Port placement for right sided nephrectomy. The numbered circles indicate the ports, all of which are 12 mm in diameter
Surgical Technique for Right Kidney Nephrectomy
Incision of the Peritoneum Under the Liver
To expose the upper pole of the kidney, it is necessary to incise the peritoneum immediately under the liver, from the beginning at a location 10–15 cm medial to the triangular ligament and continuing laterally to the ligament itself (Fig. 62.2).
Right laparoscopic nephrectomy. Incision of the peritoneum under the liver
Mobilization of the Colon
Incision of the peritoneum is extended inferiorly, parallel to the vena cava. During this step, the colon is minimally retracted medially. In right-sided nephrectomy, only the colon covering the lower pole of the kidney needs to be moved. The duodeneum is carefully mobilized medially.
Dissection on Kidney’s Upper Pole
At the level of the renal pedicle, the Gerota fascia and the connective tissue anterior to the renal pedicle are dissected mechanically and with bipolar energy along the vena cava to the upper pole.
When the renal vein and the vena cava can be clearly seen, the superior side of the junction of the renal vein and the vena cava is further dissected. During this step, we use blunt dissection with blunt tipped instruments (bipolar, aspirator or dissector). At this junction we pass superior to the renal vein and lateral to the vena cava to enter the Morrison space (hepatorenal recess or subhepatic recess) (Fig. 62.3), which is the anatomical space bounded by the liver, the posterior part of the upper pole of the right kidney and the lateral surface of the vena cava. This anatomical space is generally not mentioned in textbooks of urological surgery. In the presence of the pneumoperitoneum, entry into this space provides easy detachment of the right kidney’s upper pole from the surrounding structures.
Right laparoscopic nephrectomy: entrance into the Morrison space (hepatorenal recess or subhepatic recess that separates the liver from the right kidney)
If the adrenal gland will be left in place, the right hand instruments (atraumatic grasper, aspirator, etc.) retract the adrenal gland laterally and superiorly while the tissue between the adrenal gland and the kidney is dissected with the bipolar. In this way the adrenal gland is completely separated from the upper pole of the kidney. If the adrenal gland will be removed, then the adrenal vein that joins the vena cava is exposed. With the left hand instrument in the Morrison space, the kidney and the adrenal gland are retracted laterally and with the right hand instrument (bipolar energy source, e.g., Ligasure 10 mm Atlas) the adrenal vein is sealed and divided. During this dissection, other adrenal gland vessels in the area are dissected. As a result of this dissection, the upper pole of the kidney and the adrenal gland are completely freed from the surrounding structures.
Dissection of the Kidney’s Lower Pole
The lower pole is dissected from the surrounding tissues to expose the psoas muscle, the ureter and the inferior side of the renal pedicle.
Ligation and Division of the Renal Artery and Vein
The renal artery and vein are dissected and skeletonized with the bipolar instrument and the aspirator (Fig. 62.4). Then, on the renal artery, usually three Hem-o-Lok clips are placed (two on the part that will remain in the patient, and one on the part that will be removed with the kidney). Next, the renal vein is ligated with Hem–o-Lok clips (two on the part that will remain in the patient, and one on the part that will be removed with the kidney) or the vascular stapler, depending on the anatomy and the diameter of the vein.