Praveen Kumar .S
Department of Urology Kasturba Medical College, Manipal 576104
urologypraveen@gmail.com
+91 9900412628

Challenges –

• Difficulty in developing Anterior Pararenal space due to obliteration by large Renal mass
• Extensive Neo Vascularization.
• Proximal Dissection of Renal Vein & Clipping distal to the Tumor Thrombi
Procedural Steps
1) Preoperative Patient Evaluation(Level of Tumour thrombus)& Preparation
2) Intraop Patient Positioning
3) Surgical Access &PneumoPeritoneum
4) Mobilization of Left Colon & Spleen
5) Identification & Proximal Tracing of Left gonadal Vein & Ureter
6) Dissection of Left Renal Vein & its Lateral Tributaries
7) Identifying & Ligation of Left Renal Artery
8) Proximal Milking of Tumor Thrombi & Clipping of Renal vein proximal to Tumor Thrombi
9) Extra Gerotal Mobilization of Left Renal mass with Left Adrenal Gland
10) Organ Entrapment & Extraction
11) Port Closure & Specimen Retrieval Site Closure

Executional Steps:

1):- EndoTracheal(ET) Intubation- General Anesthesia to avoid Nitrous Oxide Agent, ET tube Securely fastened to patient Face

2):- Naso Gastric Tube insertion Confirm position & Aspirated, Bladder Catheterization with 16 Fr Folley Catheter bulb inflated with 10 Ml of distilled water after confirming balloon Position, Large bore IV canula in Left wrist.

3):- Antithromboembolic Leggings fitted & Activated & checked on both Lower Limbs.Preop CECT images displayed inside Operation Room (O.R) Critical points re noted.

4):- Intraop Patient Positioning

1) Patient brought towards right end of the table,turned towards right &placed in Left Lateral Decubitus Position & Patient Right flank centered over Kidney Rest
2) Patient Head & E.T tube supported with Head rest from Below
3) Left upper arm is flexed about 70 – 90 degress At Shoulders & supported with well padded  arm boards care taken to ensure good flow IV line
4) Axillary roll Placed @ level of nipple, Right arm is placed on arm board & flexed @ shoulders And Elbow. 
5) Dependent lower Limb Flexed at Thigh & Knee, Left lower limb is kept straight, Both legs separated by cushion,all pressure points adequately padded
6) 10 x 10 Return Cautery pad placed in a Non hair bearing area contact Jelly applied to the inner of the pad fixed to patient body over which gauze roll applied. Care taken to ensure no patient body is in contact with any metal parts of O.T table, Patients metal ornaments are removed or covered with bandages.
7) Table placed in slight Trendelenburg position & flexed at the center with a table flexion angle about 30 degree
8) Patient back supported with a generous Roller Cushion, patient maintained at right angles, patient securely Taped to the table with broad adhesive tapes @ level of Greater Trochanter of Hip, thighs, Legs chest & over the arm.
9) Parts painted & draped from nipple to just above the pubis

5):- Special Instruments to be readied

1) Ultra sonic energy source- Harmonic Scalpel is kept ready with an Instrument setting of Minimum 3 & maximum 5. 
2) Monopolar energy setting & circuit is checked. Foot pedals placed in correct position for surgeon
3) Light source, insufflator checked & kept stand by, co2 cylinders volume checked & spare cylinder in place
4) Second Instrument trolley is kept ready with instruments for open conversion with Vascular Instruments
5) Warmed saline kept in a sterile flask
6) Site of 1st Optical trocar marked @ left Mid clavicular line lateral to rectus @ level of 7 cm below the coastal margin, before creating Pneumoperitoneum.1st trocar site corresponds to Renal Pedicle
7) Monitor is placed @  in surgeon visual axis towards back & towards the left head end of the table

6):- Surgical Access &Pneumoperitoneum

1) Pneumoperitoneum is achieved thru veress needle @ Palmer point, Stomach is deflated, Veress needle is checked for spring action & Patency, gas is expelled from the Insufflator tube & flow rate is set @ 1L/min and kept ready.
2) 2mm stab is made @ palmer point Veeres needle is inserted directing towards stomach, 3 click or give away sensation is felt
3) Intraperitoneal position of Veeres is confirmed by Irrigation test, Suction Test & Hanging Drop Test 
4) Confirming the position of needle, Insufflator is connected with flow rate of 1L/Min after actual flow of 200 -300ml of gas, actual pressure increase should be gradual, final pressure should reach a preset pressure of 12
5) End tidal C02 in capnographic monitor should be around 25 – 30 & should never exceed 40,
6) uniformpneumoperitoneum is formed. 
7) A 11 mm incision is made @ marked site 1st 10mm port is introduced perpendicular to the skin it is held like pistol with trocar resting on thenar eminence, index finger pointed over the shaft 
8) & middle finger wrapped around the air inlet trocar it is introduced in a gradual progressive right & left movement like a screw 
9) Signs of Port entry into abdominal cavity are Audible click, Loss of resistance & whooshing sound Trocar is removed, through cannula 10 mm 30 degree white balanced & focus adjusted telescope is introduced with light cable facing downwards is introduced with valve pressed after the camera tip passes the rubber, camera is gradually introduced 
10) Inside the peritoneal cavity light cable is held straight entry site injury Is ruled out
11) Snap shot of point of interest renal pedicle is mentally noted, size of the renal mass, extent of obliteration of dissection area, extent of neovascularity, presence of omental adhesion to mass, spleen & abdominal wall noted. 
12) Under vision 2nd 10 mm trocar is placed in left midclavicular line just below the left coastal margin port introduced perpendicularly till the tip of trocar is seen then the port is directed towards area of interest
13) 3rd 10 mm port is placed in left iliac fossa as per baseball diamond concept during trocar insertion care taken not to injure inferior epigastric vessel & colon
14) 4th 5mm trocar is placed in 1cm medial to anterior axillary line 2-4 cm below the coastal margin so that retractor can be used thro the port & retract the renal mass without clashing withn instruments

7):- Mobilization of left colon & Spleen

1) Telescope introduced in the 2nd 10 mm port with light cable facing downwards, 5mm atraumatic fenestrated grasper is introduced through a 10 -5mm tube reducers into 1st 10 mm port insufflator tubing is connected to second port to avoid fogging of telescope, Ultrasonic dissector harmonic scalpel is introduced through a 10 – 5mm reducer
2) 3rd port in the left iliac fossa, left colon needs to be completely mobilized medially, incision is made in avascular line of Toldt, mobilization starts inferiorly from the level just above the iliac vessels, using left hand instrument the large bowel is medially retracted peritoneum is held & the incision is by harmonic scalpel, vibrating handle of harmonic is always kept under vision, the tented peritoneum is cut the silicone blade is introduced below the raised peritoneum leaflet
3) Descending Colon with the mesenteric fat should be mobilized medially the medial traction given by the left hand atraumatic grasper throughout to aid the step, essentially a avascular plane but neovascularity expected due to large tumor size, the incision should be  extended cranially up to the spleno phrenic attachments
4) Mesenteric fat has a brighter hue compared to the retroperitoneal fat &Gerota’s fat this helps in identifying & maintain the correct plane of dissection between the mesentery of Descending colon & Anterior surface of Gerota`s Fascia, care should be taken not to give pressure over the renal mass to prevent tumor rupture
5) When difficulty arises to maneuver the ultrasonic dissector as dissection proceed cranially over the renal mass, the harmonic scalpel is introduced through the 4th 5mm port dissection proceed cranially care is taken not to injure tail of pancreas, Mesentery bowel & spleen  as plane develops
6) Complete spleno renal attachments & spleno phrenic attachments are transected to achieve a good plane once this step is done spleen, colon & pancreas to fall over medially. Care taken not to injure the diaphragm while realizing the cranial attachments of spleno phrenic ligament, the vibrating handle can inflict thermal injury on contact area, care needs to prevent contact over vital structures - large bowel, mesenteric vessel, pancreas & spleen

8):- Identification & Proximal Tracing of Left gonadal Vein & Ureter

1) The Gonadal vein & Ureter is identified on complete medial mobilization of left colon
2) Thin fascia over the gonadal vein is identified & lifted with atraumatic grasper, using harmonic the plane is developed, tracing the gonadal vein leads to renal vein 
3) Fascia is gently lifted towards abdominal wall and cut, care is taken when dissection proceed cranially, small tributaries of gonadal vein are managed using coagulation setting of harmonic, secondary to tumor thrombi gonadal vein may be more  dilated 
4) Ureter is dissected in medial aspect&separated from mesentery, on dissection psoas muscle is identified.

9):- Dissection of Left Renal Vein & its Lateral Tributaries

Lower pole of kidney is kept in minimal lateral traction by a 5 mm retractor through the 4th port & second assistant gives the constant gentle traction from other side of the table. 
Anterior surface of left renal vein is identified the layer over anterior layer of vein is dissected bluntly with back 5 mm right angle/mary land forceps, tip of suction & irrigation cannula Vein dissection has to be gentle & carried proximally. 
Renal vein appears dilated secondary to tumor thrombus dissection needs to be carried medially till the distal limit of thrombus is visualized.Left adrenal vein is identified generally opposite to entry of gonadal vein on the superior aspect both the vein are dilated & adrenal vein is short,more thin walled &  fragile than gonadal vein, Using suction cannula from 1st 10 mm in 5mm reducer, anterior surface of adrenal vein can be cleared with gentle blunt dissection Plane is cleared parallel on eitherside of adrenal vein by 5mm right angled instrument introduced from the third port for a distance of 8 – 10mm. Tip of right angle is turned inward and gently dissection of posterior adrenal vein wall is freed from the underlying fascia care is taken not to alter elevation angle dissection weckhaemolock clip is applied to vein close to the renal vein, the clip applicator introduced through 3rd port, after a 6 mm gap a medium-large metal clip is applied a second metal clip is applied 3mm beyond the 1 st metal clip during clipping both the arms of clip must be seen before clipping. Between the haemolock&1st metal clip the vein is cut using a 5mm laparoscopic scissors introduced thro 10-5 mm reducer through 3rd port.Similar procedure is repeated for the gonadal vein. 
Plane developed beween medial aspect of the supra hilar portion of kidney and rest of colon, a gentle medial retraction can be given thro the 4th port. Posterior dissection of renal vein is started parallel to the inferior border of renal vein using Maryland forceps if any small unnamed tributaries present should be managed with harmonic dissector/ Medium metal clips similarly superior border of vein is also freed care taken not to poke the Maryland forceps deep or injure the vein. Posterior dissection is started from inferior aspect just proximal to the gonadal vein stump, never hold the ligated end of gonadal vein with forceps for traction maryland forceps is replaced by 5mm right angle posterior dissection is done with incremental gentle advancement and opening of jaws the vein wall can be hold gently with atraumatic 5mm fenestrated grasper in the left hand vein should not be held thin only gentle movement of instrument should be done jerky movements should be avoided or might result in bleeding this step if done carefully greatly aids in dissection of posterior vein wall Once the right angle dissect up to the superior wall of renal vein the entire posterior vein wall can be dissected free. Care taken not to blindly mobilize the portion of renal vein distal to the gonadal vein, tiny thin wall lumbar vein is usually present.

10):- Identification & Clipping of lumbar veins & Left Renal Artery Ligation & clipping:

Renal artery is identified through an anterior approach, camera is introduced thro 3rd 10 mm port, 5mm atraumatic grasper/ 5mm suction canulla  is introduced thro a tube reducer in left 2nd10 mm port, 5mm maryland dissector is introduced thro reducer in 1st 10 mm port. Medial retraction of dissected ureter with gentle renal traction through the retractor aids in identification of trouble some lumbar vein entering the postero inferior aspect of renal vein minimally dissected & clipped using haemolock clips introduced thro 1st 10 mm port  one clip  towards the renal vein & 2nd clip towards the posterior abdominal wall & cut between the two clips minimum 6mm distance should between 2 clips. Following transection of lumbar vein renal artery pulsation can be seen by slightly reducing the traction, it is surrounded by lymphatic tissues which can be dissected with mary land forceps or monopolar hook with short burst the dissection is done parallel to pulsation. Once the arterial wall is identified the dissection is carried proximally & the dissection is carried on the anterior wall of the renal artery towards aorta , the lateral wall & posterior wall of renal Artery is dissected in the proximal portion of renal artery during dissection a gentle traction is maintained preop CECT will help in identifying clinically significant first branch from renal artery, proximal dissection help in prevent injuring the early branch arising from renal artery, the artery can be safely clipped using large haemolock clips(violet color) 2nd clip is applied 3mm distal to  the first clip 3rd clip is applied minimum 6mm away from the 2nd clip. Renal artery transacted between 2nd& 3rd clip.
 Due to presence of tumour thrombi in the renal vein classic complete collapse of renal vein cannot be appreciated. 

11):- Proximal Milking of Tumor Thrombi & Clipping of Renal vein beyond Tumor Thrombi

Camera is introduced in 1st 10 mm port, 5mm suction irrigation cannula thro reducer is introduced through the 2nd 10 mm port, maryland grasper introduced thro a reducer in 3rd 10 mm port. Gentle traction is maintained thro the 4th port, the proximal end of thrombus is identified by change in renal vein luminal diameter gentle milking of tumour thrombi is done using the above 2 instruments towards the kidney once a length of 10 mm is achieved in the renal vein the thrombi is kept in the proximal portion by the left hand cannula large haemolockweck clip (violet catridge) is introduced thro 3rd 10 mm port & three haemoclip are applied similar to the renal artery and cut between the 2nd& 3rd clip. Ureter is traced upto pelvic brim & ligated distally with  2large haemolockweck clip (violet catridge) with minimum 8 mm distance between both the clips & cut. 

12):- Extra Gerotal Mobilization of Left Renal mass with Left Adrenal Gland

Post ligation of renal artery & renal vein the entire medial dissection of renal mass & aorta & medial left colon is done.
Grasping the Transected ureter lateral traction is applied and posteriordissection is done with harmonic scalpel, loose areolar tissue plane is developed small vessel encountered are dissected with harmonic scalpel, complete posterior dissection is done except a 2x2 cm region in supero lateral aspect of the renal mass, rest of the renal mass & adrenal is completely freed of attachments by harmonic scalpel

13):- Organ Entrapment & Extraction

1) `D’ size organ entrapment bag is introduced through the 3rd 10 mm cannula
2) Traumatic grasper is introduced through 2nd 10mm port via reducer to hold the renal mass
3) Specimen bag is opened & applied like a bag on the renal mass the grasper directs the specimen into the bag,
4) Bag is directed supero laterally once more than 70% of specimen is in the bag  assistant hold the handle of specimen bag ,  harmonic scalpel is introduced through the 4th port &superolateral attachment of mass to the abdominal wall is released. 
5) Bag is gradually closed. Incision on the 3rd port extended along the langer lines for 5-6 cm gas is closed, gently under vision the bag is brought to the third port & bag is held near the third port by assistant. 
6) Renal fossa is inspected transected pedicles are re inspected saline washis given thro the cannula from the fourth port. 
7) Suction catheter is introduced thro 4th cannula & placed in renal fossa 4thcannula removed and drain tube fixed
8) Incision @ 3rd port site is deepened in layers care taken not to injure the bag the specimen is retrieved thro gentle screwlike movement of the hand

14):- Port Closure & Specimen Retrieval Site Closure

1) Two 10 mm port are withdrawn & port is closed using veress needle technique thro the specimen retrieval wound gauze is used to pack bowel and Omentum away from the port site
2) Telescope is introduced thro the specimen wound using liver retractor the bowel &omentum can be pushed away from the port site. 
3) Veress needle or suture passer is introduced from the subcutaneous tissue of one side of the port all layers of abdominal wall is pierced the suture in the peritoneal cavity is caught between the veress needle & the loop brought to the skin
4) Veress needle is reintroduced through the subcutaneous tissue  of the superior (opposite)side of the wound all layers of abdominal wall  are pierced and entered through the middle of the wound inside the peritoneal cavity the other end of suture material is caught brought outside the skin surgeon knot is tied, suture gets buried in the subcutaneous tissue
5) Similar procedure is done in the 2nd port, through the specimenextraction site  under vision port wound is seen intraperitonealy, complete closure of the wound & absence of bowel &omentum attachment to the wound is confirmed. 
6) Specimen side wound the muscle are closed in continuous fashion with 1-0 vicryl closure is started from either sides & closed in the Centre dressing done.