Patient Selection Indications And Contraindications

Indications for hand-assisted laparoscopic nephrectomy can include almost any scenario in which an open nephrectomy is warranted. The most common indications include nephrectomy for functional renal masses (renal cell carcinoma being the most common pathology), nonfunctioning kidneys, and renovascular hypertension. Hand-assisted techniques can also be applied to nephroureterectomy hand-assisted laparoscopic nephrectomy for live donor renal transplants and upper tract transitional cell carcinoma.

Care must be taken in evaluating whether a patient is appropriate for handassisted laparoscopic nephrectomy. The most favorable patients, especially during the initial learning phase, include those who are relatively thin, have unviolated abdominal cavities, and have small lower pole tumors located away from the renal hilum.

Several conditions make a patient less than ideal for initial attempts at handassisted cases. Obese patients can be a significant challenge since excessive adipose tissue can make dissection tedious and difficult. Multiple prior abdominal surgeries predispose to intraperitoneal adhesions, which are time consuming to lyse and increase the risk of visceral injury. Patients with extremely muscular abdominal walls have reduced abdominal wall compliance that reduces the working space, restricting the use of the hand. Relative contraindications to hand-assisted techniques also include extremely large tumors, extensive renal vein or inferior vena cava thrombus, history of severe perirenal and/or intra-abdominal inflammatory conditions, ipsilateral abdominal wall stomas, and pregnancy. As the surgeon's experience grows, patients with relative contraindications become more amenable to the hand-assisted technique. Absolute contraindications include caval thrombus extending above the hepatic veins, large tumors with direct extension into the body wall or adjacent viscera, and uncor-rectable bleeding disorders.

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