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Laparoscopic Nephrectomy

Dr. SUNIL SHROFFProf.Urology & Renal Transplantation

Sri Ramachandra Medical College & Research Institute

( Deemed University )Chennai, India

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“These are Exciting times to be a Surgeon”

Lord Lister said 100 years ago!!Lord Lister said 100 years ago!!

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Conventional Open Surgery vs

Laparoscopic Surgery

Quantum LeapQuantum Leap

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Suitable Surgery for Zero Gravity

( Weightlessness)

Suitable Surgery for Tele-Mentoring

Maybe suitable Surgery for Tele-

Presence Surgery

Laparoscopic Surgery

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Prof.Kurt Semm, Kiel, Germany

First peep inside body cavity was looking into urethra - 1805

The Father of Laparoscopy SurgeryThe Father of Laparoscopy Surgery

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Laparoscopic Nephrectomy was first performed in 1990 by

Clayman, Kavoussi et al, where they removed the Right kidney from a patient diagnosed with

Renal Oncocytoma

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TRANSPERITONEAL

RETROPERITONEAL

Laparoscopic Approaches to Kidney

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ADVANTAGES OF RETROPERITONEAL APPROACH

Peritoneal cavity not entered -

No Post-op adhesions

Contamination of peritoneal cavity –

Risk Minimum

Injury to Intraperitoneal organs -

Risk Minimum

No Retraction of Intra-abdominal viscera -

Minimum ports

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Minimum Ileus in post- operative period - Faster convalescence

If Previous H/O Intraperitoneal surgeries - Safe

Bowel herniation -Incidence Low

For Retroperitoneal organs -Access direct

ADVANTAGES OF RETROPERITONEAL APPROACH

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DISADVANTAGES OF RETROPERITONEAL APPROACH

Space available to perform surgery- Less

Landmarks in Retro-peritoneum - Few

Learning curve – Steeper

In Inflammatory pathologies like pyelonephritis - Space can be obliterated

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Large tumour mass does not allow - Free manipulation.

Pneumothorax or Pneumo-mediastinum - Higher incidence

Reports suggest that there is - Greater absorption of CO2 due to

fat

DISADVANTAGES OF RETROPERITONEAL APPROACH

Aortic Aneurysm contra-ind. to Retro-peritoneal approach

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COMPLICATIONS OF BALLOON DISSECTION

Loss of Orientation due to inflation in an

incorrect plane

Injury to abdominal muscles due inflation in a

wrong plane

Rupture of peritoneum

Rupture of balloon

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ADVANTAGES OF TRANSPERITONEAL APPROACH

More space is available to perform surgery

The anatomical landmarks are easier to

identify and therefore short learning curve

Large tumour masses are easy to manipulate

in the large peritoneal space

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DISADVANTAGES OF TRANSPERITIONEAL APPROACH

Intra-abdominal adhesions chances –

More

Contamination of Peritoneal cavity by urinary contents -

More

Injury to Intraperitoneal organs –

Risk higher

Previous Intra-peritoneal surgery –

Not suitable

Bowel Herniation –

Risk higher

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• Operation starts by retracting the colon (splenic flexure) downward by cutting on the line of Todlt. This maneuver exposes Gerota’s fascia

• Colon retracted medially and inferiorly exposing Gonadal vessels • Ureter is the first structure to be identified. Once a window is made, this helps in retraction during further dissection •Dissection of Renal hilum can be tedious. Artery and vein should be identified and ligated. The artery first Isolated and divided between 9 or 11 mm Titanium clips.• This is followed by ligation and division between clips of the renal vein. Can use an Endo GIA stapler to secure the vein

Transperitoneal left Nephrectomy

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• This is followed by ligation and division between clips of the renal vein. Can use an Endo GIA stapler to secure the vein

• The kidney is lifted up once vessels of the hilum has been divided. Blunt dissection continues dividing any remaining attachments to Retroperitoneum• The ureter is divided and Kidney ready for retrieval• Kidney is placed in a plastic bag using the grasper holding the organ by the ureter• When dealing with renal cancer, a 6 cm incision is made in abdominal wall to allow specimen to be retrieved under minimal tension. The plastic bag should be protecting the skin all the time.

Transperitoneal left Nephrectomy…

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Laparoscopic Hand Assisted Nephrectomy

Laparoscopic Hand Assisted Nephrectomy

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Why Laparoscopic Hand-Assisted Nephrectomy

“Delivery of kidney anyway requires a

6 to 9 cm incision at the end. So it is only

logical to use this incision as a port to help

with retraction and dissection of the organ

right from start of the surgery”

“Delivery of kidney anyway requires a

6 to 9 cm incision at the end. So it is only

logical to use this incision as a port to help

with retraction and dissection of the organ

right from start of the surgery”

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HAND IS THE MOST VERSATILE INSTRUMENT

( To Feel, to dissect, To Retract & For Knot-Tying)

HAND IS THE MOST VERSATILE INSTRUMENT

( To Feel, to dissect, To Retract & For Knot-Tying)

Why Laparoscopic Hand-Assisted Nephrectomy

‘Endohand’ for laparoscopy - undergoing trial ( Jackman – 1999)

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I. Compared to hand, Instruments reduce Sensory

perception by a factor of 8

II. Conventional laparoscopic procedures – Steep

learning Curve

1. Operating looking at “Pixels”

2. Hand Eye co-ordination

3. Unlearn old habits

4. Not part of PG training programme

5. Unless practice regularly loose dexterity

Why Laparoscopic Hand-Assisted Nephrectomy

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1994 Tierney et al reported - Hand assisted

Spleenectomy, Colectomy & Nephrectomy

1995 Cuschieri & Shapiro – Pneumo-peritoneum Access

Bubble

1996 Bannenberg et al – devised Pneumosleeve – to

preserve pneumoperitoneum

1997 Wolf et al reported – OR time with pneumosleeve

for nephrectomy less by 85 mins

1998 Schichman et al - Efficacy, safety and recovery

with hand assisted nephrectomy similar to

conventional laparoscopic surgery and superior to

open surgery.

HISTORY – Laparoscopic Hand Assisted Nephrectomy

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I. No difference in:

a. Post operative Pain

b. Return of Bowel function

c. Duration of Convalescence

II. Less number of complications

III. Operation time less by 85 min (Wolf - 1997)

Laparoscopic Hand Assisted Nephrectomy Versus Conventional Laparoscopic Nephrectomy

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Pneumo-Sleeve for Hand Assisted Laparoscopy

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Advantages of Hand-assisted Laparoscopy Donor Nephrectomy

Tactile Sensation

Blunt dissection

Quicker dissection

Intact Specimen Removal

Ability to apply Digital pressure

Quick learning curve

Decreased OR Time

Shorter Warm Ischemia time for Donor

Nephrectomy

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Laparoscopy For Benign Renal Disease

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Laparoscopic Nephrectomy for benign

Renal disease Laparoscopy Abalation of Renal Cyst Hydronephrosis – NF Kidney Chr. Pyelonephritis ESRD Renal hypoplasia

Xanthogranulomatous Pyelonephritis –Relative Contra-ind to lap. Nephrectomy

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Laparoscopy Abalation of Renal Cyst

Transperitoneal preferred If Retroperitoneal approach – port

inserted under vision Send wall for histology Recurrance can again be approached

laparoscopically

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Retroperitoneal approach preferred

UPJ obstruction with Extra-renal pelvis

Excellent long term results reported

300 telescope Preferred

Laparoscopic Pyeloplasty

Operating time initially 6 to 8 hrs, currently 3 hrs

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Laparoscopic Pyelolithotomy

Indication Failed ESWL Failed PCNL Ectopic Kidney Renal calculus with UPJ obstn. Where

dismemembered pyeloplasty planned

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Laparoscopic PyelolithotomyTechnique:

Ureteral catheter or DJ stent placed before positioning patient

Sling the ureter

Palpate stone between cannula and dissector

Transverse incision on pelvis using a cold knife

DJ pushed once stone removed into renal pelvis

Close Pyelotomy

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Laparoscopic Donor Nephrectomy

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History - Laparoscopic Live Donor Nephrectomy

1994 - Porcine Model – Gill et al.

1995 - 40 yrs old Lap Donor nephrectomy – Ratnor et al

( Kidney removed with 9 cms incision at end of procedure )

Since then over 2000 Lap. live Donor Nephrectomy

performed world-wide

Mostly left kidney preferred for lap. donor Nephrectomy

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Issues - Laparoscopic Donor Nephrectomy

Warm Ischemia Time

Complication Rate

Vascular Pedicle

Rejection Episodes

Long term Graft outcome

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Laparoscopic Donor Nephrectomy Vs Open Donor Nephrectomy

Novick (1999) – Compared outcomes of 132 Recipient of Lap. Nephrectomy versus 80 Recipients of open

Nephrectomy

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1. Serum Creatinine - 1 week to 1 month after Transplant significantly higher in Laparoscopic group compared to open group

Serum Creatinine - 3 & 6 months similar in both groups

2. Number of Ureteral complication higher in Lap. group compared to open group

Laparoscopic Donor Nephrectomy Vs Open Donor Nephrectomy

Current series show complication rate higher during early part of experience. Later on there is no statistical

difference

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Arguments for Laparoscopic Donor Nephrectomy

Smaller Scar, Less post-operative pain and Early Return to work

Resulted in 55% Increase in Live Donor rates in most of the units offering Lap. Donor Nephrectomy

Worldwide on an average 38,000 kidney transplants done every year however 150,000 patients added to waiting list

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Laparoscopic Nephrectomy for Renal cell carcinoma

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Issues – Lap Nephrectomy for RCC

Prolonged operating time

Complication rates

Specimen Extraction

Potential for Tumour Spread

Port site Recurrence

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Op. Time - 5.9 hrs lap vs 2.8 hrs open ( Clayman 1997)

Specimen extraction - Lapsac & Morcellation

Tumour spread – No difference

Port site recurrance - Rare

Complication – Similar to open 5 yrs Survival – 95.5% lap vs 97.7% open

( Ono 1999)

Issues – Lap Nephrectomy for RCC

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Lap. Nephrectomy - RCC

Indication - T1-T2 N0 M0 Transperitoneal approach preferred 3 to 4 ports

Advantages: Less Blood loss than open Less Analgesia Less Hospital stay

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Newer Treatment Modalities for RCC and Laparoscopy

Cryo-abalation - Peripheral Renal

tumour below 4 cms

High Intensity Focussed Ultrasound

Interstitial Contact laser

Radio frequency abalation

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Tele-mentoring

Tele-mentoring is guiding surgical and

other clinical procedure from a remote

distance by a mentor

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Tele-Mentoring in Urology

Tele-Mentoring at John Hopkin’s for 14

advanced & 9 Basic urology procedures

Telestrator and Robotic arm used

Operative time not statistically different

96% success with no complications

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CONCLUSION

Live Donor Laparoscopic Nephrectomy

likely to become the commonest Indication

for lap. nephrectomy Hand-Assisted Lap Nephrectomy will be

practised more commonly for Abalative

Renal Procedures Reconstructive Renal procedures likely to be

tackled by conventional Laparoscopic

Techniques

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THANK YOUTHANK YOU