How is an extraperitoneal nephrectomy performed?

Updated: Sep 24, 2019
  • Author: Michael Grasso, III, MD; Chief Editor: Bradley Fields Schwartz, DO, FACS  more...
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Answer

Answer

Surgical access to the retroperitoneum begins with a 1-cm transverse incision off the tip of the 11th or 12th rib. Subcutaneous tissues and underlying muscle are bluntly divided, defining the lumbodorsal fascia, which is gently traversed. Development of the retroperitoneum is then accomplished with a spherical balloon dissector, expanding and inflating parallel to the psoas muscle. Care must be taken not to dissect too anteriorly, as the peritoneum may be opened. Full inflation of the balloon dissector requires approximately 500-800 cc of air. See the image below.

A retroperitoneal balloon access device, inflated A retroperitoneal balloon access device, inflated with approximately 800 cc of air (AutoSuture PDB 1000, Covidien, Mansfield, Mass).

A 10-mm port is then placed 1 cm below the 12th rib posteriorly, adjacent to the paraspinous musculature. Care is taken to avoid the neurovascular bundle along the inferior surface of the 12th rib.

Insufflation and endoscopic inspection is performed thru the middle port. Typically a 3-port technique is used for RLN, but occasionally a fourth anterior port is required for specimen retraction. See the image below.

Intraoperative photograph demonstrating placement Intraoperative photograph demonstrating placement of the laparoscopic ports. The 10-mm laparoscope port is inserted just off the tip of the 12th rib, a 5-mm port is inserted approximately 8 cm anteriorly in the anterior axillary line, and a 12-mm port is inserted 1 cm below the 12th rib.

To seal the middle port site, a 10-mm port with a balloon seal is used. Pneumoretroperitoneum at 15 mm Hg is then established. The anterior port is placed after endoscopic dissection is used to mobilize the peritoneum medially as described above. This third dissecting port (5 mm) is placed under direct vision in the midaxillary line, just lateral to the peritoneal reflection.

Orientation of the endoscope and camera system is essential during retroperitoneoscopy. Opening Gerota fascia posteriorly with prompt localization of the great vessels and renal hilum is essential. The renal artery is identified as a vertically oriented, pulsating structure, perpendicular to the aorta. See the image below.

The renal artery is identified as a vertically-ori The renal artery is identified as a vertically-oriented pulsating structure at the tip of the suction.

The ureter, gonadal vessels, and great vessels (IVC for right sided tumors, pulsating aorta for left sided tumors) are first identified as longitudinal structures coursing parallel to the psoas. See the image below.

The suction tip is pointing to the flattened infer The suction tip is pointing to the flattened inferior vena cava (IVC), which is running parallel to and medical to the horizontally-oriented psoas muscle tendon.

The renal vessels are meticulously dissected free of adipose and lymphatics. See the image below.

The renal artery and vein. The renal artery and vein.

The renal artery is typically secured with Weck (10 mm or 15 mm) and standard metal surgical clips. See the image below.

The renal artery is typically secured with Weck cl The renal artery is typically secured with Weck clips (10 or 15 mm) and standard metal surgical clips.

The renal vein is addressed with an endovascular GI anastomosis stapler (bladed or unbladed) using small vascular staples. See the image below.

The renal vein is stapled allowing controlled divi The renal vein is stapled allowing controlled division.

Subsequent to hilar control, dissection turns cephalad dividing perirenal attachments with a haemostatic dissector (eg, LigaSure, Harmonic scalpel). The adrenal arcade of vessels are then developed if adrenalectomy is to be performed, with the adrenal vein being secured with clips and divided. The contents of Gerota’s fascia are then developed anterior, with blunt dissection used to separate Gerota’s fascia from the peritoneum. The extraperitoneal liver and duodenum on the right and the spleen and pancreatic tail on the left are landmarks. Finally, inferior attachments, including the ureter are divided.

For specimen extraction, an extraperitoneal space inferiorly is developed through which a 15 mm laparoscopic port is introduced and a large entrapment sack is used. A small Gibson extraction incision around this port is created and the underlying fascia and musculature widened sufficiently to deliver the specimen. In contrast, specimen entrapment and morselization can also be performed. Perinephric drainage is not typically used, but if desired, a closed suction catheter is placed through the most dependent posterior port.


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