1. CONTRAINDICATIONS TO LAPAROSCOPIC NEPHRECTOMY

2. Dr. Anmar Nassir, FRCS(C) Fellowship in Andrology (U of Ottawa) Fellowship in EndoUrology and Laparoscopy (McMaster Univ) Chairman, Department of Surgery Umm Al-Qura Univ Consultant Urology, King Faisal Specialist Hospital, Jeddah

3. Pt w severe COPD – further studies (i.e., ABG and PFT) are required. – In severe COPD, helium is an alternate. Significant cardiac arrhythmias – evaluated – treated  hypercarbia and acidosis may have bad effect on the myocardium. Before starting  select your patient

4. Absolute contraindications Uncorrectable coagulopathy Intestinal obstruction Abdominal wall infection Massive hemoperitoneum/hemoretroperitoneum Generalized peritonitis Retroperitoneal abscess Suspected malignant ascites

5. Relative contraindications (if …) Morbid Obesity Extensive Prior Abdominal or Pelvic Surgery Organomegaly Ascites: Benign Etiology Pregnancy Hernia Iliac or Aortic Aneurysm

6. Relative contraindications BMI, according to the WHO Overweight = 25 to 29.9 kg/m 2 Obese = 30 to 34.9kg/m 2 30 to 34.9 kg/m 2 Morbid obesity= > 35 kg/m 2 > 35 kg/m 2

8. Relative contraindications (if …) Morbid Obesity Extensive Prior Abdominal Organomegaly Ascites: Benign Etiology Pregnancy Hernia Iliac or Aortic Aneurysm

9. From inside

10. Indications for Simple lap nephrectomy Renovascular hypertension, symptomatic acquired renal cystic disease nephrosclerosis, Symptomatic ADPKD reflux or obstructive nephropathy, multicystic dysplastic kidney chronic pain of renal origin refractory to conservative measures, chronic pyelonephritis, Fricke et al, 1998

11. Postoperative Management  The orogastric tube is removed at the conclusion of the procedure.  Clear fluids after flatus, then normal after bowel movement.  Foley catheter removed once the patient is ambulating.  The patient is discharged when tolerating diet.  Unrestricted activity resumed according to the patient's comfort.  If a specimen has been removed through an incision, lifting is limited to 6 weeks.

12. Results The postop results comparable to that of open with much less pain and shorter convalescence. – Postoperative pain requirements are 4X < traditional open incisions. – LOS decreased by 50%, – Time to full convalescence has been reported to be markedly less. Mean operative times > 300 minutes. – With advances in techniques, experience, and equipment, operative times have decreased dramatically