There are general contraindications for performing surgical intervention, and specific clinical states which would prohibit a transperitoneal laparoscopic radical nephrec-tomy. General contraindications include those patients who cannot tolerate a general anesthetic, those who present with an uncorrectable bleeding diathesis, or patients with underlying severe cardiovascular or pulmonary disease, who are thus not ideal surgical candidates. Relative contraindications to transperitoneal laparoscopic surgery include abdominal wall infection or suspected carcinomatosis and malignant ascites. Other specific and relative contraindications to a transperitoneal laparoscopic nephrectomy include multiple prior intra-abdominal procedures with severe adhesions, a history of severe peritonitis, or a diaphragmatic hernia. Patients with a history of cirrhosis with portal hypertension reflect another relative contraindication to transperitoneal laparoscopic radical nephrectomy. A retroperitoneal approach can be safely performed and is preferred in many of such patients.
In patients whose preoperative imaging suggests severe hilar adenopathy or encasement of the renal vasculature with tumor, there is a relative contraindication to laparoscopic nephrectomy. Finally, the presence of a renal vein or vena cava thrombus is a relative contraindication to laparoscopic surgical intervention. Although resection of a renal tumor with laparoscopic control of the renal vein distal to a tumor thrombus has been reported with a successful outcome, extensive vein thrombosis or extension into the vena cava should generally lead to open intervention, often with the assistance of vascular or cardiothoracic colleagues (16).
Severe hepato- or splenomegaly is a relative contraindication to transperitoneal laparoscopic nephrectomy. An enlarged or fatty liver, which must be retracted to allow access to the kidney, adds to the complexity of the overall procedure. In these patients, a retroperitoneal approach is preferred.
Obesity, however, is not a contraindication to laparoscopic nephrectomy. In fact, in obese patients whose renal pathology fits the criteria for laparoscopic nephrectomy, this endoscopic approach is the preferred treatment, although a modification of the standard port placement scheme may be required and excess adipose tissue can make dissection and landmark identification challenging (17).
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