Patient Positioning

The patient is brought into the operating room and positioned supine on the table. After induction of anesthesia, the patient is placed in a modified lateral decubitus position at 30° with the ipsilateral side of the abdomen elevated. Gel rolls or pillows may be placed behind the back to aide in positioning. The contralateral arm is placed out on armrest at less than 90°. The ipsilateral arm is bent and placed across the chest. At this degree of rotation, the legs may remain in anatomic position and should not require bent knee positioning and/or elevation of the ipsilateral leg as there should not be a significant degree of hip adduction and thus no strain on the sciatic nerve. At this degree of rotation, there is also generally no need for an axillary roll. However, for obese patients, an axillary roll may be necessary to relieve any pressure on the brachial plexus. The patient is secured to the surgical table with tape or straps placed across the hips and across the chest (underneath the ipsilateral arm). The authors prefer wide silk tape placed over gel pads and surgical towels. All pressure points should be padded to prevent soft tissue injury and rhabdomyolysis (refer to Table 2.1 for further description regarding positioning injuries [5]). The ipsilateral arm is loosely secured to prevent movement during the case. Bilateral legs are also loosely secured to the surgical table to prevent significant movement during the case. See Fig. 2.1.

When positioned in this manner, there should be no need to flex the bed or to use kidney bar. Unlike open surgery, these maneuvers are unlikely to aide in exposure and have known potential associated morbidity. Once in position, the surgical bed should be lowered and then rotated toward the operating surgeon to ensure the patient remains secure and immobile.

Trocar Positioning

The surgeon stands on the contralateral side of the surgical bed. Access and pneumoperitoneum can be achieved via closed (Veress needle) or open (Hasson) techniques. The Veress needle may typically be inserted via the umbilicus. In cases of prior midline abdominal surgery, hernias, or obesity (body mass index >30), the Veress may be introduced at Palmer’s point, which is located 3 cm below the left costal margin in the midclavicular line [21]. Two “clicking” sounds should be heard as the needle passes through fascia and peritoneum. Aspiration and saline “drop test” are used to help confirm intraperitoneal location. Opening pressures should be ≤5–10 mmHg and were shown to be the most reliable in avoiding iatrogenic injury [22]. Refer to Table 2.1 for further discussion regarding Veress needle injuries. Once insufflation pressure has reached 15 mmHg, trocar placement can take place.

Generally, the camera port (10 mm) is placed at the level of the umbilicus, a 5 mm port is placed in the subxiphoid position, and a 12 mm working port is placed in the lateral position of the ipsilateral side of the abdomen cephalad to the anterior superior iliac spine. Please refer to Fig. 2.2 for diagram of placement.

For right-sided procedures, there may be a need for an additional port for liver retraction. This port (5 mm) may be placed just superior and/or medial to the upper 5 mm trocar. A ratcheting grasper can then be placed from this medial port underneath the liver and then grasping the side wall to displace the liver cephalad and out of the surgical field. It is important that the grasper is placed cephalad enough through the abdominal wall to allow for adequate superior retraction of the liver and prevent clashing with the right-hand port. Liver retraction can also take place from an inferior approach by placing an additional 5 mm port lateral and cephalad to the lateral 12 mm port. A laparoscopic liver retractor can then be used to superiorly displace the liver without obstructing the left- and right-hand working ports.

There are additional considerations for trocar placement in specific patient populations. For obese patients, trocars should be shifted laterally secondary to habitus (Fig. 2.3). In patients with prior surgeries, initial trocar placement should take place away from prior surgical incisions. In patients with multiple prior surgeries and complicated abdomens, the surgeon must take great care with access to avoid complications. In select cases, after successful initial insufflation with a Veress needle, one can employ a second Veress needle in a proposed site for the initial trocar. If the surgeon hears a stream of air when that location is probed with the second Veress needle, this suggests few if any adhesions in that area and raises confidence of this being a safe location for trocar placement¹. For very complex abdomens, one should strongly consider the open Hasson technique for access or a retroperitoneal approach. For the open Hasson approach, a 10–12 mm incision is made through the skin, and blunt dissection is performed down to the fascia which is incised sharply. The peritoneum is grasped between two clamps and cut with Metzenbaum scissors. A Hasson trocar is then placed after a “360° sweep” with a finger to ensure proper entry into the peritoneal cavity and assess the abdomen for adhesions. Subsequent trocars can then be placed under direct visualization and with incisions hidden within prior scars after it is ensured that there are no intra-abdominal adhesions that may prevent safe trocar placement.

Once trocars are placed, the surgical bed is lowered and rotated to the contralateral side to allow for medial displacement of intra-abdominal contents and to promote exposure of the retroperitoneum as in Fig. 2.4.

Exposing the Kidney

Begin by reflecting the colon medially to expose the retroperitoneum. An incision is made along the white line of Toldt from the splenorenal (left) or hepatorenal (right) flexure inferiorly to below the level of the lower pole of the kidney. The colon is then reflected medially. Care should be taken to avoid entrance into Gerota fascia. There is a distinction in the color of the retroperitoneal fat and perinephric fat which is contained within Gerota fascia, with the latter being a more “golden” shade. Recognizing this slight difference in color aids in dissection. With appropriate dissection, the anterior surface of Gerota fascia remains intact as the posterior aspect of the mesocolon is dissected free. Holes within the mesentery may be made during this dissection and should be closed once identified to avoid internal hernia. If the hole is small, laparoscopic metal clips may be used for closure. Larger holes may require reapproximating with sutures.

During right-sided procedures, care must be taken to identify and prevent injury to both the duodenum and gallbladder. Dissection should not take place on the duodenum itself. Kocher maneuver is typically needed to medially reflect the duodenum and expose the renal hilum and should be performed in a sharp, athermal manner. Attachments to Gerota fascia should be taken down sharply and at an adequate distance from the duodenum so that if bleeding is encountered, cautery can be safely used without risking injury to the duodenum.

Identification of the Renal Hilum

Once the colonic reflection is complete, the anterior surface of the psoas muscle should be easily identified. If the muscle is not directly visualized, care should be taken to identify the gonadal vessel and/or ureter just inferior to the lower pole of the kidney. Dissection posterior to the gonadal vessels and ureter will allow for identification of the anterior surface of the psoas muscle. In obese patients, the field of vision is altered by lateralization of the ports, and thus the anatomy may appear aberrant. Dissection tends to be more medial than it appears, and hence clear identification of the vena cava (for right-sided procedures) and the aorta (for left-sided procedures) should take place to ensure dissection within the appropriate planes.

With the psoas muscle identified, the overlying gonadal vein and ureter can be traced superiorly toward the renal hilum with a combination of sharp and blunt dissection. Generally, the ureter is retracted anteriorly, and the gonadal vessels may be retracted with it or left down in its anatomic position. The posterolateral aspect of the kidney can be dissected free bluntly. This allows for strong anterior retraction of the kidney to best expose the renal hilum.

Careful dissection should take place around the renal hilum to identify the primary renal vein and renal artery, which generally lies posterior to the vein. Dissection takes place primarily in a blunt fashion with the suction/irrigator. Generally, there is thin connective tissue both inferior to and overlying the renal vein that needs to be transected to allow for complete identification. Preoperative imaging can be reviewed to check for aberrant renal vasculature so that these vessels can additionally be identified and controlled. Gonadal vessels, aberrant venous vasculature, and lumbar vessels may be clipped and transected as needed to aide in isolation of the hilum.

Renal Vasculature Control and Transection

Once identified and safely dissected freely, control of the renal hilum is the next step. Options for renal artery and vein control include endovascular stapler (Endo-TA-type device, US Surgical, Norwalk, CT), nonlocking titanium clips and locking polymer clips (Hem-o-lok, Weck Closure Systems, Research Triangle Park, NC), or a combination of these. Weck Hem-o-lok clips for renal artery control have been contraindicated by the FDA since 2005 for laparoscopic donor nephrectomy secondary to potential for dislodgement with resultant profuse bleeding which could lead to reoperation or death (https://​www.​accessdata.​fda.​gov/​cdrh_​docs/​pdf13/​K133202.​pdf) [23]. However, they continue to be used for renal vascular control by many urologists [24, 25], with an emphasis on appropriate practice of safe application techniques [25]. In a 2015 survey, about 10% of transplant surgeons still used them for one or both vessels during donor nephrectomies and most consider them safe if multiple locking clips are used [26]. A review of the FDA database for mechanisms of failure of renal hilum control during laparoscopic donor nephrectomy found that of the 92 failures reported between 1992 and 2007, more cases were reported from staplers and titanium clips (64% and 23%) compared to just 13% from locking clips [23]. The data emphasizes the importance of surgeon’s experience, knowledge of various options available, and ability to troubleshoot quickly for safe management of the renal hilum.

The renal artery should be controlled first. In our practice, we use a laparoscopic endovascular stapler for its benefit of transfixion and transection. Careful use and knowledge of the stapler is important. Failures most often occur in the form of missing/malformed staple lines (51%) or failure to release (25%) [23]. If the renal vein is obstructing appropriate visualization of the artery, we place a single Weck Hem-o-lok on the artery to allow for venous transection with endovascular stapler prior to arterial transection. This should only be done when adequate safe exposure of both vessels has been achieved.

Adrenal Management and Final Dissection

Once the hilar vessels are transected, dissection can continue superiorly. The adrenal gland should be spared when possible during most radical nephrectomies, including large upper pole tumors, as it has been linked to negatively affect overall patient survival [27]. Adrenal involvement can often be ruled out preoperatively, with the negative predictive value almost 100% with modern cross-sectional imaging [28, 29]. Tumors larger than 7 cm (T2) have been shown to have a higher rate of adrenal involvement than smaller (T1) tumors, but this remains still very low at only 3% [30]. Contemporary indications for concomitant ipsilateral adrenalectomy are evidence of adrenal metastasis on imaging, macroscopic evidence of disease at the time of surgery, or direct extension of tumor into the adrenal gland [31].

In adrenal sparing surgery, dissection should take place in the plane between the adrenal gland and the upper pole of the kidney. The adrenal has a rich blood supply such that small adrenal branches may be encountered, and therefore meticulous hemostasis should be ensured. This portion of the dissection is aided by use of an electrothermal tissue/vessel sealing instrument, of which we prefer the bipolar LigaSure™ (Medtronic, Minneapolis, MN).

Once complete, the only remaining attachments should be the lateral attachments of the kidney, which can be taken down with a combination of blunt and sharp dissection, and the ureter, which can be transected after placement of clips or with an additional reload of endovascular GIA stapler.

Specimen Extraction and Closure

The kidney is then placed within a laparoscopic specimen bag. The site of extraction can be determined on an individual basis. A prospective comparison between extending a port site and a Pfannenstiel incision found the Pfannenstiel group had less early postoperative pain, slightly shorter hospital stay, and trends toward better patient satisfaction, however no statistically significant differences in complications at 6 months [32]. Based on the size of the specimen, we generally remove via an umbilical site extension if amenable. The incision is extended through the skin and then down through the fascia with care taken to avoid injury to intra-abdominal contents. For simple nephrectomies when malignancy is not suspected, intra-abdominal morcellation can be performed. The specimen bag can then be removed and the incision closed. The abdomen should be re-insufflated and the surgical bed inspected to ensure adequate hemostasis after a period of desufflation. Hemostasis can also be assessed before specimen extraction by lowering the intra-abdominal pressure of the pneumoperitoneum down to 5–10 mmHg. The area should also be inspected for any evidence of injury to other intra-abdominal contents. Table 2.1 discusses management of these injuries as well as potential means of preventing other organ injuries.

The fascia at the sites of 12 mm ports, cutting trocars, and 10 mm trocar sites should be closed to prevent hernia (see Table 2.1). Any smaller ports do not require fascial closure. A suture passer system may be employed with a 0 Vicryl or a doubled over 2-0 Vicryl suture that is placed under direct visualization through the fascia on either side of the trocar defect while the abdomen remains insufflated. Skin incisions can then be closed in a subcutaneous fashion with your choice of absorbable sutures, such as a 4-0 Monocryl.

Intraoperative Localization

Following mobilization, the next step is localization of the renal mass. Preoperative imaging should be reviewed thoroughly prior the procedure and available for review intraoperatively. Intraoperative ultrasound is used to identify the renal mass, its characteristics (e.g., solid/cystic), exact borders, and relationship to renal structures (e.g., vessels, collecting system). If available, it should be used for partial nephrectomies as it has been found to reveal findings additional to preoperative imaging in about 10% of cases – which could significantly impact surgical approach [33].

With emphasis on nephron-sparing surgery, intraoperative imaging and augmented reality technologies continue to be developed, although intraoperative ultrasound continues to be most commonly used. One emerging method is the use of near-infrared fluorescence imaging (NIRF) using intravenous indocyanine green (ICG) minutes before clamping. This has been shown to aid in tumor localization, pathology prediction, super-selective clamping, and adequate clamping [34–36]. However, it does require specific endoscopic systems for laparoscopic use (SPY® Imaging System, Novadaq Inc., Mississauga, ON, Canada).

Renal Mass Resection

Once the lesion is localized, the kidney should be positioned to allow for adequate exposure during resection. In rare occasions, the surgeon may place an additional 5 mm port for use as an assistant port to aide in retraction and/or exposure. Gerota fascia is then incised away from the border of the tumor. The perinephric fat is dissected off the renal capsule around the area of the tumor with care taken to neither cut into the tumor nor remove the fat overlying the tumor. An outline of the line of incision can then be made into the renal capsule using shears (hot or cold) or monopolar hook. This incision should be made just lateral to the previously identified extent of the tumor to provide an adequate margin and prevent entering the tumor. A marked sponge may be placed in the abdomen at this time to prevent any blood loss that does occur from tracking into the contralateral side of the abdomen.

Next, a decision is made as to extent/type of vascular control needed for the procedure. There are many series reporting an off-clamp technique for excision of renal mass [37]. This method is associated with increased blood loss but has the ultimate goal of decreased (zero) ischemia and thus potential preservation of renal function. Other approaches to decrease ischemia time include early unclamping [38], segmental clamping, and tumor-specific clamping [20]. Patient factors, intraoperative feasibility, and surgeon preference should determine the method of vascular control to be used.

When a clamp technique is used, laparoscopic bulldog clamps can be placed on the main renal artery for complete occlusion or on segmental vessels for selective ischemia. We generally employ a method of early unclamping such that hilar clamp time should be limited to reduce the detrimental impact of warm ischemia on renal function [38, 39]; however, the amount of kidney removed and underlying renal function are of greater consequence to postoperative renal function [40].

The renal capsule is then incised at the previously marked position. A combination of blunt and sharp athermal dissection is used to excise the renal mass. Vessels that are directly visualized during this dissection may be clipped prior to transection to aide in hemostasis. Extreme care should be taken to prevent violation of the tumor that could lead to tumor spillage. Gentle manipulation with the suction/irrigator or with a laparoscopic DeBakey forceps may be employed to handle the tumor. Often, the overlying perinephric fat may be used to aide in tumor retraction with decreased risk of injury to mass. Once the tumor is completely excised, the specimen should be placed directly into an entrapment sac. The resection bed should then be examined. Cold cup or excisional biopsies may be taken and sent for permanent or frozen section.

Hemostasis is then obtained using a variety of techniques. The tumor resection bed may be cauterized using argon beam coagulator. Hemostatic matrix, such as Floseal (Baxter, Deerfield, IL), may be placed into the tumor bed. Additionally, some surgeons may employ a multilayered closure with initial placement of suture (3-0 Vicryl interrupted or running) along the floor of the defect to aide in both hemostasis and/or closure of the collecting system (refer to Table 2.1 for discussion of urine leaks). Renal parenchymal edges are then reapproximated. Absorbable suture (0, 2-0, or 3-0 Vicryl) with Lapra-Ty and/or barbed suture may be used to reapproximate the parenchymal edges. Suture must be placed at an adequate distance (approximately 1 cm) to the edge of the defect to prevent the suture from tearing through the renal parenchyma. Sutures should be pulled in the direction of placement to also prevent tissue tearing. This can be performed in an interrupted or running fashion. Sutures should be placed until the renal edges appear well approximated and hemostasis is obtained. At this point, bulldog clamps can be removed from the renal hilum, and warm ischemia time can be calculated. Early clamp removal, prior to completion of the renorrhaphy, can be performed to limit ischemic time [38]. Mannitol administration can also be considered prior to hilar clamping with the theoretical potential for reduction of postoperative renal dysfunction. The data to support the use of mannitol is in animal models and transplant literature, which lead to routine use traditionally [41, 42]. Recent studies, including a randomized trial comparing mannitol vs. hydration in minimally invasive partial nephrectomies in a population with normal preoperative renal function, found no clinically or statistically significant difference in renal function between their cohorts at 6 months postoperatively [43]. Other retrospective and prospective trials had similar findings and thus contemporary data does not support mannitol use in this population [42, 44].

Once reperfusion has occurred, the kidney should be reexamined. Additional sutures may need to be placed to aide in hemostasis. The specimen is then extracted, and port sites can be closed as previously described in the nephrectomy section above. As the specimen is often much smaller, these can almost always be removed through a minor extension of a port site. A closed suction drain should be left if there is known or suspected collecting system involvement. The drain is used as an aide to diagnose and manage urine leak after partial nephrectomy, which occurs in about 4–5% of cases [45].

Patient Positioning

Unlike in the transperitoneal approach, the retroperitoneal approach requires full flank patient positioning. After induction of general anesthesia, the patient is positioned at 90° to the bed with the ipsilateral side up. Gel rolls or pillows may be placed behind the back to aide in positioning. It is necessary to place an axillary roll to prevent brachial plexus injury with this position. The contralateral arm is placed out on armrest at less than 90°. The ipsilateral arm is draped over the chest in a neutral position and placed onto arm rest secured to the surgical table. At this degree of rotation, it is necessary to place contralateral leg in a bent position and then place pillows between the legs to elevate the ipsilateral leg and thus prevent a significant degree of hip adduction and/or strain on sciatic nerve (refer to Table 2.1 for further description regarding positioning injuries). The patient is secured to the surgical table with tape or straps placed across the hips and across the chest (underneath the ipsilateral arm). The authors prefer wide silk tape placed over gel pads and surgical towels. All pressure points should be padded. The ipsilateral arm is loosely secured to prevent movement during the case. Bilateral legs are also loosely secured to the surgical table to prevent significant movement during the case.

Trocar Positioning

Once secured, the bed can be flexed and the kidney bar raised to increase the distance between the ribs and hips and hence maximize access to the retroperitoneum. An incision is then made approximately two fingerbreadths below the tip of the 12th rib along the posterior axillary line. Dissection is taken down through the lumbodorsal space until the retroperitoneum is entered. Blunt dissection or a trocar-mounted dissecting balloon is used to develop the retroperitoneal working space. A blunt 12 mm trocar can be placed within newly developed space and retroperitoneum. The trocar balloon is inflated, placed on tension at the level of the skin, and then insufflated to 15 mmHg (Fig. 2.5). Working space is significantly diminished with this approach.

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