Transperitoneal laparoscopic radical nephrectomy

作者群

摘要

The description of the transperitoneal 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: left pedicle, right pedicle, dissection of lumbar fossa, specimen extraction.
Consequently, this operating technique is well standardized for the management of this condition.

關鍵字

laparoscopy,radical nephrectomy,transperitoneal approach

媒體類型

刊物

2004-10

普通的

最愛

音訊

數位出版

WeBSurg.com, Oct 2004;4(10).
URL: http://www.websurg.com/doi-ot02en289.htm

Transperitoneal laparoscopic radical nephrectomy

1. Introduction

The first laparoscopic radical nephrectomy was described in 1991 (Clayman et al.). Several surgical teams who use this technique have reported oncological results equivalent to those conferred by open radical nephrectomy (Portis et al., 2002) and have found this minimally invasive technique superior in terms of postoperative recovery (Siqueira et al., 2002; Kim and Schulam, 2001).

Three approaches to laparoscopic radical nephrectomy have been developed:
1. The transperitoneal laparoscopic approach;
2. The retroperitoneal laparoscopic approach;
3. The hand-assisted technique.
This chapter presents the transperitoneal 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 each side of the spine and of the large vessels. The perinephric fat, limited by Gerota’s fascia, surrounds them. Posteriorly, a plane between Gerota’s fascia and the transversalis fascia is easily dissected, and is called the posterior pararenal space. Similarly, the anterior pararenal space, which is limited by Gerota’s fascia and the posterior parietal peritoneum, is found anteriorly.
In a radical nephrectomy, the dissection takes place outside Gerota’s fascia, in the fibrofatty tissue of the posterior and anterior pararenal spaces.

• Renal pedicle

• Left

1. Gonadal vein
2. Ascending lumbar vein/second lumbar vein
3. Adrenal vein
The left renal artery originates on the left lateral surface of the aorta, practically at the level of the ligament of Treitz.
The left renal vein and its branches are situated ventral to the artery in the dissection plane of Toldt’s fascia. The gonadal vein runs parallel and anterior to the ureter. The adrenal vein is encountered on the superior margin of the renal vein, in a more medial position. The second lumbar vein takes off from the posterior surface of the renal vein.

• 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. More cephalad, the renal vein joins the vena cava on a course that is often very short. The renal artery is situated inferior and posterior to the renal vein. 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 right kidney is bordered anteriorly and superiorly by the liver (upper pole and adrenal gland), anteriorly by the right colon, and medially by the duodenum, which covers the right renal hilum.

• Left side

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

3. Indications

Both transperitoneal and retroperitoneal laparoscopic approaches confer results that are equivalent to open surgery for stage T1 kidney cancers (localized tumors <=7 cm) (Portis et al., 2002).
With larger localized tumors (>=7 cm), laparoscopy is not advantageous because of the large incision required to extract the specimen. Nevertheless, certain teams using the morcellation technique for extraction of the specimen extend the indications to include stage T2 cancers.
Local spreading to the perinephric fat or to the renal vein are absolute contraindications to the laparoscopic technique.
The role of laparoscopic radical nephrectomy for metastasized tumors is controversial and is being studied (Walther et al., 1999). It may have a role in the context of research protocols on immunotherapy, to reduce tumoral burden before treatment.
Past intraperitoneal surgery is not a contraindication to the transperitoneal approach, but adhesions might have to be taken down.

4. Preoperative management

Kidney tumors are often incidentally discovered during an abdominal ultrasound.
CT scan of the abdomen and pelvis, with and without injection of contrast medium, is the key diagnostic tool. It provides useful information on the stage of the tumor, its local and regional extension, the presence or absence of a renal vein thrombus and of liver metastases, and the condition of the contralateral kidney.
An MRI may be indicated to rule out an angiomyolipoma, or to evaluate the extension of a caval thrombus more precisely.
A chest X-ray is always performed. If the patient presents with other symptoms, a brain CT scan, bone scan or chest CT scan are included in the workup.
The patient is kept NPO at midnight the day of surgery. Determination of blood type and a crossmatch are carried out. Prophylactic antibiotic therapy with a second generation cephalosporin is administered. Deep vein thrombosis prophylaxis with low molecular weight heparin is begun on the day of surgery. Bowel preparation is not required.

5. Operating room setup

• Patient

- general anesthesia;
- right or left lateral decubitus, contralateral to the side to be operated on;
- anterior abdominal wall at the edge of the table;
- an optional cushion can be useful in case of conversion;
- the patient is maintained in place with 2 supports placed posteriorly at the level of the sacrum and the shoulders;
- adhesive strips are placed at shoulder and hip level to secure the patient to the table;
- urinary catheter.
The arm against the table is positioned perpendicularly on an arm rest. The other arm is placed parallel to the first on another arm rest, or secured to the bar or arch placed above the patient.

• Team

1. The surgeon stands in front of the patient, closer to the feet for a right nephrectomy and closer to the head for a left nephrectomy.
2. The assistant stands on the surgeon’s right, for both right and left nephrectomies.
3. The scrub nurse (optional) stands in front of the patient, near the feet.

• Equipment

1. Video unit and monitor are placed behind the patient.
2. Insufflation system
3. Suction device
4. Monopolar and bipolar cautery

6. Major principles

Radical nephrectomies are performed following the principles of Robson (Robson et al., 1969):
1. Early ligation and division of the vessels;
2. Removal of the kidney with Gerota’s fascia and perinephric fat, including adrenal gland;
3. Dissection of the hilar lymph nodes.
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 to obtain precise staging, but its therapeutic utility has not been proven (Blom et al., 1999).

Advantages of the transperitoneal approach as compared to a retroperitoneal approach:
- the intraperitoneal space exists naturally and is larger than the space created by a retroperitoneal approach;
- anatomical landmarks are identified more easily;
- the work space is larger;
- intraperitoneal exploration is possible (exploration of the liver, for example).

Disadvantages of the transperitoneal approach:
- need to mobilize the colon before approaching the kidney, especially on the left side;
- risk of injury to intraperitoneal organs;
- presence of intraperitoneal adhesions that must be taken down in case of previous surgery.

There is virtually no risk of intraperitoneal tumoral seeding if the tumor does not invade the perinephric fat.

7. Trocar placement

• Landmarks

The landmarks used for trocar placement are:
- the umbilicus, the lateral edge of the rectus abdominis muscle, the costal margin, the anterior superior iliac spine.
The first trocar is placed using an open approach. It can be placed after creation of a pneumoperitoneum using a Veress needles, or directly, by lifting the abdominal wall. The other trocars are inserted under laparoscopic visual control.

• Trocar position

• Right nephrectomy

The size and position of the trocars are as follows:
A: 10-12 mm, on the lateral margin of the rectus abdominis muscle, at the level of or 2 to 3 cm superior to the umbilicus. If insufflation has not yet been performed with a Veress needle before introduction of this trocar, it is essential to insufflate the peritoneum before placing the other trocars. Trocar placement is never the same depending on whether or not the abdomen is insufflated.
B: 12 mm, 5 to 7 cm lateral to A, sometimes slightly cephalad. The A-B axis constitutes the principal axis of surgery. The position of B may vary according to the patient’s body habitus, but trocar B should always be placed in a position that allows the surgeon to work comfortably.
C: 5 mm, 2 cm medial to and sometimes superior to the anterior superior iliac spine.
D: 5 mm, below the costal margin on the same line as C. Trocars B, C and D are joined by a straight line, or a curvilineous line looking medially. C and D must be sufficiently away from B to avoid trocar conflict.
E: a fifth trocar is often useful to retract the liver. It is placed 3 cm medially to trocar D for a right nephrectomy.

• Left nephrectomy

The size and position of the trocars are as follows:
A: 10-12 mm, on the lateral margin of the rectus abdominis muscle, at the level of or 2 to 3 cm superior to the umbilicus. If insufflation has not yet been performed with a Veress needle before introduction of this trocar, it is essential to insufflate the peritoneum before placing the other trocars. Trocar placement is never the same depending on whether or not the abdomen is insufflated.
B: 12 mm, 5 to 7 cm lateral to A, sometimes slightly cephalad. The A-B axis constitutes the principal axis of surgery. The position of B may vary according to the patient’s body habitus, but trocar B should always be placed in a position that allows the surgeon to work comfortably.
C: 5 mm, 2 cm medial to and sometimes superior to the anterior superior iliac spine.
D: 5 mm, below the costal margin on the same line as C. Trocars B, C and D are joined by a straight line, or a curvilineous line looking medially. C and D must be sufficiently away from B to avoid trocar conflict.
E: a fifth trocar is often useful to retract the left mesocolon. It is placed 3 cm medially to trocar C for a left nephrectomy.

8. Instruments

• Instruments

The following instruments are required for the performance of a transperitoneal radical nephrectomy:
1. 0° laparoscope
2. Monopolar scissors
3. Ultrasonic scissors (depending on availability and surgeon’s preference)
4. Bipolar forceps
5. Grasper
6. Vascular stapler
7. 5 mm clip applier
8. Suction device
9. Retrieval bag
10. Urinary catheter

• Instruments/trocars

• Right nephrectomy

The instruments are inserted in the following trocars for a right-handed surgeon:
A: laparoscope
B: monopolar or ultrasonic scissors; vascular stapler, clip applier
C: grasper or bipolar forceps
D: grasper
E: forceps to retract liver by grasping the subhepatic peritoneum
For a right nephrectomy, the surgeon uses trocars B and C and the assistant uses trocars A, D and E.
The suction system can be introduced through trocars B, C, D or E.

• Left nephrectomy

For a left nephrectomy:
A: laparoscope
B: monopolar or ultrasonic scissors; vascular stapler, clip applier
C: grasper
D: bipolar forceps or grasper
E: forceps to retract the left mesocolon by grasping the peritoneum
For a left nephrectomy, the surgeon uses trocars B and D, the assistant uses trocars A, C and E.
The suction system can be introduced through trocars B, C, D or E.

9. Left pedicle

• Principles

The left pedicle can be accessed in two different ways: after mobilizing the colon or via a direct aortic approach.

• After colon mobilization

• Principle

1. Left iliopsoas muscle (left psoas muscle)
2. Left gonadal vein
3. Ureter
The descending and sigmoid colon are mobilized laterally, from the sigmoid loop to the splenic flexure.
After the left colon is mobilized, the left psoas muscle and the left gonadal vein on its medial border are identified. The vein must not be misidentified with the left ureter, which lies more medially and posteriorly.

• Dissection/renal vein

1. Adrenal vein
2. Renal vein
3. Second lumbar vein
4. Gonadal vein
The left gonadal vein is followed cephalad, and leads to the renal vein. The vein is dissected posteriorly and anteriorly. With experience and when the anatomy is not obliterated by adipose tissue, the surgeon can approach the renal vein directly. The gonadal vein is at this stage clipped and divided. The adrenal vein is identified on the superior border of the renal vein. It may be clipped and divided at this point if an adrenalectomy is indicated.
Posteriorly the second lumbar vein is identified, and is kept inside the dissection plane.

• Renal artery

The main trunk of the renal artery is identified posteriorly to the renal vein, deep in the middle of a cellular-lymphatic tissue. This artery is often dissected inferiorly to the vein. Sometimes it is necessary to dissect the artery superiorly to the vein as shown on the illustration.
The renal artery is dissected free, and clipped three times proximally and twice distally, then divided between clips. More often, there is space for only one or two clips on the artery. This helps to stop the renal blood flow and facilitates the dissection of the vein. When the vein has been dissected, the dissection and division of the artery can be completed.

• Renal vein

After arterial control is ensured, the dissection of the empty renal vein continues to allow the passage of a vascular stapler.
The vascular stapler must be placed appropriately in order to avoid a partial division of the vein. Perfect control of the positioning of the linear stapler is of utmost importance to avoid including the stump of the artery into the staple line.
It is also important to make sure that the clips of the adrenal and genital vein are not trapped into the linear stapler.
As shown on the illustration, the grasper held by the assistant controls the vein caudally to the linear stapler (towards the vena cava), thus preventing any bleeding from the inferior vena cava in case of malfunctioning of the stapler.
Once the renal vein is divided, the dissection, clipping and division of the artery can be completed.

• Direct aortic approach

1. Treitz muscle
2. Renal artery
3. Gonadal artery
The dissection of the left renal pedicle may be done by first approaching the renal artery at its take off from the left side of the aorta.
The dissection begins with mobilizing the angle of Treitz just caudad to the inferior mesenteric vein.
The anterior surface of the aorta is thus exposed.
The left renal artery is the only artery that takes off from the lateral side of the aorta at this level, and is easily identified. The gonadal artery is much thinner and originates from the anterior surface of the aorta. The renal artery is clipped.
If the dissection space is large enough, the renal artery can be clipped three times proximally and twice distally, then divided between clips.
The vein is then dissected on its course over the aorta and divided with a linear vascular stapler.
It is also possible to deal with the vein later, after having mobilized the colon, as described above.
The main advantage of the latter technique is a dissection that is facilitated by the empty and flat renal vein.

10. Right pedicle

• Principles

The right pedicle may be approached in two ways, either by mobilizing the colon, or by a direct subhepatic access.

• After colon mobilization

• Dissection/renal vein

1. Exposure of second portion of duodenum
2. Inferior vena cava
3. Right renal vein
4. Gonadal vein
The first 10 cm of the right colon and the hepatic flexure are mobilized.
The second portion of the duodenum is then dissected posteriorly. The anterior surface of the vena cava is thus exposed.
The dissection of the right border of the inferior vena cava cephalad towards the liver exposes the take off of the right renal vein. This structure is dissected on its anterior, posterior, inferior and superior sides. The gonadal vein lies far below, and drains directly into the inferior vena cava. If it needs to be removed along with the nephrectomy specimen, it can be clipped and divided at this stage. In some cases, it can be preserved.

• Renal artery

The renal artery enters the renal hilum crossing the posterior surface of the inferior vena cava.
After the posterior dissection of the junction of the right renal vein and vena cava, the trunk of the renal artery is identified.
The renal artery is dissected free, clipped three times proximally and twice distally, then divided between clips. More often than not, as described on the left side, one or two clips should be applied on the artery in order to stop the renal blood flow and control the empty vein. The artery control can then be completed after the renal vein.

• Renal vein

Once the control of the renal artery is achieved, the dissection of the renal vein, which is now empty, can be completed to allow the passage of the linear stapler.
The vascular stapler must be placed appropriately in order to avoid a partial division of the vein. A perfect control of the positioning of the linear stapler is of utmost importance to avoid taking the stump of the artery into the staple line.
It is also important to make sure that the clips of the adrenal and genital vein are not trapped into the linear stapler.
Before the vein is divided using the mechanical stapler, the inferior portion of the stapler is controlled to check that the wall of the vena cava is not trapped into the staple line.
Once the renal vein is divided, control of the artery is completed if necessary.

• Sub-hepatic approach

1. Kidney
2. Liver
3. Inferior vena cava
The inferior border of the liver is retracted ventrally by a grasper introduced in trocar D. The peritoneal attachments along the course of the inferior vena cava are incised, exposing the inferior vena cava.
The anterior surface of the vena cava is dissected and the origin of the renal vein is identified.
The renal vein may often be accessed without mobilization of the colon at this stage of the procedure. Mobilization of the duodenum only can sometimes be necessary.
The rest of the dissection of the renal pedicle is performed as described above. The colon must be mobilized at the end of the dissection to allow access to the lower pole of the kidney, but the mobilization is not as extensive as it is on the left side.

11. Dissection/lumbar fossa

• Dissection/psoas muscle

1. Psoas muscle
Once the renal pedicle is controlled and divided, the dissection is continued posteriorly until the psoas muscle is reached.

• Adrenal vessels

• Left nephrectomy

The dissection is carried cephalad, along the plane of the psoas muscle and following the lateral border of the aorta, which reveals the adrenal veins and arteries. These vascular structures are clipped and divided. The dissection stops at the diaphragm.
In cases of a tumor of the lower pole of the kidney, the adrenal gland is preserved. The plane of dissection passes in that case between the upper pole of the kidney and the adrenal gland. The inferior adrenal pedicle only is clipped and divided.

• Right nephrectomy

After the division of the pedicle, the dissection follows the right border of the inferior vena cava.
The inferior border of the adrenal gland is exposed and is progressively dissected off the vena cava. The inferior adrenal vein is then exposed and divided between two clips.
The medial side of the adrenal gland is dissected, and the upper and middle adrenal pedicles are progressively divided.
The dissection ends at the diaphragm.
In case of a tumor of the lower pole of the kidney, the adrenal gland is preserved. The dissection plane in this case passes between the upper pole of the kidney and the adrenal gland. This often allows the preservation of all adrenal pedicles, the inferior pedicle included.

• Ureter

The dissection is continued caudad, following the plane of the psoas muscle.
The ureter is identified and divided between clips.
It is sometimes necessary to divide the gonadal vein again at that level, after having clipped it, if it is to be included in the specimen. In that case, this vein has already been clipped at its junction with the vena cava.
When the gonadal vein is preserved, the dissection plane passes between it and the ureter.

• Gerota’s fascia

The lymph node dissection is continued outside of Gerota’s fascia, along the lateral abdominal wall, dividing the attachments of the kidney.

12. Specimen extraction

• Strategy

The kidney is retracted cephalad by the surgeon and assistant.
Trocar C is retrieved and replaced by an extraction bag.
The bag is opened and completely unfolded, to allow insertion of the specimen, including fatty tissues and the ureter.

• Extraction

The incision of trocar C is elongated to 5 or 6 cm, and the retrieval bag is exteriorized through this incision. If another scar is already present, it can be used alternatively.

• End of procedure

The pneumoperineum pressure is lowered to detect any hemorrhage. The trocars are retrieved under direct vision. A closed suction drain is put in through the trocar opening that is placed in the most declive position.
The extraction incision is closed in layers, and the skin is closed with staples.

13. Postop period

The nasogastric tube is taken out on postoperative day one. The patient is put on a progressive liquid diet when GI transit resumes. The urinary catheter is taken out. The closed suction drain is taken out when the drainage is inferior to 50 cc, on postoperative day two at the latest. The patient usually leaves on postoperative day 4 to 6.
First postoperative visit takes place one month after surgery. Blood ionogram and creatinine levels are checked to assess the function of the remaining kidney, with an abdominal ultrasound or CT scan.

14. Conclusions

Laparoscopic radical nephrectomy respects the same oncological principles described by Robson for the treatment of renal cancer. Its use is limited to intraparenchymal tumors of a size of 7 cm or less. Laparoscopic radical nephrectomy has become in many centers the procedure of choice because of its low morbidity. The choice of a transperitoneal or retroperitoneal approach are a matter of surgical schools and surgeon’s preference.

15. Reference

使用者名稱
密碼
	記得我 (必須啟動Cookies設定)