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Laparoscopic Radical Nephrectomy

  • Indications
  • Standard of care for patients with T2 renal tumors ( tumor >7 cm, limited to kidney) or smaller tumors not treatable by partial nephrectomy
  • Although significant experience has been accumulated with LRN, the maximum tumor size for LRN remains unclear. In general, the principles of oncologic surgery propose the performance of LRN in tumors up to stage T3bN0M0 . Higher stage disease (T4, renal vein involvement), tumors with diameter up to 14cm (without positive surgical margins) have been reported to be successfully managed by LRN. In fact, the indications of the technique are expanding along with the accumulation of laparoscopic experience.

  • Methods
  • Transperitoneal access
    • Surgical steps
      • 1. Positioning of patient
        • Lateral decubitus position, table flexed at level of patient’s umbilicus, appropriate padding and support
      • 2.Planning and placement of trocars
        • Establish pneumoperitoneum with Hassan or Veress needle technique at lateral margin of rectus muscle, at the level of the umbilicus
        • 12 mm trocar – at the level of the lateral rectus muscle sheath on the anterior axilliary line
        • 10 mm trocar – umbilical
        • 5mm trocars – at the level of the mid-clavicular line under the costal margin
      • 3.Entry into peritoneal cavity
        • Inspection of peritoneal contents, division of adhesions
      • 4. Exposure of retroperitoneal space (White line of Toldt)
      • 5.Identification of ureter and hilar structures (renal vessels and pelvis)
      • 6. Transection of ureter
      • 7. Dissection and ligation of renal vessels (hemolock clips or EndoGIA stapler)

      • 8. Dissection of renal attachments outside Gerota’s fascia
      • 9.Entrapment of surgical sample
      • 10.Retrieval of surgical sample
      • 11.Removal of trocars, exit from peritoneal cavity, suture of incisions

    • Tips and Tricks
  • Adequate mobilization of the liver on the right side and full mobilization of the spleen on the left side are essential for proper visualization of the surgical field
  • Mobilization of the colon should be done close to the body wall in order to minimize thermal injuries to the large intestine.
  • For right nephrectomy, the duodenum must be well mobilized
  • The ureter should be used as a guide to the hilar structures and to the lower pole
  • Division of the ureter may be left for the final stages of the operation, as it aids in holding the kidneys in their proper position
  • Division of the lateral attachments of the kidney to the body wall should be done after ligating the vessels, in order to prevent medial “rolling” of the kidney
  • Renal vessels may be ligated and divided en-bloc, with an endoscopic stapler, provided that the vessels are clearly inside the jaws of the device. Arteriovenous fistulas are exceedingly rare complications.
  • The ureter will usually be slightly posterior and lateral to the gonadal vessels
  • On the left side, the gonadal vein is an excellent guide to the renal vein
  • Beware of excessive tension on the right gonadal vein, as it may avulse from the IVC
  • Clinical Videos
    Laparoscopic Radical Nephrectomy (Right kidney)

    Laparoscopic Radical Nephrectomy – Dissection along Toldt’s line

    Laparoscopic Radical Nephrectomy – Ureteral Mobilization

    Laparoscopic Radical Nephrectomy – Identifying the ureter

    Laparoscopic Radical Nephrectomy – Ureter ligation

    Laparoscopic Radical Nephrectomy – Upper pole dissection (Left)

    Laparoscopic Radical Nephrectomy – Lower pole dissection (Left)

    Laparoscopic Radical Nephrectomy – Ligatio of Vessels using Linear Stapler

    Laparoscopic simple nephrectomy – Non-functional left kidney