LAPAROSCOPIC RADICAL NEPHRECTOMY

Radical nephrectomy for patients with clinically localized renal cell carcinoma provides the best opportunity for cure. However, the pain and morbidity associated with an open flank incision can be significant. The laparoscopic approach to renal cell carcinoma has evolved into a safe and effective minimally invasive alternative to open surgery. The perioperative benefits of the procedure are well established, and as long term follow up matures, the disease free and cancer specific survival rates for laparoscopic radical nephrectomy are comparable with those of open surgery. 

Indications and Contraindications

Laparoscopic radical nephrectomy has been applied to patients with advanced stages of renal cell carcinoma. Contraindications to laparoscopic radical nephrectomy include tumors with renal vein or vena cava thrombi. To date, a reliable method to perform a laparoscopic thrombectomy does not exist. Patients with a prior history of ipsilateral renal surgery, perinephric inflammation, or extensive intra abdominal surgery may still be candidates for laparoscopic surgery based on the experience of the surgeon and an informed patient who understands that it may be necessary to convert to open surgery. Locally advanced disease may also require open conversion.

Preoperative Evaluation

The preoperative evaluation of the patient with a suspected renal malignancy is the same whether an open or a laparoscopic approach is planned. A complete metastatic evaluation is necessary and includes a chest radiograph or CT and abdominal CT scans. A bone scan is obtained in patients with elevated serum calcium or alkaline phosphatase levels and in those with symptomatic bone pain. If there is a question of renal vein tumor thrombus, then an appropriate study (MRI, venography, sonography, or three dimensional CT) to preoperatively evaluate the vein is required. Contralateral renal function is assessed before radical nephrectomy by measuring serum creatinine levels and evaluating the kidney appearance on contrast enhanced CT. In equivocal cases, a functional renal scan and 24 hours urinary creatinine clearance studies can be obtained. The presence of renal insufficiency should prompt the surgeon  to consider partial nephrectomy

Positioning and Trocar Placement

Patient positioning and trocar placement are similar to those described for the simple nephrectomy (Fig 1). Three ports are generally sufficient to complete the procedure, although a fourth trocar may be necessary for organ entrapment and liver retraction during right sided nephrectomy.

Procedure

Re?ection of the Colon

The colon is reflected to provide adequate visualization of the anterior surface of Gerota’s fascia. On the right, the duodenum is mobilized medially, using the Kocher maneuver, until the vena cava is clearly visualized.

Dissection of the Ureter

The midureter is located in the retroperitoneal fat medial to the psoas muscle. During proximal mobilization, the gonadal vein is usually first encountered and should be swept medially. The ureter is located just posterior to this structure (Fig. 2). Once located, the ureter is elevated, revealing the psoas muscle and traced proximally to identify the renal hilum.

Mobilization of the Lower Pole

As opposed to a simple nephrectomy, the radical nephrectomy preserves Gerota’s fascia so that the renal parenchyma and mass are not visualized during this operation. Once the ureter is mobilized up to the ureteropelvic junction, forceps are inserted beneath Gerota’s fascia and lower pole along the psoas fascia. The specimen is lifted superolaterally, and, with the use of the suction irrigator and electrosurgical scissors, the inferior and posterior side wall attachments are divided. The inferior cone of Gerota’s fascia lateral to the ureter is also divided. To facilitate this dissection and assist with lateral specimen retraction during the hilar dissection, the fourth port may be necessary as outlined earlier.

Securing the Renal Blood Vessels

During right-sided radical nephrectomies, retraction of the liver to improve visualization of the renal hilum and upper pole can be accomplished by passing a 3- or 5-mm instrument through a fourth trocar placed below the ribs in the anterior axillary line. The renal artery and vein are individually dissected and divided. The surgeon places the renal hilum on gentle tension by lifting the lower pole laterally. With the use of the electrosurgical scissors and the suction-irrigator, the hilum is identified by moving cephalad along the medial aspect of the ureter and renal pelvis. The renal vein is usually identified first and is dissected circumferentially. Lumbar veins must be identified and divided between a pair of double clips. After the renal vein is dissected, the renal artery is identified and transected with the GIA stapler (Fig. 3). For left sided tumors, the GIA is placed proximal to the adrenal vein if the adrenal gland is to be taken with the specimen. If the gland is to be left, the GIA is positioned distal to the adrenal vein. Extended lymphadenectomy can be readily performed once the vessels are identified and dissected circumferentially.

Dissection of the Upper Pole

The decision whether to remove the ipsilateral adrenal with the specimen determines the superior margin of dissection. If the adrenal is not removed, upper and lateral attachments to Gerota’s fascia are incised utilizing the electrocautery scissors. Care must be taken to avoid injury to the diaphragm at this point. In some cases, it may be helpful to transect the ureter and rotate the lower pole of the kidney over the liver (right) or spleen (left) to incise upper pole posterior attachments.

If the adrenal is to be removed with the specimen, control and division of the adrenal vein is imperative. On the right side, dissection cephalad along the vena cava identifies the adrenal vein. Once it is divided, the superior, medial, and posterior attachments of the adrenal are mobilized (Fig. 4). On the left side, the adrenal vein is left in continuity with the specimen by transection of the renal vein proximal to the take-off of the adrenal branch.

Specimen Entrapment and Extraction

Intra abdominal entrapment of the excised specimen is performed to facilitate removal. If it is to be removed intact through an incision, an Endocatch device is recommended. It consists of a plastic sack attached to a self- opening, flexible metal ring. The primary advantage of a self-opening bag is that the specimen can be easily manipulated into the opening of the bag with a single grasper.

 The retrieval device is 15 mm and thus needs to be placed through one of the 10 mm trocar sites after the trocar has been removed (Fig.5). Once the specimen is placed into the sack, the opening is withdrawn through the trocar site. Using electrocautery, the trocar site is enlarged to allow extraction of the specimen, and the specimen and sack are protected by the surgeon’s finger positioned through the trocar site alongside the specimen (Fig.6). Alternatively, the kidney can be removed through a Pfannenstiel incision.

If the specimen is to be morcellated, a LapSac fabricated from a double layer of plastic and nondistensible nylon is used. This sac has been shown to be impermeable to bacteria and tumor cells even after its use for morcellation. The LapSac is introduced and held open with several graspers (Fig. 7). Once the specimen is inside the entrapment sack, the drawstring is grasped, tightened, and withdrawn into the 10 mm umbilical port. The sack is pulled tightly against the abdomen and morcellation initiated. The pneumoperitoneum should be preserved throughout the morcellation process so that the intra abdominal portion of the sack can be monitored laparoscopically for possible perforation. Surgical towels are placed around the sack, and the entire surgical field is covered to prevent port site contamination with any spillage of the morcellated specimen (Fig. 8)