Right Laparoscopic Radical Nephrectomy

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Right Laparoscopic Radical Nephrectomy

• Ralph V. Clayman, MD
• Professor of Urology
• University of California, Irvine

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Patient Selection

• Indications
• Renal mass (not amenable to partial nephrectomy)
• Contraindications
• Vena caval thrombus
• Peritonitis
• Uncorrected coagulopathy
• Multiple prior abdominal surgeries (relative)
• Significant medical comorbidities (relative)

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Equipment Required

• Veress needle (14G Surgineedle) Autosuture
• Knife with 15 blade
• Kelly and Allis clamps
• Trocars 12 mm (3), 5 mm (2)
• Laparoscopic camera with 30? Lens (have 5 mm 30?
  available)
• Argon Beam Coagulator
• Hook Electrocautery with Active Electrode
  Monitoring Encision
• LigaSure (5 mm) Valleylab
• Harmonic Shears-5 mm curved Ethicon
• Kuttner Dissectors 5 mm Endo Peanut
  Autosuture
• 10 mm Endoscopic blunt cherry dissector
  Ethicon
• 5 mm atraumatic bowel forceps Karl Storz
• Laparoscopic Right Angle Clamp (5 mm and 10 mm)
• EndoGIA stapler (45 mm vascular load,
  articulating handle) Ethicon
• Nezhat-Dorsey suction-irrigator Davol
• Grasping forceps with teeth (locking handle) (3)
• Endoholder (self-retaining retractor) Codman
• Floseal hemostatic collagen matrix Baxter
• Oxidized cellulose (Surgicel)

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Patient Positioning

• Full flank, supported by hip grips and gel pads
• Lower (left) leg bent, 3 pillows supporting upper
  (right) leg
• Table flexed 15?
• Axillary roll
• OR table covered with gel pad (never bean bag)
• Right arm draped over chest, supported by 2
  pillows
• Table airplaned 10? to the right
• Arms, hips, and lower leg secured by tape over
  eggcrate padding
• Kidney rest raised only during insufflation, then
  lowered

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Patient Positioning
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Port Placement

• Veress needle placed 2 finger breadths medial and
  superior to iliac crest, followed by 12 mm port
• Primary 12 mm camera port umbilicus in thin
  patient, gt6 cm lateral and slightly superior to
  umbilicus for obese patient
• 12 mm port 1 finger breadth below costal margin,
  midclavicular line
• Liver retraction (5 mm), midline, subxiphoid
• Accessory (5 mm) retraction/working port
  anterior axillary line, subcostal

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Port Placement
5 mm accessory port
Primary (12 mm) working ports
Liver retraction (5 mm)
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Steps of the procedure
1. Placing the ports
2. Mobilizing the colon
3. Mobilizing the liver and upper pole
4. Kocherizing the duodenum
5. Freeing the lower pole
6. Dissecting the hilum
7. Dividing the ureter

• Placing the specimen in a Lap Sac for
  morcellation

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1. Placing the ports
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2. Mobilizing the colon
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3. Mobilizing the liver and upper pole
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4. Kocherizing the duodenum
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5. Freeing the lower pole
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6. Dissecting the hilum
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7. Dividing the ureter
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Placing the specimen in a Lap Sac
for morcellation
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Technical points Tips

• Make sure to take down the triangular and
  posterior coronary hepatic ligaments in order to
  mobilize the liver cranially and medially and
  expose the vena cava.
• The argon beam coagulator can stop small
  bleeders.
• Make liberal use of Kuttners for dissection and
  retraction. They are especially useful around
  the hilum.
• There is no camera port. The camera and
  instruments should be freely shifted between the
  12 mm ports as necessary wherever exposure is the
  best.
• 5 mm ports are free. If you are struggling, do
  not hesitate to place one to provide a better
  working angle.

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Technical points Caveats

• When dissecting the midportion of the kidney
  medially, the first structure encountered will
  ALWAYS be the duodenum, not the vena cava.
  Temporarily lowering the pneumoperitoneum to 5 mm
  will help it to fill out.
• The hook can be used to dissect on the anterior
  surface of the vena cava. When approaching the
  lower pole, beware the insertion of the gonadal
  vein on the anterolateral surface of the IVC
• Take extreme precaution when morcellating to
  avoid tumor spillage triple drapes, change of
  gowns/gloves, instillation of betadine in the
  wound.

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Credits

• Surgeon Ralph V. Clayman, MD
• Professor of Urology
• Chairman, Department of
  Urology
• UC Irvine Medical Center
• Orange, CA 92868
• 714-456-6782
• RClayman_at_uci.edu
• First assistant and video editor
• James F. Borin, MD
• Clinical Instructor
• Laparoscopy/Endourology fellow
• UC Irvine Medical Center
• 714-456-3431
• JBorin_at_aya.yale.edu