Preoperative Upper Tract Drainage

Patients with a grossly dilated collecting system are best served by a minimum four-week period of drainage prior to nephrectomy. Occasionally this is necessary to check function following relief of obstruction, before recommending ablative surgery over reconstruction, but it is certainly of benefit from a technical point of view because a tense, grossly dilated pelvis may otherwise overlap the renal vessels and make their identification and control more difficult.

Stay Suture

A stay suture inserted through the abdominal wall and into the pelvis, to support it and identify those structures deep to it, is also helpful in a patient with a grossly hydronephrotic kidney. A similar technique can be used to display the ureter.

Fourth Trocar

The use of an extra port for retraction purposes is encouraged. This decision should be made early at the first sign that additional organ retraction is likely to be needed. This trocar may be inserted near the tip of the 12th rib (a 5 to12 mm port), when operating on either side, or below the xiphoid (5 mm port) for hepatic retraction using a ratcheted grasper.

Harmonic Scalpel

This reduces bleeding during colonic reflection and mobilization of the kidney and facilitates dissection of inflammatory tissue. It can be used in close proximity to bowel and large vessels without risk of thermal injury.

Maximizing Use of Endovascular Stapler Device

The stiffness of laparoscopic endovascular staplers makes them very useful instruments for blunt dissection of the lateral attachments, after division of the pedicle and upper pole mobilization. Using a craniocaudal sweeping motion, and with the instrument closed, the kidney can be mobilized free of its lateral attachments very quickly.

Rolling the Patient

With the patient secured by lumbar and thoracic supports or surgical tape, the operating table may be tilted toward or away from the surgeon to facilitate exposure, in case the colon or adjacent organs fall into the operative field.

Obese Patients

Trocars should be positioned more laterally than usual. Consider using long trocars, and a purse string suture of the rectus sheath to facilitate closure at the end of the procedure.

Specimen Retrieval

This can be a surprisingly awkward step in the procedure, particularly when a larger catchment bag is used. Using a heavy grasping instrument (e.g., laparoscopic Babcock forceps, endo-gastrointestinal anastomosis) greatly improves the chances of success. The use of a Terumo guide wire to facilitate kidney entrapment when using the Lap SacĀ®a, keeping the sac mouth stiff and open, has also been described (14).

Ribbon Gauze

Intracorporeal ribbon gauze strips can be used for temporary hemostatic control to absorb any blood or clot and to facilitate blunt dissection (15).

COMPLICATIONS Intraoperative Complications

The major intraoperative complications are bleeding (usually from the renal vein, adrenal vein, or accessory branches), visceral injury (spleen, liver, bowel, or omentum), and vascular injury (superior mesenteric artery, aorta, and inferior vena cava) (16-18). While these occur uncommonly, they can cause serious morbidity or death. Rapid conversion may be necessary, although the experienced laparoscopist may be able to deal with bleeding from the renal and adrenal vein by judicious use of compression and retraction. There are reports of the linear cutting/stapling device failing to fire. This almost inevitably necessitates rapid conversion, but if the device can be rapidly closed and maintained in position, it may be possible to insert a second device medial to the first through an extra port placed just medial to the one carrying the failed device.

Open conversion rates vary between institutions, ranging from 0% to 16% (3,11,19,20), however this is affected by the indication for surgery and surgical experience.

aCook Surgical, Spencer, IN.

In an analysis of factors, which predict the outcome of the laparoscopic approach, positive urine culture and renographic clearance (more than 10 mL/min) were found to increase the likelihood of conversion of both trans- and retroperitoneal laparoscopic nephrectomy for benign disease. In addition, learning curve and large kidney size were risk factors for conversion for trans- and retroperitoneal approaches, respectively (21). Conversion rates are also higher for inflammatory conditions (2-4).

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