Both the transperitoneal and retroperitoneal laparoscopic approaches are reasonable for the majority of nephrectomy procedures. With specific regards to laparoscopic radical nephrectomy, the procedure has been accepted as the alternative to traditional open radical nephrectomy in the treatment of many renal cell carcinomas. Accepted indications currently include T1 to T3a lesions with even very large tumors (>20 cm) being safely and effectively removed. Ultimately, sound clinical judgment remains the mainstay in deciding whether a particular tumor is most amenable to a laparoscopic or an open approach.
This chapter focuses on transperitoneal laparoscopic nephrectomy and concludes with a brief discussion of retroperitoneal laparoscopic simple nephrectomy.
All patients consenting to undergo a laparoscopic nephrectomy regardless of the indication should thoroughly understand the benefits, risks, and potential complications associated with laparoscopic renal surgery. Intraoperative complications associated with laparoscopic nephrectomy include vascular and visceral injuries, as well as failure to progress. Any of these complications may necessitate open conversion, and as such, patients should be consented for possible open conversion. Accordingly, the operating room should be prepared with an open surgical tray for emergent conversions. Postoperative complications include neurapraxias, rhabdomyolysis, deep vein thrombosis (DVT), and cardiac events associated with pneumoperitoneum, and this must also be carefully reviewed with the patient. A reasonable understanding of the risk of these complications should be shared with the patient. For example, patients scheduled for simple laparoscopic nephrectomy for presumed xanthogranulomatous pyelonephritis or patients with multiple prior abdominal procedures should understand that they are at higher risk for complications.
Patients are typically admitted to the hospital on the morning of surgery. Currently, the authors do not use any special bowel preparation for laparoscopic renal surgery. A cephalosporin administered within 1 hour of the incision will usually suffice for antimicrobial prophylaxis. Sequential compression devices should be used in all patients when possible, and those at increased risk for DVT should also receive heparin 5000 IU given subcutaneously just before surgery.
Patient Positioning and Protection
After the induction of general endotracheal anesthesia, a urethral catheter is placed to decompress the bladder and allow for monitoring of urine output. Proper positioning is important to minimize the risk of postoperative complications ( Fig. 12.1 ). Ideally, the operating table should be reinforced with either gel padding or egg crate. First, the patient is moved along the longitudinal plane of the table until the iliac crest is over the break in the table. Next, the patient is placed in a 70-degree semilateral decubitus position, with the pathologic kidney on the upside. The table is then flexed to increase the working space for placement of laparoscopic trocars between the anterior superior iliac spine and the costal margin. The patient’s lower leg is flexed to 90 degrees and separated from the upper leg by pillows. The upper leg remains extended. Next an axillary roll is deployed under the patient caudal to the axilla. It is important that the axillary roll does not occupy the axilla to avoid the potential development of a brachial plexus palsy. The ipsilateral arm is draped across the torso and separated from the dependent arm by multiple pillows. Alternatively, a Kraus arm board can be used to support the ipsilateral arm. Careful attention should be paid to placing extra padding under the lateral malleolus and the fibular head of the dependent leg to prevent compression injury. The patient is then secured to the table with Velcro straps and 3-inch cloth tape or gel straps at the shoulders, hips, and knees. This is important to prevent shifting when the table is rotated intraoperatively to help with laparoscopic exposure.
After the patient is appropriately positioned, the abdomen is widely prepared and draped from the symphysis pubis to a level just above the xiphoid process and from the posterior axillary line of the upward side to the midclavicular line of the downward side. If specimen extraction through a Pfannenstiel incision is a consideration, the appropriate area must be shaved and prepared as well.
Obtaining Access and Establishing Pneumoperitoneum
Two techniques are generally available to achieve the pneumoperitoneum: the closed technique with a Veress needle and the open (Hasson) technique.
When using the Veress technique, proper needle function should be ensured before the procedure. Either a disposable or nondisposable 15-cm Veress needle is placed 2 fingerbreadths superior and medial to the anterior superior iliac spine on the ipsilateral side ( Fig. 12.2 ). After the skin is incised with a #11 blade, the Veress needle is advanced into the peritoneum with its tip directed slightly medially and inferiorly. There are usually three “pops” as the needle is inserted, but this solely depends on the state of development of the musculofascial layers and is largely patient dependent. Next, to confirm appropriate placement of the Veress needle within the peritoneal cavity, it should be aspirated with a 10-cc syringe followed by irrigation with up to 3 cc of saline and finally removal of the syringe, thus allowing the column of saline to fall under gravity into the peritoneum. If neither blood nor bowel contents are aspirated and the column of saline falls easily under gravity, then the insufflator tubing is connected to the needle, and insufflation is begun at a low flow rate. The expected opening pressure should be less than 10 mm Hg. The insufflator is then switched to high flow until an initial pressure of 15 to 20 mm Hg is reached. This higher pressure is transiently maintained only during the deployment of the initial trocars and should not be maintained for longer than 10 minutes. The pressure is then lowered to 12 to 15 mm Hg for the remainder of the case. With newer valveless insufflation, the authors have now routinely turned to working with a pneumoperitoneum of 10 to 12 mm Hg.
The first trocar placed should be a 12-mm port with a visual obturator, allowing a 10-mm, zero-degree lens to view the subcutaneous tissue followed by the external fascia, internal fascia, preperitoneal fat, and finally the peritoneal cavity in a controlled rotating fashion. This lens is immediately switched to a 10-mm, 30-degree lens, and the site of Veress entry is inspected for any obvious injury.
When using the open (Hasson) technique, a 2-cm transverse incision is made superior and lateral to the umbilicus about 3 fingerbreadths from the costal margin. The fascia and peritoneum are opened individually with a transverse incision, sufficient to accommodate the surgeon’s finger. After visual and digital confirmation of entry into the peritoneal cavity, either a Hasson cannula or blunt-tip balloon port (e.g., Blunt Tip Trocar with Balloon Tip, U.S. Surgical, Inc., Norwalk, CT or the Kii Balloon Blunt Tip System, Applied Medical, Rancho Santa Margarita, CA) is advanced through the incision with the blunt tip protruding. A horizontal mattress suture can be placed in the anterior fascia before placement of the cannula to aid at the time of closure. With the Hasson cannula or balloon port in place, the abdomen is insufflated, and pneumoperitoneum is achieved. The 10-mm, 30-degree lens laparoscope can now be inserted and the remaining trocars placed under direct vision.
Templates for trocar placement on both sides are shown in Fig. 12.3 . Each patient’s anatomy and pathology are different, so trocar templates must be adapted to the individual’s body habitus and site and nature of his or her pathology. In general, the lower quadrant 12-mm trocar is placed approximately 2 fingerbreadths medial and superior to the anterior superior iliac spine. Either a second 10- or 12-mm trocar or a 5-mm trocar is placed in the midclavicular line approximately 2 cm below the costal margin. The camera trocar, also a 10- or 12-mm trocar, is placed superior and lateral to the umbilicus and situated between the two working trocars. For a right-sided nephrectomy, an additional 5-mm trocar is typically necessary to retract the liver cephalad after it has been mobilized. It is placed in the epigastrium just inferior to the xiphoid process, entering the peritoneum on the right side of the falciform ligament.
If desired, an additional 5-mm trocar can be inserted as an assistant port or to be used for countertraction with a mechanical retractor (e.g., PEER. Jarit Surgical Instruments, Hawthorne, NY). If the additional trocar will be used as an assistant port, it can be placed in the lower quadrant inferior and medial to the 10- or 12-mm lower quadrant trocar, such that the two sites can be joined during specimen extraction. Alternatively, if the additional trocar will be used for a mechanical retractor, it can be placed in the mid to posterior axillary line at the level of the 12th rib.
Steps for Left Nephrectomy
The first step in performing a left nephrectomy begins with complete mobilization of the left colon, initiated by incision of the white line of Toldt from the splenophrenic attachments superiorly down to the level of the iliac vessels inferiorly ( Fig. 12.4 ). Often the initial dissection needs to be focused on the release of any adhesions tethered to the anterior abdominal wall before mobilization of the colon begins. These adhesions are common in the region of the splenic flexure. Caution must be used when releasing these attachments, which can appear insignificant but may contain bowel structures.
Next, the plane between the mesentery of the descending colon and the anterior surface of Gerota fascia is identified. Identifying these natural tissue planes is greatly facilitated by traction–countertraction maneuvers. As the colon and its mesentery are swept medially, it is important to maintain dissection in the avascular plane between Gerota fascia and the mesentery. Visually, this can be achieved by staying in the thin areolar tissue lying between the pale yellow fat of Gerota fascia and the darker yellow fat of the mesentery ( Fig. 12.5 ). This plane is often most easily identified at or just below the lower pole of the kidney. Deviation from this plane results in increased blood loss. The goal is for the colon to be reflected medially until the most medial portions of the kidney are exposed. Mobilization of the spleen is also essential to gain access to the medial aspect of the kidney. This is achieved by dividing the splenophrenic attachments followed by dissection and incision of the splenorenal ligaments ( Fig. 12.6 ). The medial reflection of the colon, combined with the mobilization of the spleen, allows the spleen and colon to fall medially, carrying the tail and body of the pancreas with them and away from Gerota fascia. In doing so, it allows for eventual exposure and dissection of the renal hilum. This dissection also allows the gonadal vein and the ureter to then be approached. The gonadal vein and ureter are best identified at the level of the lower pole of the kidney. After it is identified, the gonadal vein is then traced by proceeding carefully along its inferior surface to its insertion into the left renal vein ( Fig. 12.7 ). This can be best achieved by retracting the gonadal vein and ureter anterolaterally with the psoas muscle exposed inferiorly.