Total nephrectomy in children by a lateral retroperitoneoscopic approach

This didactic video demonstrates the retroperitoneal approach to nephrectomy in children. A simple technique for creation of the retroperitoneal space and different methods of dissection, vessel division and specimen extraction are presented. These techniques are applicable for use in patients ranging from infants to adolescents. The tip of the telescope progressively enlarges the working space created in the retroperitoneoscopic approach. This frees retroperitoneal fibrous tissues behind the kidney. The authors place two additional ports under direct vision: one to gently sweep the peritoneum anteriorly and to increase the working space for the placement of a third trocar.

Create account

Browse the WORLD

Virtual University

Google translate

Summary
Chapters
Your comments
Ask the Experts

You need to log in to watch this media!

Click here to log in.

Total nephrectomy in children by a lateral retroperitoneoscopic approach

Authors

Abstract

This didactic video demonstrates the retroperitoneal approach to nephrectomy in children. A simple technique for creation of the retroperitoneal space and different methods of dissection, vessel division and specimen extraction are presented. These techniques are applicable for use in patients ranging from infants to adolescents.

The tip of the telescope progressively enlarges the working space created in the retroperitoneoscopic approach. This frees retroperitoneal fibrous tissues behind the kidney. The authors place two additional ports under direct vision: one to gently sweep the peritoneum anteriorly and to increase the working space for the placement of a third trocar.

Keywords

retroperitoneal approach, nephrectomy, children

Media type

Surgical video

Duration

08'20''

Publication

2007-01

Popular

Favorites

Favorites Media

Audio

Subtitles

E-publication

WeBSurg.com, Jan 2007;7(01).
URL: http://www.websurg.com/doi-vd01en2054.htm

Total nephrectomy in children by a lateral retroperitoneoscopic approach

1. Patient positioning and 1st port placement 00'13''

The lateral position for retroperitoneal access has been used for more than 10 years in adults and children. This access has been demonstrated as reliable for a large number of indications. The patient is placed in a lateral position with lumbar hyperflexion in order to enlarge the space between the last rib and the iliac crest. The first port is inserted by open technique. This is a key point because the majority of complications relate to access problems. The skin incision is made just below the tip of the last rib. Its length is chosen according to the size of the patient. A muscle-splitting approach is used to cross the 3 muscle layers.

2. Creation of retroperitoneal space 01'15''

When the yellow peri-renal fat is visible, a small gauze is introduced into the retroperitoneal space and manipulated carefully to create the space. Stay sutures are placed on each side of the muscle layer. Visibility is reduced if a 5mm trocar is selected, and much better if a 10mm port is used as in this case. The primary blunt-tipped port is placed and secured to create the seal for the retroperitoneum. Carbon dioxide insufflation is started at 8 to 12 mm pressure running at 1 litre/min. The working space, already created, is progressively enlarged using the tip of the telescope, used as a dissector, to free the retroperitoneal fibrous tissues behind the kidney

3. Additional port placement 02'14''

Then, 2 additional ports are placed under direct vision. Through the first one, an instrument is introduced to gently sweep medially the peritoneum and to enlarge the working space, so that the 3rd trocar can then be introduced safely.

4. Exposure of renal hilum 02'49''

In adolescents, using a 10mm balloon trocar avoids gas leak and trocar dislodgement. With the help of two atraumatic instruments, Gerota’s fascia is opened widely along the posterior aspect of the kidney. Anterior dissection should be limited at the beginning to prevent peritoneal injury and the kidney from flapping ventrally. If the search for the renal vessels proves difficult, the ureter may serve as a lead. Dissection with a hook or scissors cleans the artery and vein; they appear vertically. A sufficiently wide area of exposure, at least one cm, is necessary to allow safe control of each side of the vessel.

5. Division of renal vessels 03'57''

The artery is controlled first. Many kind of haemostases could be used according to the anatomical situation and vessel diameter. Monopolar coagulation, with a hook in this case, of tiny vessels in the case of left dysplastic multicystic kidney is appropriate. Bipolar coagulation, LigaSure or ultrasonic scalpel in cases of midsized vessels, as shown in this case of small pyelonephrotic kidney, is another option. A ligature by extra- or intra-corporeal knotting is very safe and could be used in particular situations, for example here because of a short right renal vein, the knot is tied close to the vena cava. Again in the case of complex vascular anatomy, using clips saves time.

6. Kidney mobilization 05'09''

Then dissection using electrocautery or ultrasonic scalpel continues from cephalad to caudad. The upper pole dissection should separate the kidney from the adrenal gland, using an avascular plane. Lastly, the anterior part of the kidney is completely freed and the kidney is totally mobilised. Usually this step is quite easy, but in the case of numerous previous episodes of pyelonephritis, dense adhesions could make the manoeuvre difficult. This is one such case where the adhesions are very dense on the anterior part of the kidney.

7. Ureter mobilization and division 06'00''

In the case of non-refluxing or atrophic ureter, the ureterectomy could be limited to the lumbar part and ligature is not necessary. In cases of refluxing or dilated ureter, ureteric mobilisation should go as low as possible as well as a ligature be applied. In small children, it is possible to remove the lower part of the ureter using the same ports as shown in this video.

8. Specimen extraction 06'31''

The benign nature of most pediatric renal diseases enables removal without concerns for spillage. Specimen extraction is a variable difficulty according to its volume. In case of multicystic kidney, puncture of all cysts makes extraction easier, sometimes morcellation into several pieces and then extraction in a bag. In this case, the pieces are placed in the finger of a glove. This allows extraction without enlargement of the port hole. Of course, enlargement of the first access hole is another solution. Finally, especially in cases of ectopic ureter, it is possible to push the kidney to the lower part of the field and then make a low inguinal incision, extract the kidney and ureter and to resect the ureter close to the bladder or vagina as the case may be. After extraction, the trocar and telescope are reintroduced to check haemostasis. If needed, a drain can be introduced via the inferior cannula.

9. Closure 08'15''

Fascial closure is facilitated by the two stay sutures placed at the beginning. Port sites are then infiltrated with bupivacaine or lignocaine for anesthesia. In conclusion, we have performed over 100 total nephrectomies with good results by this technique. Immediate access to the hilum is a key advantage of retroperitoneoscopy. The lateral position is the safest option if conversion for a vascular problem is needed, even if a learning curve is necessary to reduce peritoneal tears.