Transcript Laparoscopic Nephrectomy

Laparoscopic
Nephrectomy
Dr. SUNIL SHROFF
Prof.Urology & Renal Transplantation
Sri Ramachandra Medical College & Research Institute
( Deemed University )
Chennai, India
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“These are Exciting times to be a
Surgeon”
Lord Lister said 100 years ago!!
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Conventional Open Surgery
vs
Laparoscopic Surgery
Quantum Leap
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Laparoscopic Surgery

Suitable Surgery for Zero Gravity
( Weightlessness)

Suitable Surgery for Tele-Mentoring

Maybe suitable Surgery for TelePresence Surgery
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The Father of Laparoscopy Surgery
Prof.Kurt Semm, Kiel, Germany
First peep inside body cavity was looking into urethra - 1805
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Laparoscopic Nephrectomy was
first performed in 1990 by
Clayman, Kavoussi et al, where
they removed the Right kidney
from a patient diagnosed with
Renal Oncocytoma
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Laparoscopic Approaches to Kidney
TRANSPERITONEAL
RETROPERITONEAL
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ADVANTAGES OF RETROPERITONEAL APPROACH

Peritoneal cavity not entered No Post-op adhesions

Contamination of peritoneal cavity –
Risk Minimum

Injury to Intraperitoneal organs Risk Minimum

No Retraction of Intra-abdominal viscera Minimum ports
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ADVANTAGES OF RETROPERITONEAL APPROACH

Minimum Ileus in post- operative period Faster convalescence

If Previous H/O Intraperitoneal surgeries Safe

Bowel herniation Incidence Low

For Retroperitoneal organs Access direct
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DISADVANTAGES OF RETROPERITONEAL
APPROACH

Space available to perform surgeryLess
 Landmarks in Retro-peritoneum Few
 Learning curve –
Steeper
 In Inflammatory pathologies like pyelonephritis Space can be obliterated
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DISADVANTAGES OF RETROPERITONEAL
APPROACH

Large tumour mass does not allow Free manipulation.
 Pneumothorax or Pneumo-mediastinum Higher incidence
 Reports suggest that there is Greater absorption of CO2 due to fat
Aortic Aneurysm contra-ind. to Retro-peritoneal approach
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COMPLICATIONS OF BALLOON DISSECTION

Loss of Orientation due to inflation in an
incorrect plane

Injury to abdominal muscles due inflation in a
wrong plane

Rupture of peritoneum

Rupture of balloon
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ADVANTAGES OF TRANSPERITONEAL
APPROACH
 More space is available to perform surgery
 The anatomical landmarks are easier to
identify and therefore short learning curve
 Large tumour masses are easy to manipulate
in the large peritoneal space
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DISADVANTAGES OF TRANSPERITIONEAL
APPROACH
 Intra-abdominal adhesions chances –
More
 Contamination of Peritoneal cavity by urinary contents More
 Injury to Intraperitoneal organs –
Risk higher
 Previous Intra-peritoneal surgery –
Not suitable
 Bowel Herniation –
Risk higher
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Transperitoneal left Nephrectomy
• Operation starts by retracting the colon (splenic flexure)
downward by cutting on the line of Todlt. This maneuver
exposes Gerota’s fascia
• Colon retracted medially and inferiorly exposing
Gonadal vessels
• Ureter is the first structure to be identified. Once a
window is made, this helps in retraction during further
dissection
•Dissection of Renal hilum can be tedious. Artery and vein
should be identified and ligated. The artery first Isolated
and divided between 9 or 11 mm Titanium clips.
• This is followed by ligation and division between clips of
the renal vein. Can use an Endo GIA stapler to secure the
vein
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Transperitoneal left Nephrectomy…
• This is followed by ligation and division between clips of
the renal vein. Can use an Endo GIA stapler to secure the
vein
• The kidney is lifted up once vessels of the hilum has been
divided. Blunt dissection continues dividing any remaining
attachments to Retroperitoneum
• The ureter is divided and Kidney ready for retrieval
• Kidney is placed in a plastic bag using the grasper
holding the organ by the ureter
• When dealing with renal cancer, a 6 cm incision is made
in abdominal wall to allow specimen to be retrieved under
minimal tension. The plastic bag should be protecting the
skin all the time.
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Laparoscopic Hand Assisted
Nephrectomy
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Why Laparoscopic Hand-Assisted Nephrectomy
“Delivery of kidney anyway requires a
6 to 9 cm incision at the end. So it is only
logical to use this incision as a port to help
with retraction and dissection of the organ
right from start of the surgery”
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Why Laparoscopic Hand-Assisted Nephrectomy
HAND IS THE MOST VERSATILE
INSTRUMENT
( To Feel, to dissect, To Retract & For Knot-Tying)
‘Endohand’ for laparoscopy - undergoing trial ( Jackman – 1999)
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Why Laparoscopic Hand-Assisted Nephrectomy
I. Compared to hand, Instruments reduce Sensory
perception by a factor of 8
II. Conventional laparoscopic procedures – Steep
learning Curve
1.
Operating looking at “Pixels”
2.
Hand Eye co-ordination
3.
Unlearn old habits
4.
Not part of PG training programme
5.
Unless practice regularly loose dexterity
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HISTORY – Laparoscopic Hand Assisted Nephrectomy
1994 Tierney
et
al
reported
-
Hand
assisted
Spleenectomy, Colectomy & Nephrectomy
1995 Cuschieri & Shapiro – Pneumo-peritoneum Access
Bubble
1996 Bannenberg et al – devised Pneumosleeve – to
preserve pneumoperitoneum
1997 Wolf et al reported – OR time with pneumosleeve
for nephrectomy less by 85 mins
1998 Schichman et al
with
hand
- Efficacy, safety and recovery
assisted
nephrectomy
similar
to
conventional laparoscopic surgery and superior to
open surgery.
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Laparoscopic Hand Assisted Nephrectomy
Versus Conventional Laparoscopic Nephrectomy
I. No difference in:
a. Post operative Pain
b. Return of Bowel function
c. Duration of Convalescence
II. Less number of complications
III. Operation time less by 85 min (Wolf - 1997)
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Pneumo-Sleeve for Hand Assisted Laparoscopy
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Advantages of Hand-assisted Laparoscopy
Donor Nephrectomy

Tactile Sensation

Blunt dissection

Quicker dissection

Intact Specimen Removal

Ability to apply Digital pressure

Quick learning curve

Decreased OR Time

Shorter Warm Ischemia time for Donor
Nephrectomy
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Laparoscopy For Benign
Renal Disease
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Laparoscopic Nephrectomy for benign
Renal disease
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Laparoscopy Abalation of Renal Cyst
Hydronephrosis – NF Kidney
Chr. Pyelonephritis
ESRD
Renal hypoplasia
Xanthogranulomatous Pyelonephritis –Relative Contra-ind
to lap. Nephrectomy
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Laparoscopy Abalation of Renal Cyst

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Transperitoneal preferred
If Retroperitoneal approach – port
inserted under vision
Send wall for histology
Recurrance can again be approached
laparoscopically
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Laparoscopic Pyeloplasty

Retroperitoneal approach preferred

UPJ obstruction with Extra-renal pelvis

Excellent long term results reported

0
30 telescope Preferred
Operating time initially 6 to 8 hrs, currently 3 hrs
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Laparoscopic Pyelolithotomy
Indication
 Failed ESWL
 Failed PCNL
 Ectopic Kidney
 Renal calculus with UPJ obstn. Where
dismemembered pyeloplasty planned
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Laparoscopic Pyelolithotomy
Technique:

Ureteral catheter or DJ stent placed before
positioning patient

Sling the ureter
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Palpate stone between cannula and dissector
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Transverse incision on pelvis using a cold knife
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DJ pushed once stone removed into renal pelvis
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Close Pyelotomy
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Laparoscopic Donor Nephrectomy
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History - Laparoscopic Live Donor Nephrectomy
1994 - Porcine Model – Gill et al.
1995 - 40 yrs old Lap Donor nephrectomy – Ratnor et al
( Kidney removed with 9 cms incision at end of procedure )
Since then over 2000 Lap. live Donor Nephrectomy
performed world-wide
Mostly left kidney preferred for lap. donor Nephrectomy
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Issues - Laparoscopic Donor Nephrectomy
 Warm
Ischemia Time
 Complication
 Vascular
Pedicle
 Rejection
 Long
Rate
Episodes
term Graft outcome
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Laparoscopic Donor Nephrectomy Vs Open Donor
Nephrectomy
Novick (1999) – Compared outcomes of 132 Recipient of
Lap. Nephrectomy versus 80 Recipients of open
Nephrectomy
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Laparoscopic Donor Nephrectomy Vs Open Donor
Nephrectomy
1. Serum Creatinine 1 week to 1 month after
Transplant significantly higher in Laparoscopic group
compared to open group
Serum Creatinine groups
3 & 6 months similar in both
2. Number of Ureteral complication higher in Lap.
group compared to open group
Current series show complication rate higher during early
part of experience. Later on there is no statistical
difference
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Arguments for Laparoscopic Donor Nephrectomy
Smaller Scar, Less post-operative pain and Early
Return to work
Resulted in 55% Increase in Live Donor rates in
most of the units offering Lap. Donor Nephrectomy
Worldwide on an average 38,000 kidney transplants done every year
however 150,000 patients added to waiting list
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Laparoscopic Nephrectomy for
Renal cell carcinoma
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Issues – Lap Nephrectomy for RCC

Prolonged operating time

Complication rates

Specimen Extraction
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Potential for Tumour Spread

Port site Recurrence
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Issues – Lap Nephrectomy for RCC
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Op. Time - 5.9 hrs lap vs 2.8 hrs open
( Clayman 1997)
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Specimen extraction - Lapsac & Morcellation
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Tumour spread – No difference
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Port site recurrance - Rare
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Complication – Similar to open

5 yrs Survival – 95.5% lap vs 97.7% open
( Ono 1999)
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Lap. Nephrectomy - RCC
 Indication
- T1-T2 N0 M0
 Transperitoneal approach preferred
 3 to 4 ports
Advantages:
 Less Blood loss than open
 Less Analgesia
 Less Hospital stay
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Newer Treatment Modalities for RCC and
Laparoscopy

Cryo-abalation - Peripheral Renal
tumour below 4 cms
 High
Intensity Focussed Ultrasound
 Interstitial
 Radio
Contact laser
frequency abalation
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Tele-mentoring
Tele-mentoring is guiding surgical and
other clinical procedure from a remote
distance by a mentor
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Tele-Mentoring in Urology
 Tele-Mentoring at
John Hopkin’s for 14
advanced & 9 Basic urology procedures

Telestrator and Robotic arm used
 Operative time
 96%
not statistically different
success with no complications
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CONCLUSION

Live Donor Laparoscopic Nephrectomy
likely to become the commonest Indication
for lap. nephrectomy
 Hand-Assisted Lap Nephrectomy will be
practised more commonly for Abalative
Renal Procedures
 Reconstructive Renal procedures likely to be
tackled by conventional Laparoscopic
Techniques
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THANK YOU
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