Preoperative Evaluation

As with any major open surgery, a complete history and physical exam, basic laboratory studies, electrocardiogram, and chest radiograph should be completed to identify any possible relative or absolute contraindications to laparoscopy. Additional studies may be necessary in patients with pulmonary or cardiac disease. In fact, such diseases

The transperitoneal approach is preferential in patients with large renal tumors or renal lesions in an ectopic or horseshoe kidney.

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.

may be exacerbated secondary to the hypercarbia and acidosis noted with pneumoperi-tonium, which may result from prolonged exposure to CO2.

Prior to removal of the diseased kidney, the function of the contralateral kidney should be assessed. A serum creatinine level and visualization of normal contrast uptake and excretion on an imaging study are usually adequate. If renal insufficiency is present or the function of the kidney is in question, a nuclear medicine renal scan and creatinine clearance level may be helpful. Partial nephrectomy should be considered in patients with marginal renal function if technically feasible.

A metastatic evaluation is employed in all patients who present with renal tumors prior to radical nephrectomy. In patients undergoing transperitoneal laparo-scopic radical nephrectomy, there is particular emphasis on the intra-abdominal organs, specifically to rule out concurrent processes or direct tumor extension to adjacent organs. Three-dimensional computed tomography or magnetic resonance imaging imaging is often useful in directing surgical intervention. Attention to the renal hilum, in particular the size, location, and number of renal vessels is always helpful. Imaging may also define and quantify the extent of a renal vein thrombus. Three-dimensional computed tomography reconstruction produces clear images that can direct surgical technique. Magnetic resonance imaging imaging with three-dimensional reconstruction and magnetic resonance angiography is often particularly useful in patients with iodine-based intravenous contrast intolerance or with renal functional insufficiency contraindicating iodine-based contrast load. If clinically indicated, a bone scan or imaging of the central nervous system can define widespread disease preoperatively and may direct the surgeon to observation or potential palliative intervention.

In preparation for surgery, patients are instructed to refrain from nonsteroidal anti-inflammatory drug and multivitamins including vitamin E due to increased risk of perioperative bleeding. Patients with large lesions and those with a heightened risk of bleeding based on a clinical presentation are offered the opportunity to bank their own blood or have donor-directed blood prepared. Mechanical bowel preparation is essential when performing a transperitoneal laparoscopic nephrectomy, because colon cleansing increases the ease of bowel retraction and mobilization. In patients where direct tumor extension into the bowel is suspected, an oral antibiotic and mechanical bowel preparation is implemented, so that an en bloc resection of adjacent organs can be performed with primary bowel repair if necessary.

Combined team efforts of the operating surgeon and the attending anesthesiology staff lead to the best outcomes. Complete muscle relaxation is essential. The anesthesiologist should be experienced in complex laparoscopic procedures, which may take several hours to complete. CO2 monitoring and relaying the extent of the hypercar-bic state during the procedure to the surgeon are particularly important.

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