Retroperitoneoscopic right-sided nephrectomy for poorly functioning kidney with associated reflux

The last decade has witnessed significant refinements in preoperative diagnostic evaluation and an improvement in surgical techniques and postoperative management for paediatric patients. Laparoscopic nephrectomy in children has become a routine practice in several centres. We present the stepwise approach for a right-sided nephrectomy in a patient with a poorly functioning kidney.

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Retroperitoneoscopic right-sided nephrectomy for poorly functioning kidney with associated reflux

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Abstract

The last decade has witnessed significant refinements in preoperative diagnostic evaluation and an improvement in surgical techniques and postoperative management for paediatric patients. Laparoscopic nephrectomy in children has become a routine practice in several centres. We present the stepwise approach for a right-sided nephrectomy in a patient with a poorly functioning kidney.

Classification

routine cases

Keywords

Retroperitoneoscopic right-sided nephrectomy, poorly functioning kidney, associated reflux

Media type

Surgical video

Duration

09'38''

Publication

2008-12

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E-publication

WeBSurg.com, Dec 2008;8(12).
URL: http://www.websurg.com/doi-vd01en2479.htm

Retroperitoneoscopic right-sided nephrectomy for poorly functioning kidney with associated reflux

1. Indication 00'23''

The indication for this right-sided nephrectomy is a poorly functioning kidney with associated reflux.

2. Creation of working space 00'30''

The dissecting balloon should create an initial working space outside Gerota’s fascia. Local anesthetic is used pre-emptively prior to insertion of the instrument ports. Using a combination of sharp dissection and monopolar diathermy, a cruciate incision is made in the Gerota’s fascia to create a second working space around the kidney. A horizontal incision is made close to the posterior abdominal wall and this is followed by a vertical incision in Gerota’s fascia.

3. Kidney reflection 02'15''

Using a combination of sharp and blunt dissection, the kidney is reflected in an antero-medial direction to expose the posterolateral surface and the renal hilum. Gerota’s fascia can be incised further to increase the size of the window and thereby the exposure of the kidney.

4. Landmark identification 03'18''

Once the kidney has been reflected anteriorly, a number of structures come readily into view: the ureter, the inferior vena cava, the kidney, and the renal hilum and vessels.

5. Vascular dissection and division 03'46''

The vessels at the renal hilum are dissected and displayed using a blunt instrument. Monopolar diathermy should be used to keep bleeding at an absolute minimum. The vessels in the renal hilum should be individually dissected and displayed. An attempt should be made to ligate the renal artery first, followed by the renal vein. The renal arteries are clipped twice proximally and once distally with a 5mm clip applicator. The renal arteries are then divided with scissors. The renal vein shown here is similarly dissected, displayed and clipped twice proximally and once distally. The controlled renal vein is divided between the clips.

6. Division of ureter 07'19''

In children with proven vesicoureteric reflux, the ureter should be dissected distally as far as possible where it should be ligated or clipped, and then divided. In the absence of reflux, the divided ureter can be safely left open without the need for a urethral catheter or a drain.

7. Kidney dissection 08'39''

In children with proven vesicoureteric reflux, the ureter should be dissected distally as far as possible where it should be ligated or clipped, and then divided. In the absence of reflux, the divided ureter can be safely left open without the need for a urethral catheter or a drain.

8. Extraction 09'03''

The fully mobilized kidney is placed in an Endobag for retrieval and the specimen can be morcellated within the bag for easier removal. A gentle shaking action can often facilitate placement of the kidney within the Endobag.