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LAPAROSCOPIC NEPHRECTOMY
 Dr. Fernando
Telleria, Director of the I.M.E.C in Junin, Argentina is presenting the technique of a transperitoneal
laparoscopic nephrectomy (left).
Laparoscopicnephrectomy was first performed in 1990 by Clayman, Kavoussi et al, where they
removed the right kidney from a patient diagnosed with renal oncocytoma.
Since then, laparoscopic nephrectomy has been performed more often for benign disease
and many times for malignancy when indicated.
Indications for benign pathology include: Renal hypertension, recurrent pyelonephritis
calculous disease. Laparoscopic nephrectomy is indicated in a malignant process if
the tumor is small (less than 5 mm). When dealing with malignant disease the specimen should be retrieved intact in a
special impermeable sack (Lapsck, Cook Urological) via a 5 cm incision in the abdomen.
This is done for cancer staging and to avoid spillage of neoplastic cells into
the abdominal cavity and port sites. For benign disease the kidney can be fragmented
in pieces and retreived through the same ports.
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After general anesthesia the patient ispositioned in lateral decubitus. Once all ports are placed, the operation starts
by retracting the colon (splenic flexure) downward by cutting the line of Told.
This maneuver will expose the Gerota fascia where the kidney lies.
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This pictures shows the
colon retracted medially and inferiorly while exposing the gonadal vessels. In
this case the gonadal vein will drain into the left renal vein.
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The ureter is the first
structure identified. Once a window is made, this will help for retraction
during dissection
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The dissection the renal hilum can be very demanding. Artery and vein should be
identified and ligated. The artery is first isolated and divided between 9 mm titanium
clips.
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This is followed by ligation
and division between clips of the renal vein. Some surgeon choose to use a Endo
GIA stapler (US Surgical) to secure this vessel, if it happens to be wide and
broad.
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This picture shows the
kidney being lifted up once the vessels of the hilum have been divided. Blunt dissection
continues dividing any remaining attachments to the retroperitoneum.
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Finally, the ureter is
divided and the organ is ready for retrieval.
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The kidney is place in a
plastic bag using the grasper holding the organ by the ureter to avoid injury
and therefore tissue spillage
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When dealing with renal
cancer, a 5 cm incision is made in the abdominal wall to allow the specimen to
be retrieved under minimal tension. The plastic bag should be protecting the
skin all the time.
Relative
contraindications for laparoscopic nephrectomy include:
- Large tumor (>5 mm)
- Intra abdominal
adhesions (scar tissue)
- Surgeon not familiar
with advanced laparoscopic techniques
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