Left Radical Nephrectomy

of the aorta and renal hilum. The investing tissue overlying the hilar vessels is grasped with the fingertips, retracted anteriorly, and a plane between these tissues and renal vein is developed using the Harmonic scalpel or scissors. Once the anterior wall of the renal vein is exposed, meticulous dissection allows identification of both the gonadal vein and left adrenal vein entering the renal vein. These veins are dissected free of their surrounding tissues and doubly clipped both proximally and distally.

In some cases we choose not to clip and divide the gonadal and adrenal vessels at this point in the case. We do not want to have clips potentially interfere with the subsequent firing of the linear stapling device across the renal vein later in the case. In other cases the anatomy may be favorable for dividing the renal vein proximal to the adrenal vein, obviating the need for division of the adrenal and gonadal veins as long as the surgeon plans on removal of the adrenal gland with the kidney.

At this point, the surgeon must not be tempted to continue dissection of the renal vasculature from the anterior approach. The key to success of the hand-assisted laparoscopic nephrectomy is obtaining vascular control from a posterior approach, which allows the fingertips to surround the renal hilum, helping with palpation, dissection, and control of the renal artery and vein. In a very rare case, the main renal artery will be easily accessible anteriorly and should obviously be ligated and divided at this point in the procedure.

Dissection now continues at the most inferior lateral portion of Gerota's fascia, identifying the body sidewall and psoas muscle. The fingertips and the dissecting instrument of choice, either electrocautery scissors or Harmonic scalpel, are used to reflect the perinephric fat in a medial and anterior direction off the psoas muscle. The surgeon works from a lateral to medial direction, coming across the gonadal vein, which is doubly clipped proximally and distally and divided. If a radical nephrectomy is performed, the ureter is also identified, clipped, and transected. Obviously, during a nephroureterectomy the ureter is left intact. If a donor nephrectomy is being performed, the periureteral tissue is left intact adjacent to the ureter as well as leaving the ureter intact and dissection of the ureter with all of its surrounding tissue is continued into the true pelvis below the iliac vessels.

The surgeon continues reflecting the inferior pole of the kidney, adjacent perinephric fat, and overlying Gerota's fascia anteriorly and medially, releasing the posterior and lateral attachments to the body sidewall and posterior wall. All lateral attachments are now released up to the level of the adrenal gland as the kidney is reflected anteriorly and medially with the back of the hand. Care must be taken not to enter Gerota's fascia. As the lateral attachments to the inferior aspect of the diaphragm are encountered, the surgeon must be careful not to perforate through the diaphragm. If perforation occurs, rapid loss of pneumoperitoneum will occur, resulting in a tension pneumothorax. Perforations can be closed using hand-assisted laparoscopic suturing techniques; conversion to open nephrectomy may be necessary.

After releasing all lateral and posterior attachments, the kidney can be rolled anteriorly and medially, exposing the posterior aspect of the renal pedicle. The kidney should then be rolled back to its normal position and the tips of the second and third finger are placed just above the exposed anterior aspect of the renal vein. Using the thumb and dissecting instrument, the kidney is now rolled anteriorly and medially and the thumb is placed on the posterior aspect of the renal vessels (Fig. 4). This maneuver helps identify the renal artery by direct palpation and allows for presentation of the artery to the dissecting instruments. Additionally, if bleeding is encountered, the fingers

Fig. 4. The posterior approach to the left renal hilum.

can compress the pedicle achieving rapid hemostasis. Using curved electrocautery shears, a Maryland dissector, or a Harmonic scalpel to dissect the surrounding lymphatic tissue, the posterior and inferior aspects of the renal artery are exposed. Often, a lumbar vein is seen coursing across the posterior aspect of the proximal renal artery. This lumbar vein can complicate exposure and dissection of the renal hilum because it may tether the renal vein or obscure the renal artery. In these situations, the lumbar vein must be clipped and divided. Following this, a right angle dissector is passed around the renal artery, completely freeing the vessel from all remaining attachments. The artery can be controlled using either three locking clips, two proximally and one distally, or by using an endoscopic linear stapling device.

After the renal artery is divided, the renal vein is freed of all surrounding lymphatic and connective tissues, and controlled using an endoscopic linear stapling device or large hemoclips. When the endoscopic stapler is used, great care must be taken not engage any previously placed clips in between the jaws of the stapler. Both visual inspection and palpation with the hand assures that the stapler has not engaged any extraneous tissue or clips. Engaging clips in the jaws of the stapler will cause the device to misfire, resulting in a disruption of the staple line and significant bleeding.

If the adrenal gland needs to be removed with the left kidney, attention is now directed to the most superior phrenic attachments. With the spleen completely mobilized medially, diaphragmatic attachments are identified and controlled using hemoclips or the Harmonic scalpel. There is usually a single artery originating from the diaphragmatic attachment, which must be clipped for adequate control. The remaining vessels can usually be divided using the Harmonic scalpel. Care must be taken to identify any accessory phrenic veins that may exist, coursing from the diaphragm along the medial aspect of the adrenal gland toward the renal vein. These structures can be easily mistaken for the adrenal vein when dissecting in the region of the superior aspect of the renal vein. The superolateral attachments from the adrenal gland to the body sidewall are left intact and the medial attachments to the aorta are divided using the Harmonic scalpel and clips when necessary. The remaining superolateral attachments and posterior attachments are now divided using the Harmonic scalpel or electrocautery scissors and the specimen is completely freed.

If the adrenal gland is to be left intact, use visual inspection and palpation with the fingertips to locate the groove separating the adrenal gland from the kidney. The attachments between the adrenal gland and the superior aspect of the kidney are divided using the Harmonic scalpel. If the adrenal vein has not already been divided, it should be doubly clipped proximally and distally, and sharply transected. Usually a single large arterial branch originating from the renal artery feeds the most inferolateral aspect of the adrenal gland. Hemoclips can be used on this vessel for adequate hemostasis.

Once dissection is complete, the kidney is removed through the hand incision. Oncologic principles are no different in the hand-assisted technique than that of open surgery. The specimen is delivered intact, without the need for morcellation, preserving the pathologic integrity of the specimen. The hand is placed back into the abdomen and pneumoperitoneum is re-established. Adequate hemostasis should be ensured at lower insufflation pressures (5-8 mmHg), confirming vascular control of all arterial and venous structures. Renal hilar vascular stumps are re-examined and any bleeding staple lines or vascular stumps can be controlled with laparoscopic suture ligation.

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