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

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

3. Conventional Open Surgeryvs
Laparoscopic Surgery
Quantum Leap

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

5. 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

6. 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

7. TRANSPERITONEAL RETROPERITONEAL
Laparoscopic Approaches to Kidney

8. 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

9. 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

10. 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

11. 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

12. 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

13. 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

14. 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

15. 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

16. 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.

17. Laparoscopic Hand Assisted Nephrectomy

18. 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”

19. 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)

20. 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

21. 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.

22. 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 )

23. Pneumo-Sleeve for Hand Assisted Laparoscopy

24. 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

25. Laparoscopy For Benign Renal Disease

26. 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

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

28. 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

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

30. 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

31. Laparoscopic Donor Nephrectomy

32. History - Laparoscopic Live Donor Nephrectomy
Porcine Model – Gill et al.
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

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

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

35. 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

36. 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

37. Laparoscopic Nephrectomy for Renal cell carcinoma

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

39. Issues – Lap Nephrectomy for RCC
Op. Time 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)

40. 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

41. 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

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

43. 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

44. 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

45. THANK YOU