostic laparoscopy
  • Take down adhesions
  • Medialise colon by dividing white line of Toldt – identifying plane between colonic mesentery and Gerota
  • Left side
    • Mobilisation of lateral spleen peritoneal attachments and lienorenal ligament – colon and spleen should fall away medially, carrying tail of pancreas away with them
    • Identification of gonadal vein, traced cranially to left renal vein
    • Ureter retracted laterally during gonadal vein dissection
  • Right side
    • Liver retracted cranially with ratcheted toothed grasper
    • Duodenum must be Kocherised by releasing its attachments to Gerota’s, to expose anterior surface of cava
    • Identify gonadal vein and ureter, ureter retracted laterally, dissection of gonadal vein and lateral border of cava
  • Mobilise the lower pole of the kidney looking for psoas as the plane posteriorly
  • Renal vein dissection – caution for adrenal vein and lumbar veins on left
  • Renal artery dissection – usually posterior to vein – if anterior, could be the SMA
  • Hilar division with stapler – artery then vein, or en bloc
    • If using clips – 3 on the stay side of artery
    • 45 mm stapler if separate; 60 mm if en bloc
  • Upper pole dissection +/- adrenalectomy or adrenal sparing – usually dissection with Gerota if adrenal sparing
  • Lateral attachments freed – usually mostly avascular and loose
  • Division of ureter
  • Large endocatch bag through caudal port – specimen removed through extension of caudal port (or Pfannenstiel)
  • Re-look to ensure haemostasis

 

Complications:

GA/anaesthetic related, positioning (brachial plexus, tibial nerve), rhabdomyolysis.

Spleen bleeding

  • Usually capsular tear. Prevent by mobilising well early to allow safe retraction.
  • Compress with ray-tec for period of time. If still bleeding – haemostasis products – Floseal, Surgicel or Tachosil.
  • If still bleeding – general surgery and consideration of splenectomy (post-operative pneumococcal, meningococcal and haemophilus vaccinations required).

Pancreatic injury

  • Usually during left hilar dissection. Can be just pancreatic bruising and subsequently raised lipase levels. If concerns for pancreatic duct injury intra-operatively, may need resection of tail of pancreas.
  • May be detected post-operatively – drain fluid lipase levels – or collection identified on CT – exclude and prevent infection, minimal diet / TPN, IV fluids and HPB consulting.

Duodenum injury

  • Usually D2 during right nephrectomy. May be thermal from hot blade of instruments.
  • If identified intra-operatively – open and general surgical repair with two layers, cover with omental patch, prolonged NGT and gut rest, leave drains and broaden antibiotics.
  • If concerns post-operatively – laparotomy with general surgeons and repair

Liver injury

  • Similar treatment to spleen – packing/compression, surgicel/floseal, HPB if needed
  • Be aware of possible bile leak and fistula post-operatively

Pleural injury

  • Close with vicryl suture during Valsalva manoeuvre (positive pressure end expiration) to expel trapped air

Adrenal vein bleeding

  • Compress and increase pneumo to 20 mm Hg
  • Consider additional port, bleeding spiel, open conversion

Bowel injury

  • Direct repair if very small with two layered transverse closure, but low threshold for wedge resection or formal resection if thermal injury with possibility of delayed progression of injury

Stapler failure

  • If malfunction during firing – leave stapler in place and use another stapler or clips to obtain proximal control
  • Consider converting to open