Laparoscopic Nephrectomy
Several obstacles are preventing the laparoscopic nephrectomy technique from being more widely embraced. The first is the time factor which is considerably longer than for an open nephrectomy. The second is the handling of the renal pedicle. Clayman and coworkers have used titanium clips to secure the renal artery and vein. Ehrlich and coworkers used an endoscopic linear stapler to secure the pedicle. Despite the fact that Clayman and coworker’s group did not report any significant intraoperative or postoperative bleeding because of inadequate pedicle control, many urologists are uneasy with this aspect of the operation. The third and perhaps most serious concern is the applicability of this technique to cases of renal malignancy. Currently, the adrenal gland is not included in the laparoscopic radical nephrectomy; although this exclusion is probably more a theoretical concern in the lower pole and midpole tumors, it would be a limiting factor in the upper pole tumors.
Tumor spillage during any laparoscopic procedure is an obvious practical concern. Several reports documented tumor implantation during laparoscopy. Clayman and coworkers tried to solve this problem by developing an entrapment system for the kidney and the lymph nodes. These systems consist of impermeable bags inserted through the laparoscopic trocar. The surgical specimen is placed within the bag or pouch and a drawstring around the opening of the bag allows for closure and acts as a handle to remove the pouch from the abdominal cavity through the laparoscopic trocar. In nephrectomy, the renal specimen is fragmented and aspirated using an especially designed electrical tissue morcellator placed through the neck of the kidney sack. The development of this type of technology decreases but does not eliminate the potential for tumor spillage. Undoubtedly, more work is needed to address the concern of tumor implantation, if this technique is to be applied to malignant renal tumors.
Operative Technique
After induction of general anesthesia, an occlusion balloon catheter is passed up the ureter of the kidney to be removed. A bladder drainage catheter is also used as well as a nasogastric tube. The patient is placed in a supine position. A Veress needle is placed at the umbilicus, and a carbon dioxide pneumoperitoneum is created in the usual manner. Then two 11 mm laparoscopy ports are placed, one at the umbilicus and one immediately subcostal along the midclavicular line. A 5 mm port is also placed in the midclavicular line, 2 to 3 cm below the level of the umbilicus. The patient is then placed in the lateral decubitus position and secured to the operating table. Two 5 mm ports are placed in the anterior axillary line, one on a level with the umbilicus and one off the tip of the eleventh or twelfth rib.
Dissection commences by incising the line of Toldt and dissection the colon medially. The ureter is then identified and secured with a 5 mm locking forceps. The lower pole lateral surfaces and upper pole of the kidney are dissected free. The adrenal gland is left in place. The kidney is then lifted upward, which places the renal hilum on traction. The renal artery and vein are then dissected. Three endosurgical clips are placed on the distal portion of each vessel, and two clips are placed on the proximal portion of each vessel; endoscopic scissors is then used to divide the vessels.
The ureter is divided between two clips and the kidney is free. An impermeable nylon surgical sack is introduced through an 11 mm port. Three 5 mm graspers are used to open the mouth of the sack, and the kidney is pushed into the open sack. The drawstrings on the sack are grasped by a 5 mm forceps and pulled through the 11 mm umbilical port, thereby closing the neck of the sack on the kidney. The mouth of the sack is then brought out through the skin, and the metal shaft of the electrical tissue morcellator is introduced into the sack. The morcellator is activated, and the renal tissue is fragmented and aspirated. In the case of donor nephrectomy incision is given to suprapubic region and hand port can be used to take the kidney out safely. In the case of donor nephrectomy, grate attention is required to prevent ischemia of the kidney and the recipient should be ready on another operation table for transplant. When all the renal tissue is removed, the empty sack is removed from the abdomen. The port sites are closed in the standard fashion.
In the two cases of transitional cell carcinoma, the ureter was dissected down to the bladder, and a laparoscopic GIA stapler was used to include the distal ureter and a cuff of the bladder. Clayman and coworkers and Gaur and coworkers also described a retroperitoneal approach to laparoscopic nephrectomy. A key advance to this approach has been the use of a retroperitoneal balloon dissector that facilitates the development of working space within the retroperitoneal space.
