Nephrectomy : Operative Technique

Describes in details about the different types of nephrectomy.

1. Operative techniques: Nephrectomy Presenter : Dr Sangamesh S K Moderator: Col S Tripathy

2. Overview of presentation Surgical anatomy Indication of Nephrectomy Types of Nephrectomy Simple, Partial & Radical nephrectomy Donor Nephrectomy Different technique of Nephrectomy Complications

3. Surgical anatomy Bean shaped organ Location: Retroperitoneal Extend :- T12-L3 Two surface ( anterior & posterior) Two pole (superior & inferior) Two border (medial & lateral)

4. Position Lies psoas muscles : Longitudinal axes oblique Upper poles more medial & posterior Medial aspect rotated anteriorly : 30 degrees Right kidney : L1 top – L3 bottom Left kidney : T12- L3

5. Anterior relation of kidney

6. Posterior relation of kidney

7. Axial section imaging

8. Renal vasculature

9. Segmental blood supply

10. Arterial supply

11. Indication of Nephrectomy Severe trauma Renal infection Xanthogranulomatous & Emphysematous Pyelonephritis Malignancy Non functioning kidney Stones & obstruction Renal fistula Renal vascular Hypertension All medical & surgical therapy have failed Transplantation

12. Types of Nephrectomy Simple Nephrectomy R emoval of kidney within Gerota fascia Partial Nephrectomy Small-sized renal cancer Benign diseases- excised renal capsule ( renorrhaphy ) Radical Nephrectomy Complete removal of kidney outside Gerota fascia Ipsilateral adrenal gland Complete regional lymphadenectomy ( crus of diaphragm - aortic bifurcation)

13. Types of nephrectomy Adrenalectomy Indicated : Diffusely involving tumor Large tumor size (>10 cm) Extrarenal tumor extension Tumor thrombus L ymphadenopathy & regional metastasis A drenal mass on imaging

14. Different surgical approach Open approach of Nephrectomy Laparoscopic Transperitoneal Retroperitoneal Hand assisted Robotic assisted

15. Pre- op evaluation Global assessment of pt’s renal function is done: Urine analysis & culture Serum Creatinine GFR evaluation C ardiac & pulmonary status: P ositioning & bleeding Cross sectional i maging (CT/MRI) :- Surgical planning Locally advanced metastatic lesion : Screen hepatic status ( stauffer syndrome) Renal Artery Embolisation (RAE) : Large tumor

16. Instruments General set Abdominal drainage tube Self-retaining retractors : omni tract, balfour Long genitourinary surgical instruments Bulldog &/or Satinsky vascular pedicle clamps Mixters right angle forceps Bulldog arterial clamp Retractor- doyen’s and deiver’s Kidney pedicle clamp

17. Positioning Induction & ET tube placement Catheterization done Pt : Lateral decubitus Table flexed b/w iliac crest & costal margin Head supported: Avoid excessive flexion Pt back supported by blanket Dependent leg flexed & top leg straight All pressure point : padded surface Pt secured to table : tape

18. Surgical approach to kidney

19. Anterior approach of kidney INCISION INDICATION BENEFIT LIMITATION Midline Transperitoneal Trauma, IVC Thrombus , B/L Renal or Ureteral disease , Horseshoe Rapid ,Early vascular control , Access both kidney Limited exposure to kidney & bowel Subcostal Radical nephrectomy , UPJO Incision can extend to chevron , early vascular control Bowel complication Hilum access poor Chevron B/L renal tumor , IVC thrombus Excellent b/l exposure , Injury to Liver , Spleen , Transection of large muscle Transverse abdominal Wilms tumor Easy access to pedicle & retroperitoneal node Modified Thoracoabdominal Radical nephrectomy , lymphadenectomy versatile Bowel complication, Transection of large muscle

20. Flank incision INCISION INDICATION BENEFIT LIMITATION 11 th or 12 th rib supracostal Partial nephrectomy , & Simple nephrectomy Good renal & retroperitoneal exposure Pleural injury 11 th rib Transcostal Partial and Simple nephrectomy Good renal & retroperitoneal exposure Pleural injury & Noticeable flank defect Thoracoabdominal Large renal mass , IVC thrombus , involvement of surrounding structure Excellent exposure , Can approach completely extraperitoneally Pleural injury , Transection of large muscles,

21. Steps of flank approach

22. After Gerota fascia incised & kidney is dissected free from surrounding perinephric fat. Renal artery identified & ligated before vein Renal vein ligated

23. Simple nephrectomy Indications Poor functionaing kidney Obstruction , infection, trauma, stones, nephrosclerosis , vesicoureteral reflux, polycystic kidney, or congenital dysplasia Functional kidney Relieve intractable symptoms : bleeding, pain, hypertension, or persistent infection

24. Simple nephrectomy Flank incision : retroperitoneal access R enal fascia incised , perirenal fat is separated from kidney Aberrant vessels : near the poles Large hydronephrotic : puncture and aspirate Adrenal dissectd in upper pole Lower pole mobilised and ureter isolated Division of ureter : access to hilar structures

25. Right kidney approach

26. Approach Incise along white line of Toldt frees the colon Duodenum is reflected Exposure of anterior Gerota fascia A nterior surface IVC exposed Care taken not to injure pancreas, gonadal vein, adrenal vein, or accessory renal vessels Main renal vein is mobilized Posterior to renal vein along its superior margin lies renal artery

27. Left kidney approach

28. Radical nephrectomy : Right Additional mobilization of liver, avascular Rt triangular ligament is incised White line of Toldt : pelvis to hepatic flexure 2 nd part of duodenum : Kocher maneuver Dissection anterior to IVC : Identification of renal vein & gonadal vein Ligature of ureter below : kidney lifted , artery more exposed Difficult hilar dissections : Dissect in the interaortocaval region Lumbar veins close approximation

29. Radical nephrectomy : left White line of Toldt : splenic flexure to descending colon is reflected medially. Renocolic ligament is divided and extreme care is taken to avoid injury to the tail of the pancreas Left renal vein is identified using the anterior surface of the aorta as a guide Left renal artery is usually located cranial and posterior to the left renal vein Further mobilization of the lower pole of the kidney, the left ureter and the left gonadal vein

30. PARTIAL NEPHRECTOMY:- INDICATION 1) Absolute:- i ) Single kidney ii) Bilateral renal tumor iii) Severe renal failure 2) Relative:- i ) Abnormal contralateral ii) Metabolic disease associated with renal failure iii) Genetic syndrome with tumor multifocality ( e.g VHL syndrome) 3) Elective:- i ) Tumor < 4cm in young & healthy pt ii) Peripheral tumor

31. Partial Nephrectomy : Relative Contraindication Technical issue Cold ischemia time >45min (consider extracorporeal approach) Less than 20% of global nephron mass retained Cancer related issue Diffuse encasement of renal pedicle by tumor Diffuse invasion of central collecting system Tumor thrombus involving major renal veins Adjacent organ invasion (stage cT4) Regional lymphadenopathy (stage cTxN1)

32. Partial nephrectomy Avascular plane : Segmental artery clamping 5ml Indigo carmine : clamped artey Cooled down to 20 o Hyperfiltration injury : Over decades, FSGS : proteinuria and progressive renal failure (nephron mass reduced by 80%) Vascular clamping: I schemia & hypothermia

33. Partial Nephrectomy :- Wedge Resection

34. Partial Nephrectomy: S egmental Polar Resection

35. Complication of partial nephrectomy Urinary fistula Post operative bleeding Renal insufficiency

36. Wound closure Hemostasis and evaluate adjacent organs for any signs of injury Pleural injury, retroperitoneum is filled to level of the flank incision with saline. anesthesiologist then inflates lungs with high inspiratory volumes Bubbling of saline irrigation in the retroperitoneum with deep inspiration would suggest a pneumothorax Fascial layers approximated : two layers Transversus abdominis & internal oblique fasciae are approximated together External oblique fascia is approximated as a separate layer

37. Donor Nephrectomy Kidney is mobilized, only remaining attachments are the ureter , renal vein, and renal artery 12.5 g of mannitol and 20 mg of furosemide are rapidly infused intravenously Immediately after dividing renal vessels , placed on workbench : Pan of ice slush covered with a towel. Flushed intra-arterially by gravity flow with renal preservation solution at 6°C Flushing should continue until it is cooled & renal effluent is clear (~500 to 1000 mL ) K ept in ice slush basin during procedure : Hypothermia

38. Donor nephrectomy Renal artery & vein are flushed independently with preservation solution : Bleeding Retrograde flushing of ureter : Collecting system leaks Transplanted into either lower quadrant, transferred to iliac fossa Renal vein anastomosed : External iliac vein . Renal artery anastomosis End-to-end anastomosis to hypogastric artery End-to-side anastomosis with external iliac artery

39. Donor nephrectomy During anastomosis, vessels should be irrigated : Heparin solution (10,000 U Heparin in 100 mL NS) Surgeon should consider injecting 1 0 mg Verapamil into renal artery following anastomosis : Vasodilation . U reter is implanted into dome of bladder with a tension-free anastomosis Prior to completion ureteral anastomosis: Ureteral stent is placed

40. Complication of Open Nephrectomy Hemorrhage Small bowel obstruction Pneumothorax Pneumonia DVT Superficial wound infection Bowel injury

41. LAPROSCOPIC NEPHRECTOMY SURGICAL APPROACHES:- Transperitoneal Retroperitoneal Hand-Assisted

42. TRANSPERITONEAL RETROPERITONEAL HAND-ASSISTED Small incision & gives advantage for trocar placement Limited working space ,result in difficulty in orientation , trocar spacing , & organ entrapment Bridge b/w lap & open surgery Affords optimal working space Preferred in pt with h/o multiple abdominal procedure or pt with peritonitis Permits tactile feedback Also preferred in pt with abnormality of posterior surface ( exophytic cyst or mass) Allow the hand to assist with dissection , retraction , extraction & rapid control of bleeding

43. PATIENT EVALUATION & PREPARATION Prior abdominal surgery Transperitoneal & retroperitoneal Pt positioning , P lacement of trocars Pre-op abdominal CT :- useful in surgical planning Rest of evaluation similar to open nephrectomy

44. Patient positioning & trocar sites

45. OPERATING ROOM

46. Procedure of transperitoneal approach Reflection of colon Dissection of ureter Identification of renal hilum Securing of renal blood vessel Isolation of upper pole Organ entrapment

47. Retroperitoneal Approach Retroperitoneal approach used for posterior or lower pole lesion Pt in full flank position ,10mm trocar is placed in posterior axillary line , halfway b/w iliac crest & 12 th rib Pneumo-peritonium is established & anterior wall is identified with gentle dissection of retroperitoneal fat

48. Retroperitoneal approach

49. Retroperitoneal Approach Second 12mm port is placed under direct vision in anterior axillary line A third port 5mm is placed superior to 2 nd port below rib cage Using the perinephric fat to elevate kidney , surgeon readily sees the lower pole & posterior surface

50. Complication of laparoscopic renal surgery Access related problems :- Solid organ injury Bowel injury Abdominal wall hematoma Epigastric vessel injury Hemorrhage Pneumonia Pulmonary embolus Unrecognized bowel injury Incisional hernia :- after intact specimen removal

51. Nephrectomy: Robotic Port Placement

52. Robotic Nephrectomy : Operating room

53. Advantage of robotic over laparoscopic Minimal invasive approach 3D visual & depth perception