- Special instruments necessary due to lack of triangulation (pre-bent)
- One incision, multitrocar port
- SINGLE PORT SIMPLE/RADICAL NEPHRECTOMY—surgical removal of kidney for oncological or functional reasons
- Surgical removal of kidneys affected by cancer or kidneys with reduced function
- Patient positioning
- Positioning of trocars
- Positioning of trocars (obese patients)
- Dissection begins in a similar fashion to conventional laparoscopic nephrectomy
- Dissection at white line of Toldt – mobilization of spleen and colon
- If necessary in right nephrectomy, place a 3mm instrument to retract liver
- Identification of ureter and hilar strictures
- Dissection of upper pole
- Preparation of renal vessels
- Ligation of vessels with Endo-Gia Laparoscopic stapler or Hemo-Lok clips
- Dissection of lower pole and posterior attachments of kidney
- Removal of specimen in laparoscopic bag
- Tips and Tricks
The ideal location for the incision in any single site surgery is the umbilicus. These incisions can be easily hidden inside the umbilical fold and upon healing will be practically invisible. In obese patients undergoing single site renal surgery, it is sometimes necessary to place the incision in a more lateral position (para-umbilically), as the instruments may not be able to reach the operating field if placed through the umbilicus.
A great variety of single-site multi-instrument ports are available in the market, with vastly different characteristics. Although there is no consensus on the “best” available multi-port, some features are desirable, whatever one’s final choice may be. The ideal port should be cheap, should allow safe and easy insertion and offer maximum instrument triangulation.
In the matter of cost, reusable multi-ports offer significant savings as they can be sterilized and re-utilized. The limiting factor for the reusability of these ports is occurrence of air leakage through the instrument valves after extensive use and repeated sterilization. Furthermore, current re-usable ports are metallic, and as such offer less flexibility and limit triangulation of instruments. Our department has been using Storz’ Endoconetm and Xconetm for the past few years, especially in single port nephrectomies. Single use ports are more expensive in comparison, but offer other advantages. Single use ports are commonly made of flexible materials, allowing greater instrument mobility. A number of single use ports have dedicated instrument entry valves, such as the Tri-porttm and the Quad-porttm from Olympus. Another single use alternative is the GelPointtm access system by Applied Medical. This port uses an Alexis wound retractor as an anchoring point, and is covered by a gel cap. This gel cap allows insertion of any size of instrument at any point of the cap, either with or without the supplied mini-trocars. A positive point of this multi-port is the greater range of instrument motion allowed by the gel cap.
Although single-site surgery can be performed with conventional laparoscopic instruments, the level of difficulty is much greater. When using conventional instruments inserted through a multi-port, the usual results are instrument cross over, instrument clashing among themselves and the camera, and minimal triangulation. A better solution is the use of instruments specifically made for single site surgery. There are two major kinds, pre-bent and flexible instruments. Our department favors the use of pre-bent instruments, as they offer superior retracting force (flexible instrument’s tips have a tendency to lose retractile strength when forceful retraction is necessary), and they minimize external and internal instrument clashing.
During all portions of tissue dissection, the use of a conventional instrument in the dominant hand and a pre-bent in the non-dominant is recommended. This allows for retraction of tissue with the non-dominant hand, and dissection or application of energy (bipolar current, ultrasonic dissection) with the dominant hand.
When using a reusable port, a 5mm camera may be used, in order to free up the larger ports for other larger instruments such as ultrasonic shears or endoscopic linear staplers.
In case of a small non-functioning kidney, it is possible to remove the sample without enlarging the incision. In cases of larger kidneys with voluminous tumors, the incision (fascia and skin ) must be be extended to allow removal of the specimen. Extension of the incision should be done at the moment of specimen withdrawal, in order to minimize the extension length.
When performing single site surgery, the surgeon will seldom have a suction cannula in his hands, but may frequently use energy sources that create smoke in the pneumoperitoneum. In order to minimize changing of instruments and obtain the best possible view, passive smoke evacuation may be performed by inserting an 18G intravenous cannula through the distended abdomen. As the needle is removed, the cannula becomes a “port” for passive smoke evacuation.
To facilitate lower pole dissection, elevation of the ureter is recommended. This can be accomplished in single site surgery without the addition of an extra trocar. A Keith (straight) needle with suture is inserted approximately in the mid-axillary line, and is grasped by the surgeon. the needle and suture are passed under the ureter and then passed again through the abdominal wall in close proximity to the entry site. The Keith needle is grasped and removed by the assistant, and the sutures may be secured at different heights to allow for greater ureteral retraction.
Single Port Nephrectomy – Placement of Endocone
Single Port Nephrectomy – Dissection of Adhesions
Single Port Nephrectomy – Mobilization of the spleen to expose upper pole of kidney
Single Port Nephrectomy – Retraction of the ureter can be done with the assistance of a Keith needle and suture passed through the abdomen and under the ureter
Single Port Nephrectomy – Dissection is done with one conventional laparoscopic instrument and one prebent instrument that provides tissue retraction
Single Port Nephrectomy – Ligation of renal vessels is performed en-bloc with a linear endoscopic stapler