In 1991, Clayman and associates reported the first simple laparoscopic nephrectomy on a 54-year-old woman with oncocytoma. Since the introduction of this revolutionary procedure, indications for laparoscopic renal surgery have expanded, and laparoscopic nephrectomy has gained worldwide acceptance as the preferred approach for most pathologic conditions of the kidney. Laparoscopic approaches to renal surgery allow for the safe removal of a nonfunctional, dysfunctional, or infected kidney while offering the benefits of decreased narcotic analgesia requirements, shorter hospital stay, improved cosmesis, and earlier return to complete activity compared with open approaches. The use of this minimally invasive technique for the removal of benign renal pathology has been verified at several institutions. Among minimally invasive tools, the robotic approach has not gained fame as laparoscopy has, because it failed to offer any obvious advantage over laparoscopy to justify the notoriously higher cost. This chapter focuses on simple laparoscopic nephrectomy via the intra-abdominal approach. The hand-assisted and retroperitoneoscopic approaches to nephrectomy can be applied to simple nephrectomy, but these methods are the subject of discussion in other chapters of this text.
Indications and Contraindications
Simple laparoscopic nephrectomy is the treatment of choice for many benign diseases of the kidney owing to the appeal of decreased perioperative pain and morbidity. Indications and absolute contraindications for laparoscopic simple nephrectomy are listed in Box 16-1 .
Indications
- •
Multicystic dysplastic kidneys
- •
Nonfunction as a result of obstruction, infection, trauma, or stones
- •
Renovascular hypertension
- •
Xanthogranulomatous pyelonephritis (XGP)
- •
Renal tuberculosis
- •
Reflux nephropathy
Absolute Contraindications
- •
Sepsis
- •
Untreated urinary tract infection
- •
Hypovolemic shock
- •
Peritonitis
- •
Uncorrected coagulopathy
To date, there is less clarity on the role of laparoscopy in the removal of kidneys affected by severe inflammatory conditions and adult polycystic kidney disease. Series have been reported of laparoscopic simple nephrectomy for xanthogranulomatous pyelonephritis, tuberculosis, and other inflammatory conditions. Advocates argue that laparoscopy, although more difficult in such cases, is possible and may result in improved outcomes in these patients. However, critics suggest that the increased level of difficulty, increased operative times, and increased risk of complications and rates of conversion to open surgery make laparoscopy in these patients unjustifiable. Inarguably, inflammatory conditions of the kidney make hilar dissection more difficult, and these patients are at higher likelihood for conversion to open procedure. These procedures should be attempted only by the urologist with vast experience in laparoscopy and on patients who understand the increased risks compared with open procedures.
In patients with an extensive history of prior abdominal surgery, the retroperitoneoscopic approach may be preferred. Abdominal cavities that have previously undergone surgery can present difficulties that increase operative time and complications. The retroperitoneal procedure gives the surgeon a more direct route to the diseased kidney while avoiding the potential adhesions and scar tissue.
Absolute contraindications to laparoscopic simple nephrectomy include uncorrected coagulopathy, untreated infection or sepsis, peritonitis, and hypovolemic shock. Although morbid obesity is not a contraindication to laparoscopic surgery, obese patients may be at increased risk for complications and open conversion. Anatomic and vascular anomalies of the kidney represent a challenge for the laparoscopic surgeon; however, surgery is feasible if the patient has undergone adequate preoperative imaging of the kidneys.
Patient Preoperative Evaluation and Preparation
Preoperative evaluation for simple laparoscopic nephrectomy consists of history and physical examination including inspection for prior surgeries, abdominal scars, and skeletal abnormalities. Laboratory tests include complete blood cell count, serum creatinine and electrolytes, clotting parameters, urinalysis and culture, and other tests as indicated depending on the patient’s age and underlying comorbidities (e.g., electrocardiogram, chest radiograph). Typing and screening with preparation of two packed red blood cell units in anticipation of major bleeding is advisable. A clear liquid diet the night before surgery is recommended. If an extensive inflammatory reaction that will make the dissection more difficult is anticipated, a mechanical bowel preparation is also highly advisable. The informed consent should include the possibility of conversion to an open procedure.
A preoperative abdominal computed tomography (CT) scan is useful in evaluating the location, size, and disease of the kidney to be removed. Areas of perinephric stranding visualized on CT scan may indicate significant inflammation and dense adhesions, which render dissection more laborious and might increase the chance of conversion to open nephrectomy. In addition, cross-sectional imaging, particularly when coupled with intravenous contrast, will provide data on the vascular anatomy to the kidney, the presence of aberrant vessels or any mural calcifications, and the relationship of the kidneys to adjacent organs and will allow a rough estimate of the function of the contralateral kidney and adrenal gland.
Operating Room Configuration and Patient Positioning
A beanbag can be placed on the operating table. After the induction of general anesthesia, place a Foley catheter and an orogastric tube to decompress the stomach. Secure eyes with patient safety goggles. Then roll the patient into the modified flank position with the side of interest up (i.e., for right-sided procedures, the patient lies on his or her left side). Place foam padding beneath all points of pressure created by contact with the operative table to avoid pressure injury. Place the umbilicus over the break in the table, and flex the table as shown in Figure 16-1 . Use an axillary roll to prevent brachial plexus injury of the decubitus side arm. Position the arms on an arm board with a pillow or rolled blankets between them. Bend the bottom leg and place a pillow or blankets between the legs so that the top leg rests nearly parallel to the table. Generously use 3-inch cloth tape to tightly secure the patient at the hips and chest ( Fig. 16-1 ). Roll the table in each direction with personnel at each side of the table to ensure adequate stabilization of the patient. Perform a sterile preparation over the entire abdomen in the event that conversion to an open procedure is required. A laparotomy instrument tray should be available in the operating room and ready at all times in case an emergent conversion to an open procedure becomes necessary.
Trocar Placement
Trocar placement starts with insufflation of the peritoneal cavity. This can be achieved by inserting a Veress needle that helps inflate the abdomen, therefore rendering the insertion of the first trocar safe from injuring the bowel or other intraperitoneal organs. Another method is the Hasson technique, which consists of a small incision and dissection to reach the peritoneum and open it to slide the first trocar under vision in an oblique direction.
The Veress needle is placed at the site of the initial trocar, which is usually lateral to the rectus muscle ipsilateral to the surgical site. With the patient situated in the lateral position, the bowel is displaced by gravity away from the site of the initial trocar. In patients with prior abdominal surgeries, place the Veress needle in a region away from prior surgical scars. To confirm intraperitoneal placement, connect a syringe to the Veress needle and aspirate. If there is no evidence of entry into the bowel or a major blood vessel, perform the drop test by placing saline into the Veress needle and watching it freely drop into the peritoneal cavity. To further confirm appropriate location, begin insufflation at low flow rates. Immediate rise of pressure indicates a wrong site of insufflation—most often still in the abdominal wall, which necessitates further advancement of the needle. Place the insufflator on the high flow setting after even distribution of air to an enlarging, tympanic abdomen and low intra-abdominal pressure are confirmed.
Once pneumoperitoneum is established, remove the Veress needle. Make a skin incision to accommodate a 12-mm trocar at the site of the needle puncture. Incisions that are too small can lead to use of excessive force to penetrate the abdominal fascia and, as a consequence, inadvertent trocar entry into underlying organs. Equally problematic are incisions made too large because they can lead to continuous air leakage and loss of pneumoperitoneum throughout the procedure. The visual obturator trocar is a safe option because it provides direct visualization of the fascial layers to gain initial trocar access. Place the laparoscope through the initial port and directly examine the abdominal cavity for injury from entry as well as adhesions to the abdominal wall.
In general, three-trocar configurations are used for laparoscopic simple nephrectomy. Figure 16-2 shows examples of trocar placement for right- and left-sided procedures as well as for trocar placement in obese patients. Shift the entire template laterally in obese patients to allow for optimal instrument movement.
