Technical Surgical Steps

Once the three initial operating ports are placed, the surgeon can employ either a 1 cm or 5 mm laparoscopic lens to illuminate the intraperitoneal contents to rule out the pres-

FIGURE2 ■ Various port placement schemes for transperitoneal laparoscopic nephrectomy. A 10/12-mm port is utilized for the camera; working ports are 5- or 10-mm; and a 5-mm port is usually sufficient for the additional retraction ports.

FIGURE2 ■ Various port placement schemes for transperitoneal laparoscopic nephrectomy. A 10/12-mm port is utilized for the camera; working ports are 5- or 10-mm; and a 5-mm port is usually sufficient for the additional retraction ports.

FIGURE3 ■ Laparoscopic right radical nephrectomy. Resection begins with incision of the white line of Toldt and peritoneal attachments between the liver and right colon. Mobilization of the first portion of the transverse colon improves access to the right renal hilum.

FIGURE4 ■ Laparoscopic left radical nephrectomy. The white line of Toldt is incised along the left colon, and the peritoneal attachments between the colon and spleen are divided. The distal end of the transverse colon is mobilized, as is the spleen laterally.

FIGURE3 ■ Laparoscopic right radical nephrectomy. Resection begins with incision of the white line of Toldt and peritoneal attachments between the liver and right colon. Mobilization of the first portion of the transverse colon improves access to the right renal hilum.

FIGURE4 ■ Laparoscopic left radical nephrectomy. The white line of Toldt is incised along the left colon, and the peritoneal attachments between the colon and spleen are divided. The distal end of the transverse colon is mobilized, as is the spleen laterally.

During transperitoneal radical nephrectomy, hilar vessels should be divided in a stepwise fashion. The arteries should be dissected free from the renal veins and carefully clipped and divided prior to addressing the main renal vein.

When all the arteries have been clipped, the renal vein will flatten. A still engorged renal vein after arterial control commonly indicates the presence of an accessory renal artery that needs to be addressed.

ence of distant metastases. On either side of the abdomen, the dissection begins with the mobilization of the colon medially and the entry into the retroperitoneum. On the right side, the colon is mobilized by incising the white line of Toldt and dividing the attachments between the liver and first portion of the transverse colon (Fig. 3).

During right nephrectomy, the mobilization of the colon is continued along the first portion of the transverse colon to allow complete retraction of the right colon, which exposes the right retroperi-toneum.

■ On the left side, the same incision along the white line of Toldt is continued up along the distal end of the transverse colon with division of the attachments between the colon and the spleen for the same reason stated above (Fig. 4).

When performing a transperitoneal right laparoscopic radical nephrectomy, entry into the retroperitoneum should direct the surgeon to specific landmarks (Fig. 5). The vena cava should be defined and traced to the renal vein. Other landmarks including the gonadal vein are commonly noted during the dissection. The most common location of the renal artery is posterior to the main renal vein. Multiple renal veins like multiple renal arteries may be present. Variations in renal vascular anatomy are common, and the surgeon should take great care in defining the vessels and carefully dissecting them free from adjacent structures.

On the left side, after entering the retroperitoneum, the surgeon should seek to define the common anatomic constellation that includes the main renal vein crossing the aorta and the adrenal and gonadal veins entering this vessel (Fig. 6).

During transperitoneal radical nephrectomy, hilar vessels should be divided in a stepwise fashion. The arteries should be dissected free from the renal veins and carefully clipped and divided prior to addressing the main renal vein. Most surgeons place multiple clips on the arteries and divide these vessels with endoscopic shears between the clips.

When all the arteries have been clipped, the renal vein will flatten. A still engorged renal vein after arterial control commonly indicates the presence of an accessory renal artery that needs to be addressed.

The renal vein is addressed with an EndoGIA stapling device (Fig. 7). There are two techniques that may be employed: (i) the stapling device fires six rows of titanium staples and divides the vessel between row three and four and (ii) the stapling device fires six rows of staples with no blade. The unbladed device is particularly useful in the case of a short renal vein or in complex presentations where the surgeon would prefer to inspect the staple lines and then divide the vessel using endoscopic shears either between staple lines or between two fires of this device.

FIGURE6 ■ Laparoscopic left radical nephrectomy. Medial mobilization of the colon exposes the renal hilum. Landmarks include the branching left renal vein commonly overlying the renal artery.

FIGURE5 ■ Laparoscopic right radical nephrectomy. After entering the retroperitoneum, the colon is mobilized medially as needed to expose the right renal hilum. Cephalad retraction of the liver is essential. In this case, note the accessory upper-pole renal artery, which is a common variant.

FIGURE6 ■ Laparoscopic left radical nephrectomy. Medial mobilization of the colon exposes the renal hilum. Landmarks include the branching left renal vein commonly overlying the renal artery.

EndoGIA staplers may misfire if a surgical clip is inadvertently caught between the jaws. Also, when separating the vessels, the surgeon should be well aware of the location of the clips on the renal artery or other vessels before employing the EndoGIA stapler.

Division of the gonadal vein is particularly useful for inferior tumors with local adhesion or involvement by the tumor mass.

EndoGIA staplers may misfire if a surgical clip is inadvertently caught between the jaws. Also, when separating the vessels, the surgeon should be well aware of the location of the clips on the renal artery or other vessels before employing the EndoGIA stapler.

When resection of the adrenal gland is planned as part of the radical nephrectomy procedure, then the hilar dissection should be extended cephalad, defining the adrenal vein and dividing it between clips. Multiple adrenal arteries may be present and need to be either clipped or sealed as the adrenal is mobilized during dissection. Left adrenal vein can be divided between clips as it enters the renal vein. Right adrenal vein usually enters directly into the inferior vena cava. Adrenal venous drainage is commonly based on multiple vessels, where a large cephalad phrenic vein may be encountered. Such vessels should be addressed in a similar fashion to the main adrenal vein, which is often inferior.

After control of the renal hilum is completed, mobilization of the kidney is continued cephalad under the diaphragm, often including the adrenal. The dissection is then continued laterally and posteriorly. The ureter is identified and divided between clips. If warranted, division of the gonadal vein as it courses through the retroperitoneum can be performed between clips at various locations.

Division of the gonadal vein is particularly useful for inferior tumors with local adhesion or involvement by the tumor mass.

Division of renal tumor friable neovascularity encountered in the retroperi-toneum is performed by clipping or sealing, e.g., using the Ligasure device.

FIGURE 7 ■ Dissection of the left renal hilum. (A) The left gonadal vein is clipped and divided to allow mobility and retraction of the renal vein, providing exposure to the renal artery. (B) The renal artery is first clipped and then the renal vein is addressed with an EndoGIA stapler. Care must be taken to avoid catching a staple from the renal artery or gonadal vein when employing the EndoGIA stapler for it will misfire if a metallic foreign body is caught in its jaws.

FIGURE 7 ■ Dissection of the left renal hilum. (A) The left gonadal vein is clipped and divided to allow mobility and retraction of the renal vein, providing exposure to the renal artery. (B) The renal artery is first clipped and then the renal vein is addressed with an EndoGIA stapler. Care must be taken to avoid catching a staple from the renal artery or gonadal vein when employing the EndoGIA stapler for it will misfire if a metallic foreign body is caught in its jaws.

The contents of Gerota's space, including all the adipose tissue surrounding the kidney, should be developed and removed en bloc.

Once the specimen has been mobilized completely, it is brought centrally into the peritoneum and entrapped into an endocatch bag. Commonly the specimen is large and so the largest available laparoscopic sac is employed. There are various methods and locations utilized to remove the specimen. There is a general debate amongst surgeons on whether the specimen should be morcellated or removed intact. However, intact specimen removal rather than morcellation allows preservation of the histologic landmarks necessary to achieve adequate tumor staging.

Specimens can be extracted either by extending the umbilical trocar site incision or with a small suprapubic incision. Transvaginal extraction has also been reported (18).

After performing transperitoneal laparoscopic radical nephrectomy, the larger port sites, e.g., 10 mm or larger ports, are closed at the fascial level. A variety of fascial closure devices that place sutures through the fascia on either side of the defect may be employed to prevent herniation. Extraction incision is closed using standard surgical technique employing absorbable suture.

In the majority of patients, the gastric tube is removed at the end of the procedure. Diet is advanced when clinically indicated based on the general course of the patient post-procedurally. The Foley catheter is usually removed the morning after the procedure.

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