Laparoscopic left upper pole nephrectomy (transperitoneal vs. retroperitoneal approach)

Transperitoneal LPN has been shown to be safe and effective. Magnification provides easy identification of vessels and precise dissection. Others have used a retroperitoneal approach, but this one is particularly difficult. This video shows a laparoscopic left upper pole nephrectomy comparing transperitoneal and retroperitoneal approaches.

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Laparoscopic left upper pole nephrectomy (transperitoneal vs. retroperitoneal approach)

Authors

Abstract

Transperitoneal LPN has been shown to be safe and effective. Magnification provides easy identification of vessels and precise dissection. Others have used a retroperitoneal approach, but this one is particularly difficult. This video shows a laparoscopic left upper pole nephrectomy comparing transperitoneal and retroperitoneal approaches.

Catégorie

contribution

Mots-clés

Transperitoneal nephrectomy, left upper pole nephrectomy

Type de vidéo

Vidéo chirurgicale

Durée

04'37''

Publication

2011-06

Popularité

Favoris

Favorites Media

Audio

Sous-titres

E-publication

WeBSurg.com, Jun 2011;11(06).
URL: http://www.websurg.com/doi-vd01en3246.htm

Laparoscopic left upper pole nephrectomy (transperitoneal vs. retroperitoneal approach)

1. Introduction 00'17''

Retroperitoneoscopic upper pole nephrectomy remains a particularly difficult procedure. The main risk of the intervention is to injure the vessels in the remaining lower moiety. The patient is lying in a semi lateral position. The surgeon is facing the patient on his right and the monitor is on the back. When the child is very young, it is probably easier and safer to perform this upper pole nephrectomy using a laparoscopic transperitoneal approach. Surgery can be performed either using a transmesocolic approach, or after the detachment of the splenic flexure of the colon. The freeing of the splenic flexure allows to keep the small bowel loops within the pouch formed by the left mesocolon, which is therefore folded onto itself. The surgical procedure can be pursued directly on the upper pole, since vascular control will be the first step of the intervention. However, when using a retroperitoneoscopic approach, the excretory ducts are first identified, allowing to reach the pole to be removed. The polar vascularization should then be identified from the main vascularization.

2. Identification of vessels 01'37''

The polar vessels are perfectly identified from the main renal vessels. The distended renal pelvis can be immediately identified underneath and posterior to the two veins draining the Y-shaped upper pole.

3. Division of polar vessels 02'35''

Once the division and coagulation of the polar vessels has been achieved, the ischemia of the upper pole can be rapidly identified. It presents an utterly clear delimitation from the rest of the parenchyma, that is the lower moiety, which should be preserved.

4. Ureter identification 02'53''

The next step of the procedure consists in finding the ureter draining the upper pole, which will be removed. The thin ureter draining the normal middle and lower pole should be preserved. In the present case, the dysplastic upper pole is drained by a megaureter. The healthy ureter is identified. When separating both ureters, care must be taken not to devascularize the remaining normal ureter. This is why there is no need to carry out this interureteral dissection too far or too caudally towards the bladder, since the objective of the intervention is to preserve the middle and lower pole as well as its vascular supply.

5. Division of ureter 03'49''

The ureter will be divided on its medial portion. The superior portion will therefore be tilted underneath the renal artery and vein.

6. Upper pole and ureter resection 03'59''

The superior portion of the ureter and the upper pole will be resected ‘en bloc’. The distal portion of the ureter will be resected at the end of the procedure, either using division by means of Ultracision® or the Ligasure® device, or using an Endoloop in order to ensure patency in case of reflux —which is quite rare in upper pole-related procedures.