Extraperitoneal simple nephrectomy

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摘要

The description of the extraperitoneal simple nephrectomy covers all aspects of the surgical procedure used for the management of symptomatic benign end-stage renal disease.
Operating room set up, position of patient and equipment, instruments used are thoroughly described. The technical key steps of the surgical procedure are presented in a step by step way: incision, dissection, hilar control, extraction.
Consequently, this operating technique is well standardized for the management of this condition.

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刊物

2002-06

普通的

最愛

音訊

數位出版

WeBSurg.com, Jun 2002;2(06).
URL: http://www.websurg.com/doi-ot02en277.htm

Extraperitoneal simple nephrectomy

1. Introduction

Laparoscopic simple nephrectomy is now an established procedure. Since the description of the first human case in 1991 by Clayman et al., hundreds of patients have undergone this procedure all over the world. In addition to the recognised generic advantages of laparoscopic surgery, this approach appears to cause less disturbance of lung function and results in an attenuated stress response (Eden et al., 1993). It is now considered to be the standard of care.

Several centres have compared the transperitoneal approach with the more direct extraperitoneal approach. Although the studies were small in scale, they concluded that the extraperitoneal approach offered shorter operating times (Guillonneau et al., 1996; McDougall et al., 1996), quicker resumption of diet (McDougall et al., 1996) and a lower opiate requirement (McDougall et al., 1996; Rassweiler et al., 1998). The view of the target is also unimpeded by peritoneal contents and there is a much lower risk of visceral or vascular injury during access and dissection if the peritoneal cavity is not transgressed. It is not surprising, therefore, that the proportion of extraperitoneal surgery reported in the urological literature increased from 26% to 51% between 1993 and 1996 (Gill et al., 1998). Initial concerns regarding excessive CO2 absorption using this approach in dogs (Wolf et al., 1995) have proved to be unfounded in the clinical situation (Ng et al., 1999).

2. Anatomy

• Topographic anatomy

1. Aorta
2. Inferior vena cava
3. Right renal vein
4. Right renal artery
5. Left renal artery
6. Left renal vein
7. Collecting system
The kidneys lie on the posterior abdominal wall on either side of the spine. An average adult kidney is 10 cm in length and weighs 100 g. Each kidney has a convex lateral border and a concave medial border from which the hilar structures exit: the renal artery, the renal vein and the renal pelvis, which transports urine into the ureter. The left renal hilum lies at the level of the first (the transpyloric plane) or second lumbar vertebra, and the right renal hilum at a slightly lower level due to the presence of the liver. Each renal artery is a terminal branch of the aorta. The left renal vein usually passes in front of the aorta to drain into the inferior vena cava, whereas the short right renal vein enters it directly.

• Anatomical variations

1. Vessel of the lower pole of the kidney
2. Duplication of the collecting system
Anatomical variations of the collecting system, such as complete or partial duplication, and vasculature, especially the presence of separate vessels to the lower pole of the kidney, are common.

3. Indications

Indications
Simple nephrectomy is indicated for symptomatic benign end-stage renal disease. The common denominator is usually infection.

Contraindications
Children <40 kg, previous renal surgery, the need for partial nephrectomy and the coexistence of renal calculi are contraindications for the novice surgeon. Recent severe inflammation, such as that seen in xanthogranulomatous pyelonephritis, is a relative contraindication even for expert laparoscopists.

4. Preop period

An up-to-date serum creatinine, urine culture, renogram and renal ultrasound or intravenous urogram should be available. While obtaining consent from the patient, the surgeon should discuss the possibility of conversion to open surgery, the circumstances that might lead to this and his or her personal experience and results with this technique. The side of the nephrectomy should be clearly marked on the patient while he or she is awake.

An appropriate intravenous antibiotic and subcutaneous heparin should be administered at induction of anaesthesia. Thromboembolic deterrent and pneumatic calf-compression stockings are used throughout the treatment.

5. Operating room set-up

• Patient

- general anaesthesia with endotracheal intubation;
- lateral position with table angulated 30° under the loin;
- a padded lumbar support applied against the upper back and a padded arm gutter prevent the torso from rolling laterally. Wide adhesive tape is wound around the patient’s hips and the operating table to support the lower body.

• Team

1. The surgeon stands behind the patient.
2. The assistant stands in front of the patient until extraperitoneal access has been achieved. Thereafter he or she stands to the left of the surgeon on a platform to prevent clashing of elbows.
3. The scrub nurse stands in front of the patient throughout the procedure.

• Equipment

1. The laparoscopic unit and monitor are placed opposite the surgeon and assistant.
2. The diathermy and suction equipment are placed at the patient’s feet.

6. Trocar placement

• Principles

It is helpful to mark the following elements on the patient’s skin:
1. the 12th rib
2. the iliac crest
3. the erector spinae muscle

• Optical trocar

Trocar A (5-10 mm), for the camera: an open access technique is used to enter the retroperitoneum inferior to the tip of the 12th rib. A balloon, made out of the middle finger of a size 8 surgical glove tied to a 20F catheter, is inserted and slowly inflated with 500-700 mL saline and kept inflated for 5 minutes before deflating.

• Other trocars

Secondary ports are then inserted under guidance of a finger inserted through this incision, as this is faster and safer than under endoscopic control.
Trocar B (5 mm), for the surgeon’s left hand: placed below the 12th rib and anterior to the erector spinae muscle.
Trocar C (5-12 mm), for the surgeon’s right hand: placed midway between port B and the iliac crest.
Trocar D (5-10 mm), for the kidney retractor: placed superior to the anterior superior iliac spine.
Once the secondary ports have been inserted, trocar A is placed in the primary access site. The skin is sutured around it to make an airtight seal.

7. Instrumentation

• Optical

1. 0° laparoscope, 5 or 10 mm
- camera system and high-flow insufflator

• Operating

1. 5 mm fine, curved scissors
2. 5 mm dissecting forceps
3. 5 mm suction device
4. 10 mm clip applier
5. Linear stapler with vascular cartridges
6. Entrapment sac

• Retracting

1. 10 mm fan retractor

8. Incision

1. Gerota's fascia
2. Psoas major muscle
3. Perirenal fat
Gerota's fascia is identified as an unyielding white sheet immediately above the major psoas muscle. It is incised just above and parallel to the major psoas muscle, as far superiorly as the deflection of the instruments allows and inferiorly to a few centimetres below the position of port A. It is difficult to confuse it with the peritoneum, which appears blue and is located more anterior. Once Gerota’s fascia has been incised the perirenal fat is revealed.

9. Dissection

The perirenal fat is dissected off the capsule of all parts of the kidney except the hilum. Care should be taken not to enter the renal capsule, as this results in bleeding. Peripelvic fibrosis due to local infection can make this step more difficult. It may be easier to dissect a tense, hydronephrotic kidney after it has been decompressed using a laparoscopic suction device.

10. Hilar control

• Mobilization

1. Fan retractor
2. Kidney
3. Hilar vessels
4. Psoas major muscle
The mobilized kidney is lifted up off the psoas muscle using a fan retractor, 2 blades of which straddle the undissected hilum. This straightens the hilar vessels, which are then oriented vertically.

• Vessels

1. Division of the clipped renal artery
2. Stapling and division of the renal vein
The fat overlying the hilum is gently teased downwards to identify the vessels, which are then dissected sharply, keeping close to the adventitia tunica. Renal arteries are clipped 3 times on the 'stay' side and once on the 'go' side using medium-large clips and then divided. A sharp linear stapler divides the renal vein, which is too wide to be clipped. This stapler is rarely used to occlude an artery. If in doubt, a sharp linear stapler should be used as once clips have been applied to a vessel, removing them to make sufficient room to apply a linear stapler risks tearing the vessel and heavy bleeding.

• Ureter

1. First clip on the ureter
2. The kidney is lifted.
The ureter is clipped twice (in case of reflux) and divided between the clips.

11. Extraction

When the kidney is fully dissected it is possible to rotate it in any direction. This is a useful test, especially when the specimen is large. An appropriately sized entrapment sac is inserted into the retroperitoneal workspace through the 12 mm port. The sac is opened fully so that the inside of the sac faces the laparoscope. Grasping forceps are used to stabilise the mouth of the sac as the kidney is manoeuvred into it. Once the kidney is entrapped a final check is made of the retroperitoneal space for bleeding before the neck of the sac is delivered through the largest port site. The kidney is morcellated using sponge-holding forceps and heavy scissors and the kidney is retrieved piecemeal for histological analysis. Finally, the sac is removed.

End of procedure
A 20F drain is inserted through the lowermost port.
The port sites are closed in 2 layers. The incisions are infiltrated with local anaesthetic.

12. Postop period

Regular oral diclofenac sodium and opiate-paracetamol compound are given until discharge, supplemented by intermittent intramuscular morphine sulphate as required. Oral fluids and diet are given on the first postoperative day. The drain and catheter are removed on the first day and patients are discharged after 2 or 3 nights.

13. Reference

Clayman RV, Kavoussi LR, Soper NJ, Dierks SM, Meretyk S, Darcy MD et al. Laparoscopic
nephrectomy: initial case report. J Urol 1991;146:278-82.
Eden CG, Carter PG, Haigh AC, Sherwood RA, Green DW, Copcoat MJ. The metabolic response to
laparoscopic and open nephrectomy. Min Invas Ther 1993;3:43-50.
Gill IS, Clayman RV, Albala DM, Aso Y, Chiu AW, Das S et al. Retroperitoneal and pelvic
extraperitoneal laparoscopy: an international perspective. Urology 1998;52:566-71.
Guillonneau B, Ballanger P, Lugagne PM, Valla JS, Vallancien G. Laparoscopic versus lumboscopic
nephrectomy. Eur Urol 1996;29:288-91.
McDougall EM, Clayman RV. Laparoscopic nephrectomy for benign disease: comparison of the
transperitoneal and retroperitoneal approaches. J Endourol 1996;10:45-9.
Ng CS, Gill IS, Sung GT, Whalley DG, Graham R, Schweizer D. Retroperitoneoscopic surgery is not
associated with increased carbon dioxide absorption. J Urol 1999;162:1268-72.
Rassweiler J, Frede T, Henkel TO, Stock C, Alken P. Nephrectomy: A comparative study between the
transperitoneal and retroperitoneal laparoscopic versus the open approach. Eur Urol 1998;33:489-96.
Wolf JS, Jr., Carrier S, Stoller ML. Intraperitoneal versus extraperitoneal insufflation of carbon dioxide
as for laparoscopy. J Endourol 1995;9:63-6.

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