You need to log in to watch this media!

Click here to log in.

Retroperitoneal laparoscopic radical nephrectomy

Authors

Abstract

The description of the retroperitoneal laparoscopic radical nephrectomy covers all aspects of the surgical procedure used for the management of kidney cancers.
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: creation of access, working space, ligature of pedicle, extrafascial dissection, division of ureter, extraction, end of procedure.
Consequently, this operating technique is well standardized for the management of this condition.

Media type

Publication

2002-05

Popular

Favorites

Audio

E-publication

WeBSurg.com, May 2002;2(05).
URL: http://www.websurg.com/doi-ot02en275.htm

Retroperitoneal laparoscopic radical nephrectomy

1. Introduction

The first laparoscopic radical nephrectomy was described in 1991 (Clayman et al.). Surgical teams who use this technique have reported results superior to those obtained by open surgery. In addition to improved cosmetic results, patient hospitalization is shorter and recovery is quicker.
Long-term oncological results are equivalent to those conferred by traditional open radical nephrectomy (Portis et al., 2002). There is no specific oncological risk related to the use of trocars or to the pneumoperitoneum.
Three approaches to laparoscopic radical nephrectomy have been developed:
1. transperitoneal laparoscopic approach;
2. retroperitoneal laparoscopic approach;
3. hand-assisted surgery.
This chapter presents the retroperitoneal technique.

2. Anatomy

• Fascias

1. Gerota’s fascia
2. Posterior pararenal space
3. Posterior parietal peritoneum
The kidneys are situated in the retroperitoneal space, in the lumbar fossa, on either side of the spine and of the large vessels. They are surrounded by the perirenal fat that is limited by Gerota’s fascia. Posteriorly, a plane between Gerota’s fascia and the transversalis fascia is found that can be easily divided (the posterior pararenal space). Similarly, the anterior perirenal space, which is limited by Gerota’s fascia and the posterior parietal peritoneum, is found anteriorly.
In a radical nephrectomy, the division is done lateral to Gerota’s fascia, in the fibrofatty tissue in the posterior and anterior pararenal spaces.

• Renal vessels

• Left

1. Gonadal vein
2. Second lumbar vein
3. Adrenal vein
Following the psoas major muscle cephalad, the first vascular structures are the branches of the renal vein. Caudally, the gonadal vein is encountered and posteriorly, the second lumbar vein is encountered. The gonadal vein runs parallel and anterior to the ureter. On the superior margin of the renal vein, and in a more posterior position, the renal artery is found. This artery must be reflected caudad or cephalad to expose the adrenal vein that crosses it anteriorly.

• Right

1. Gonadal vein
2. Renal artery
3. Adrenal vein
Following the inferior vena cava cephalad, the right gonadal vein is the first vascular structure encountered. It runs parallel to the ureter, which is situated posteriorly. Further cephalad, the course of the renal vein is vertical in a patient in lateral decubitus position. The renal artery is on the superior border of the renal vein, but its location is more posterior. It crosses the inferior vena cava posteriorly. The adrenal vein drains into the suprarenal portion of the vena cava.

• Intraperitoneal relations

• Right side

1. Liver
2. Right colon
3. Duodenum
The liver is situated anterior to the superior pole of the kidney and the adrenal gland. The right colon covers the anterior surface of the kidney. The duodenum is anterior to the renal hilum.

• Left side

1. Splenic vein
2. Tail of the pancreas
3. Left colon and jejunum
The splenic vein is in contact with the left adrenal gland. The tail of the pancreas is anterior to the renal pedicle. The left colon and jejunum are adjacent to the left kidney’s anterior surface and inferior pole.

3. Indications

Both transperitoneal and retroperitoneal laparoscopic approaches confer results that are equivalent to open surgery for stage T1 kidney cancers (Portis et al., 2002).
With larger localized tumors, laparoscopy is not advantageous because of the large parietal opening required to extract the specimen. Nevertheless, certain teams using the morcellation technique extend the indications to include stage T2 cancers.
Local spreading to the perirenal fat or to the renal vein is an absolute contraindication to the laparoscopic technique.
The role of laparoscopic radical nephrectomy for metastasized tumors is controversial and is being studied (Walter et al., 1999).

Past history of retroperitoneal lumbar surgery is a relative contraindication, as it makes the dissection difficult.

4. Preop management

Kidney tumors are often discovered by chance during an abdominal ultrasound.
CT scan of the abdomen and pelvis, with and without injection of contrast medium, is the key element of the diagnosis. It is used to assess not only the stage of the tumor, its local and regional extension and a possible thrombus, but also the condition of the contralateral kidney and the possible presence of a hepatic metastasis.
An MRI may be indicated when there is doubt concerning the presence of an angiomyolipoma, or to evaluate the extension of a caval thrombus more precisely.
A chest X-ray is performed systematically. If the patient presents with other symptoms, a brain scan, bone scan or chest scan can be included in the workup.
The patient must fast starting midnight on the night before surgery. Determination of blood type and a crossmatch are carried out. When inducing the anesthesia, prophylactic antibiotic therapy with a second generation cephalosporin is administered. Prophylactic treatment with low molecular weight heparin is begun on the day of surgery.

5. Operating room

• Patient

1. Lumbar support
- general anesthesia;
- placement of a nasogastric or orogastric tube and urinary catheter;
- patient placed in lumbar position with the lumbar support raised to its maximum height;
- legs flexed slightly forward and placed on the anterior leg rest. The posterior leg rest is removed to leave room for the assistant who holds the videocamera.

• Team

1. The surgeon is positioned behind the patient.
2. First assistant
3. Second assistant
4. Scrub nurse

• Equipment

1. Video unit, preferably with 2 monitors, one on either side of the patient
2. Insufflation system
3. Suction device
4. Monopolar and bipolar cautery

6. Trocar placement

1. AAL: anterior axillary line
2. MAL: mid axillary line
3. PAL: posterior axillary line
The retroperitoneal space is approached via a minimal lumbotomy. Five trocars are used:
Trocar A: 12 mm disposable trocar with sealing ring
Trocar B: 5 or 10 mm
Trocar C: 5 mm
Trocar D: 10 mm reusable trocar
Trocar E: 10 mm

7. Instruments

• Laparoscope

Trocar D (second assistant or scrub nurse):
- 0° laparoscope

• Operators

Trocars A and E (surgeon):
1. Monopolar scissors
2. Bipolar grasping forceps
3. Linear stapler
4. Suction device
5. 10 mm clip applier
6. Needle holder (required only exceptionally)
7. Retrieval bag

• Retractors

Trocars B and C (first assistant):
1. Fenestrated grasper
2. Toothed grasper

8. Major principles

Radical nephrectomies are performed following the principles of Robson (Robson et al., 1969):
1. Initial ligature of the vessels;
2. Removal of the kidney along with the perirenal fat and the adrenal gland;
3. Lymph node dissection.
According to recent data, systematic ipsilateral adrenalectomy can be omitted for a small tumor situated on the inferior pole of the kidney (Mickisch et al., 2001). Lymph node dissection is useful in order to obtain precise staging, but its therapeutic utility has not been proven.
Certain aspects of the laparoscopic retroperitoneal approach differ from the laparoscopic transperitoneal approach. As opposed to the natural, preexisting intraperitoneal space, the retroperitoneal working space must be developed by the surgeon. This is done by mechanical expansion between Gerota’s fascia and the transveralis fascia. These fascias limit the posterior pararenal space.
The retroperitoneal approach has the following advantages over the transperitoneal approach:
- the renal pedicle and vessels are approached directly;
- it is not necessary to dissect the intraperitoneal organs. Preservation of the peritoneum provides a natural retractor that acts as a small bowel loop bag, allowing the surgeon to operate without being hindered by the intraperitoneal organs;
- if a postoperative seroma forms, it is limited by the retroperitoneal space, and any risk of hemoperitoneum or peritonitis is therefore excluded.
The disadvantage of the retroperitoneal approach is the limitation of the work space by bone structures. The limited angulation between the instruments may cause ergonomic difficulties, especially if suture is required.

9. Creation of access

• Step 1

A minimal lumbotomy (about 2 cm) is performed below the 12th rib, on the anterior border of the sacro-lumbar muscular mass that projects roughly onto the posterior axillary line.
Computerized tomographic studies have shown that this is always found posterior to the peritoneal reflection (Chiu et al., 1995). No vascular structures are found nearby. Consequently, the surgeon can approach the retroperitoneal space in a zone of near-absolute security. After incision of the transversalis fascia, finger dissection is done in the posterior pararenal space. The renal fascia and the peritoneum are mobilized from the abdominal wall.

• Step 2

The secondary trocars are placed under digital control. The surgeon’s index finger is placed in a latex finger glove. When the 4 secondary trocars have been inserted, a 12 mm trocar is introduced through the initial minimal lumbotomy incision. This trocar includes:
1. a sponged sealing ring.

• Step 3

Insufflation is begun. The maximum CO2 pressure is set at 12 mm Hg. The 0° laparoscope is then introduced.

10. Working space

• Landmarks

1. Psoas major muscle
The first anatomical landmark is the psoas major muscle. To find it, the assistant standing opposite the surgeon pulls the renal sinus and the peritoneum towards himself or herself. The surface of the muscle is freed cephalad and caudad, to create a sufficient working space.

• Left kidney

1. Gonadal vein
2. Left renal vein
3. Second lumbar vein
4. Renal artery
On the left side, the dissection is pursued cephalad. Very often, the ureter and the gonadal vein, which run parallel to the psoas major muscle, are exposed at this point. By following them cephalad, the renal pedicle can be identified by a deep arterial pulsing.

• Right kidney

1. Psoas major muscle
2. Inferior vena cava
3. Gonadal vein
4. Ureter
On the right, the psoas major muscle is followed laterally and medially until the surgeon reaches the inferior vena cava. The dissection that is pursued along the inferior vena cava exposes the gonadal vein and often the ureter.

11. Ligature of pedicle

• Renal vessels

• Landmarks

1. Gonadal vein
2. Left renal vein
3. Second lumbar vein
4. Renal artery
When the fatty tissue is freed from the left kidney, the branches of the renal vein are exposed. The gonadal vein drains into the proximal portion of the renal vein. Posteriorly, the second lumbar vein forms a bridge above the aorta and courses towards the psoas major muscle. On the superior border of the renal vein, the renal artery appears.

• Division of artery

A 2 cm portion of the renal artery is freed completely and ligated with three 9 mm clips. The artery is divided, leaving 2 clips on the remaining stump.

• Division of vein

1. Gonadal vein
2. Renal vein
3. Second lumbar vein
The proximal portion of the renal vein must be completely dissected. A linear stapler is positioned. Its tip must go beyond the renal vein, without catching the deep tissue layers in its jaws. The linear stapler is closed to staple and divide the renal vein.

• Dissection

1. Renal artery
2. Inferior vena cava
3. Renal vein
For the right kidney, the gonadal vein is divided between 2 clips to avoid tearing, which could result in bleeding that is hard to control. The dissection is pursued cephalad. The renal vein, and the renal artery more laterally, are entirely freed.

• Division of adrenal vein

1. Renal vein
2. Adrenal vein
The renal artery and vein are clipped and divided following the same principles as those described for the left kidney. If an adrenalectomy is combined with the radical nephrectomy, the freeing of the vena cava is pursued cephalad until the adrenal vein is found a few centimeters higher. The adrenal vein is then clipped and divided.

12. Extrafascial dissection

• Freeing of superior pole

1. Perirenal fat covered by Gerota’s fascia
2. Diaphragm
The mobilization of the kidney surrounded by perirenal fat and Gerota’s fascia begins at its posterior surface and is extended cephalad. At this point, the anterior attachments are left intact. They keep the kidney suspended and, along with the ‘retraction’ effect of the pneumoperitoneum, facilitate the posterior cleavage. The surgeon then reaches the diaphragm and can free the superior pole entirely.

• Separation of peritoneum

1. Gerota’s fascia
The anterior leaflet of the perirenal fascia is separated from the peritoneum. It is of no consequence if the peritoneum tears. However, the surgeon must avoid using intensive cauterization with the monopolar scissors because of the close proximity of the digestive tract and the tail of the pancreas on the left side.

• Freeing of inferior pole

1. Peritoneal attachments
2. Inferior pole of the left kidney
The inferior pole of the kidney is then freed.

13. Division of ureter

1. Peritoneum
2. Ureter
3. Inferior pole of the left kidney
The ureter is freed up to the iliac crest. It is divided between 2 clips.

14. Extraction

• Strategy

The kidney is reflected cephalad with the assistant’s grasping forceps.
The first trocar (A) is removed. A pursestring suture is performed around the edges of the minimal lumbotomy. The retrieval bag is placed in the retroperitoneal space. The suture is tightened, enabling a reestablishment of the pnemoperitoneum.
The bag is deployed. The kidney is released by the assistant, and the whole operative specimen, including the fatty covering and the ureter, is pushed into the bag.

• Extraction

The bag is then extracted through the wall, after enlarging the initial incision that should measure between 5-6 cm.

15. End of procedure

The pressure of the retroperitoneum is decreased to 5 mm Hg to check for possible bleeding. The trocars are removed. A drain is inserted through the lower trocar on the posterior axillary line (trocar E). Careful exsufflation is carried out. The muscular and fascial planes of the minimal lumbotomy incision are closed. The other trocar wounds do not require fascial closure. The skin is sutured using an intradermic running suture with rapidly absorbable 4.0 polyglactin suture.

16. Postop period

At the end of the procedure, the nasogastric or orogastric tube is removed. On the morning after the operation, the patient can resume fluid intake. The urinary catheter is no longer necessary. A complete blood count and chemistry panel are performed. The drain is removed as soon as there is an output of less than 50cc per 24 hours, generally on POD1 or POD2. The patient should get up and resume a normal diet on POD2 at the latest. Hospital discharge is authorized on POD3.
The first follow-up visit should take place a month later. An abdominal ultrasound and a chemistry panel are performed at this time to check the function and morphology of the contralateral kidney.

17. Conclusions

Laparoscopic radical nephrectomy has become a new alternative for the curative treatment of small-sized kidney tumors. This technique should be included in the training of urological surgeons.

18. Reference

Chiu AW, Chen KK, Wang JH, Huang WJ, Chang LS. Direct needle insufflation for
pneumoretroperitoneum: anatomic confirmation and clinical experience. Urology 1995;46:432-7.
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.
Mickisch G, Carballido J, Hellsten S, Schulze H, Mensink H. Guidelines on renal cell cancer. Eur Urol
2001;40:252-5.
Portis AJ, Yan Y, Landman J, Chen C, Barrett PH, Fentie DD et al. Long-Term Followup after
Laparoscopic Radical Nephrectomy. J Urol 2002;167:1257-1262.
Robson CJ, Churchill BM, Anderson W. The results of radical nephrectomy for renal cell carcinoma. J
Urol 1969;101:297-301.
Walther MM, Lyne JC, Libutti SK, Linehan WM. Laparoscopic cytoreductive nephrectomy as
preparation for administration of systemic interleukin-2 in the treatment of metastatic renal cell
carcinoma: a pilot study. Urology 1999;53:496-501.

Username
Password
	Remember me (needs cookies)