Laparoscopic Nephrectomy Dr. SUNIL SHROFF Prof.Urology & Renal Transplantation Sri Ramachandra Medical College & Research Institute ( Deemed University ) Chennai, India

“These are Exciting times to be a Surgeon” Lord Lister said 100 years ago!!

Conventional Open Surgery vs Laparoscopic Surgery Quantum Leap

Laparoscopic Surgery Suitable Surgery for Zero Gravity ( Weightlessness) Suitable Surgery for Tele-Mentoring Maybe suitable Surgery for Tele-Presence Surgery

First peep inside body cavity was looking into urethra - 1805 The Father of Laparoscopy Surgery Prof.Kurt Semm, Kiel, Germany First peep inside body cavity was looking into urethra - 1805

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

TRANSPERITONEAL RETROPERITONEAL Laparoscopic Approaches to Kidney

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

ADVANTAGES OF RETROPERITONEAL APPROACH Minimum Ileus in post- operative period - Faster convalescence If Previous H/O Intraperitoneal surgeries - Safe Bowel herniation - Incidence Low For Retroperitoneal organs - Access direct

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

DISADVANTAGES OF RETROPERITONEAL APPROACH 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 Aortic Aneurysm contra-ind. to Retro-peritoneal approach

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

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

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

Transperitoneal left Nephrectomy 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… 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.

Laparoscopic Hand Assisted Nephrectomy

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”

HAND IS THE MOST VERSATILE INSTRUMENT Why Laparoscopic Hand-Assisted Nephrectomy HAND IS THE MOST VERSATILE INSTRUMENT ( To Feel, to dissect, To Retract & For Knot-Tying) ‘Endohand’ for laparoscopy - undergoing trial ( Jackman – 1999)

Why Laparoscopic Hand-Assisted Nephrectomy I. Compared to hand, Instruments reduce Sensory perception by a factor of 8 II. Conventional laparoscopic procedures – Steep learning Curve Operating looking at “Pixels” Hand Eye co-ordination Unlearn old habits Not part of PG training programme Unless practice regularly loose dexterity

HISTORY – Laparoscopic Hand Assisted Nephrectomy Tierney et al reported - Hand assisted Spleenectomy, Colectomy & Nephrectomy Cuschieri & Shapiro – Pneumo-peritoneum Access Bubble Bannenberg et al – devised Pneumosleeve – to preserve pneumoperitoneum Wolf et al reported – OR time with pneumosleeve for nephrectomy less by 85 mins Schichman et al - Efficacy, safety and recovery with hand assisted nephrectomy similar to conventional laparoscopic surgery and superior to open surgery.

Laparoscopic Hand Assisted Nephrectomy Versus Conventional Laparoscopic Nephrectomy 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)

Pneumo-Sleeve for Hand Assisted Laparoscopy

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

Laparoscopy For Benign Renal Disease

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

Laparoscopy Abalation of Renal Cyst Transperitoneal preferred If Retroperitoneal approach – port inserted under vision Send wall for histology Recurrance can again be approached laparoscopically

Laparoscopic Pyeloplasty Retroperitoneal approach preferred UPJ obstruction with Extra-renal pelvis Excellent long term results reported 300 telescope Preferred Operating time initially 6 to 8 hrs, currently 3 hrs

Laparoscopic Pyelolithotomy Indication Failed ESWL Failed PCNL Ectopic Kidney Renal calculus with UPJ obstn. Where dismemembered pyeloplasty planned

Laparoscopic Pyelolithotomy Technique: 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

Laparoscopic Donor Nephrectomy

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

Issues - Laparoscopic Donor Nephrectomy Warm Ischemia Time Complication Rate Vascular Pedicle Rejection Episodes Long term Graft outcome

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

Laparoscopic Donor Nephrectomy Vs Open Donor Nephrectomy 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 Current series show complication rate higher during early part of experience. Later on there is no statistical difference

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

Laparoscopic Nephrectomy for Renal cell carcinoma

Issues – Lap Nephrectomy for RCC Prolonged operating time Complication rates Specimen Extraction Potential for Tumour Spread Port site Recurrence

Issues – Lap Nephrectomy for RCC 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)

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

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

Tele-mentoring Tele-mentoring is guiding surgical and other clinical procedure from a remote distance by a mentor

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

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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