Lee E. Ponsky

Introduction

Increased use of three-dimensional (3D) imaging has led to better detection of renal tumors in recent years. Since the introduction of laparoscopic nephrectomy by Clayman and colleagues in 1990, this minimally invasive approach to kidney removal has become the “gold standard.” Laparoscopic radical nephrectomy has demonstrated oncologic outcomes comparable to those seen with open radical nephrectomy, but with less morbidity, shorter hospital stay, less pain, quicker recovery, and improved cosmesis.

Preoperative Imaging

Typically, a contrast-enhanced computed tomography (CT) scan or a magnetic resonance (MR) image is obtained before surgery. Although not necessarily required, CT and MRI offer precise mapping of the kidney, its vasculature, and relation to adjacent organs. Also, imaging of the renal vein and vena cava helps ensure no evidence of tumor thrombus and provides preoperative clinical staging. It is also prudent to visualize the contralateral kidney to confirm adequate function. Cross-sectional images are usually sufficient, but coronal images can be extremely helpful as well (Fig. 53-1, A).

Surgical Approach

The kidney can be removed by using either a transperitoneal or a retroperitoneal approach. Both techniques have been demonstrated to be safe and effective. The transperitoneal approach is more common, but it is helpful for surgeons to be able to perform the retroperitoneal approach, particularly for patients with multiple previous intraabdominal surgeries or a hostile abdomen. The retroperitoneal approach also offers the ability to control the renal hilum almost immediately. However, with limited recognizable landmarks for orientation using the retroperitoneal approach, the majority of laparoscopic radical nephrectomies are performed transperitoneally.

Patient Positioning and Trocar Placement

For a left radical nephrectomy, the patient is placed in the right lateral decubitus position with the left flank up (Fig. 53-1, B). The patient is centered over the break in the bed. The lower leg is bent and the top leg straight, and the dependent hip, knee, and ankle padded appropriately. Pillows can be placed between the legs. An axillary roll should be placed under the axilla, to protect from nerve damage. The patient’s lower arm is placed straight out on an arm board, and the upper arm should be secured to an upper arm board. The upper arm must be safely positioned away from the working field to ensure full access to laparoscopic instrumentation.

It is important to secure the patient to the table with heavy tape wrapped around the patient (preferably directly to skin) and table several times, to prevent the patient from moving or sliding during surgery. For the transperitoneal approach, the patient can be rotated posteriorly just before being secured to the table. It is also helpful to plan for the extraction site, marking it before positioning and including it in the prepped and draped area.

Port sites have been described in several ways, depending on surgeon preference. The author’s group typically uses the Verres needle for access, although the Hasson cutdown technique is also appropriate. Correct placement of the right-handed port is typically marked half the distance between the anterior superior iliac spine and the umbilicus, then moved superiorly up to the level of the umbilicus. This would typically be a 10-mm port. The middle camera port is typically placed just lateral to the rectus abdominis muscle, approximately in line with the tip of the 12th rib. The left-handed, typically 5-mm port is approximately at the junction of the lateral aspect of the rectus muscle and the subcostal border.