TABLE 1 Technique of Laparoscopic Simple Nephrectomy

Anesthetic

Patient positioning

Insufflation and trocar placement

Initial assessment

Initial dissection Identification of the lower pole

Pedicle control

Mobilization of the upper pole

Ureteric division Specimen retrieval

Wound closure

General anesthesia with muscular relaxation and endotracheal intubation

Modified lateral decubitus position with umbilicus over break of operating table

Hasson or Veress needle technique; three to four trocars in triangle or diamond formation, secured with silk sutures

Visual inspection of the upper abdomen and division of adhesions

Colon mobilized medially by incising its lateral attachment

Lower pole elevated while dividing medial tissue advancing in the direction of the pedicle

Elevate lower pole; blunt dissection using right-angled forceps and the sucker-irrigator tip; avoid excessive use of clips close to main vein; artery clipped with laparoscopic clips and divided, followed by ligation and division of the vein using Endo-GIA

Dissection continued close to the kidney avoiding hilum; combination of sharp and blunt dissection; consider using clips, harmonic scalpel or endo-GIA for perforating vessels

Ligated with Liga clips and divided; final step before specimen retrieval

Kidney grasped with heavy laparoscopic forceps; inspection for hemostasis; kidney removed in laparoscopic catchment bag in tact or after morcellation

Consider drain; retrieval site closed in two layers using continuous 0 PDS; 12 mm port sites closed with 0 Vicryl on a J needle; skin closed with clips or subcuticular suture

FIGURE 1 ■ Patient position for laparoscopic simple nephrectomy.

FIGURE 1 ■ Patient position for laparoscopic simple nephrectomy.

4 or 5 mmHg at this stage. A sudden increase in pressure during initial insufflation signals incorrect trocar placement. In this situation, insufflation is stopped and the reason for the problem identified. After insufflation of 1 to 1.5 L of gas, flow can be increased to a high rate (approximately 6L/min) and intraabdominal pressure maintained at 12 to 15 mmHg. Rapid initial insufflation occasionally results in a severe bradycardia.

For right nephrectomy, two other main ports are inserted under laparoscopic control: a 5- to 12-mm port inferior to the costal margin and a 5-mm port at the level of the umbilicus, both in the anterior axillary line and roughly equidistant from the camera port; so the three ports form an isosceles triangle. For left nephrectomy, the 5- and 12-mm ports are reversed in position so that the larger port is always on the surgeon's right. This is to permit passage of 10-mm clip appliers and linear cutting/stapling devices. A fourth 5- to 12-mm port, if required for retraction, may be inserted in a lateral position, in line with the camera port near the tip of the 12th rib (Fig. 3). The trocars are secured using silk sutures through the skin.

Anterior super iliac spine

Mid clavicular I

Anterior axillar

Costa] margin

Anterior super iliac spine

Mid clavicular I

Anterior axillar

Costa] margin

A 5 mm port

O 12 mm port

□ Optional port (liver retractor)

FIGURE 2 ■ Surface anatomy.

A 5 mm port

O 12 mm port

□ Optional port (liver retractor)

FIGURE 2 ■ Surface anatomy.

FIGURE3 ■ Transperitoneal laparoscopic nephrectomy trocar placement.

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