Figure 61.1
Patient position
The surgeon stands cephalad and contra-lateral to the side of the kidney to be surgically removed, and the first surgical assistant stands caudally next to the surgeon. The laparoscopic cart with the monitor and insufflation pressure monitor is positioned opposite to the surgeons in an ergonomic position. It is important to ascertain the “horizon” view so surgeon’s muscle fatigue is not triggered by bad positioning of the monitor. Moreover, the insufflation pressure monitor should be visible at all times so issues with hemodynamics and bleeding can be adjusted accordingly. The scrub technician and instruments table should be positioned opposite to the operative team to facilitate transfer of instruments (Fig. 61.2) and they should have a monitor opposite to them to visualize the procedure and predict the next surgical step.
Figure 61.2
Room setup
Access and Trocar Placement
With the advent of optical trocars that allow entry visualization may securely use the Veress needle for insufflation, while other may prefer the open access technique is used to place the first trocar (Hasson technique [5]). Both techniques offer similar outcomes and results [6]. One may prefer the open access to the Veress needle in cases of previous surgery to avoid injuries of the underlying anatomical structures (bowel, adhesions, etc.). The first 12-mm trocar is placed 3–4 cm lateral and cranial to the umbilicus (to the edge of the rectal muscle) and it is used to maintain pneumoperitoneum. The skin incisions should be large enough to maintain air seal and allow trocar range of motion. Preferably, one should follow the Langer lines of skin tension (horizontal incisions on the abdomen, except the para-umbilical one which is vertical). Previous surgical scars can be used for specimen retrieval. Pneumoperitoneum is established with an intra-abdominal pressure between 15 and 20 mmHg and can be lowered to 10–12 mmHg depending on patient’s hemodynamic stability. A 30° optic is then introduced through the trocar, and the abdomen is inspected for injuries due to insertion of the trocar, and to identify adhesions in areas where the secondary ports will be placed. To prevent lens fogging, we use to insert the distal end of the optic into warm sterile water or in a warm and wet gauze before intra-abdominal optic introduction. The optic will allow to place all the other trocars under direct laparoscopic visualization. Operative trocars are than positioned in a traditional diamond port configuration (Fig. 61.3); a linear port configuration has been suggested to reduce interaction between the camera holder and surgeon’s working envelope [7]. We use disposable 5-mm and 12-mm trocars with blunt obturator tip. Blunt tip may be associated with a lower incidence of injury to intraperitoneal structures and vessels of the abdominal wall as well as a lower risk of postoperative incisional hernias.
Figure 61.3
Trocar placement
The triangulation rule must be followed for the placement of the trocars: four fingerbreadths between the optic trocar and the working trocars and five fingerbreadths between the working trocars.
A second 12-mm trocar is placed lateral to the rectus in the lower quadrant. This incision will allow a Gibson incision at the end of the LRN in order to finally extract the organ. Once placed, the insufflator line is then moved from the first trocar to the second one to avoid lens fogging.
A third 12-mm and a forth 5-mm trocars are then placed respectively to the anterior axillary line at the level of the first trocar and subcostal position on the edge of the rectus muscle. If liver retraction is necessary during a right-side nephrectomy, a sub-xiphoid skin incision is made and a 5-mm port is introduced to retract the liver.
In obese patients, often all trocars are shifted laterally and cranially [8].
Surgical Technique
Colon Mobilization
For a left–side nephrectomy, a plane between the descending colon and the underlying Gerota’s fascia is obtained by the incision of the white line of Toldt with endoshears or other laparoscopic cutting device. The differentiation of a darker yellow mesenteric fat medially and the lighter and brighter yellow retroperitoneal fat is pivotal for the dissection that is carried out cranially from the lower pole of the kidney to the spleen following the renal convexity on medial side (Fig. 61.4). The splenorenal and lienocolic ligaments are incised, allowing the spleen, the tail of the pancreas and the colon are isolated from the upper pole of the kidney and reflected medially. The Colon is dissected off the Gerota’s fascia but the renal attachments are preserved until the end to prevent the kidney falling medially prior to the vessel ligation.
