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Laparoscopic Nephrectomy
Dr. SUNIL SHROFFProf.Urology & Renal Transplantation
Sri Ramachandra Medical College & Research Institute
( Deemed University )Chennai, India
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“These are Exciting times to be a Surgeon”
Lord Lister said 100 years ago!!Lord Lister said 100 years ago!!
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Conventional Open Surgery vs
Laparoscopic Surgery
Quantum LeapQuantum Leap
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Suitable Surgery for Zero Gravity
( Weightlessness)
Suitable Surgery for Tele-Mentoring
Maybe suitable Surgery for Tele-
Presence Surgery
Laparoscopic Surgery
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Prof.Kurt Semm, Kiel, Germany
First peep inside body cavity was looking into urethra - 1805
The Father of Laparoscopy SurgeryThe Father of Laparoscopy Surgery
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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
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TRANSPERITONEAL
RETROPERITONEAL
Laparoscopic Approaches to Kidney
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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
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Minimum Ileus in post- operative period - Faster convalescence
If Previous H/O Intraperitoneal surgeries - Safe
Bowel herniation -Incidence Low
For Retroperitoneal organs -Access direct
ADVANTAGES OF RETROPERITONEAL APPROACH
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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
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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
DISADVANTAGES OF RETROPERITONEAL APPROACH
Aortic Aneurysm contra-ind. to Retro-peritoneal approach
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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
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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
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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
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• 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
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• 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.
Transperitoneal left Nephrectomy…
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Laparoscopic Hand Assisted Nephrectomy
Laparoscopic Hand Assisted Nephrectomy
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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”
“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”
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HAND IS THE MOST VERSATILE INSTRUMENT
( To Feel, to dissect, To Retract & For Knot-Tying)
HAND IS THE MOST VERSATILE INSTRUMENT
( To Feel, to dissect, To Retract & For Knot-Tying)
Why Laparoscopic Hand-Assisted Nephrectomy
‘Endohand’ for laparoscopy - undergoing trial ( Jackman – 1999)
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I. Compared to hand, Instruments reduce Sensory
perception by a factor of 8
II. Conventional laparoscopic procedures – Steep
learning Curve
1. Operating looking at “Pixels”
2. Hand Eye co-ordination
3. Unlearn old habits
4. Not part of PG training programme
5. Unless practice regularly loose dexterity
Why Laparoscopic Hand-Assisted Nephrectomy
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1994 Tierney et al reported - Hand assisted
Spleenectomy, Colectomy & Nephrectomy
1995 Cuschieri & Shapiro – Pneumo-peritoneum Access
Bubble
1996 Bannenberg et al – devised Pneumosleeve – to
preserve pneumoperitoneum
1997 Wolf et al reported – OR time with pneumosleeve
for nephrectomy less by 85 mins
1998 Schichman et al - Efficacy, safety and recovery
with hand assisted nephrectomy similar to
conventional laparoscopic surgery and superior to
open surgery.
HISTORY – Laparoscopic Hand Assisted Nephrectomy
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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)
Laparoscopic Hand Assisted Nephrectomy Versus Conventional Laparoscopic Nephrectomy
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Pneumo-Sleeve for Hand Assisted Laparoscopy
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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
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Laparoscopy For Benign Renal Disease
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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
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Laparoscopy Abalation of Renal Cyst
Transperitoneal preferred If Retroperitoneal approach – port
inserted under vision Send wall for histology Recurrance can again be approached
laparoscopically
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Retroperitoneal approach preferred
UPJ obstruction with Extra-renal pelvis
Excellent long term results reported
300 telescope Preferred
Laparoscopic Pyeloplasty
Operating time initially 6 to 8 hrs, currently 3 hrs
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Laparoscopic Pyelolithotomy
Indication Failed ESWL Failed PCNL Ectopic Kidney Renal calculus with UPJ obstn. Where
dismemembered pyeloplasty planned
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Laparoscopic PyelolithotomyTechnique:
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
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Laparoscopic Donor Nephrectomy
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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
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Issues - Laparoscopic Donor Nephrectomy
Warm Ischemia Time
Complication Rate
Vascular Pedicle
Rejection Episodes
Long term Graft outcome
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Laparoscopic Donor Nephrectomy Vs Open Donor Nephrectomy
Novick (1999) – Compared outcomes of 132 Recipient of Lap. Nephrectomy versus 80 Recipients of open
Nephrectomy
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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
Laparoscopic Donor Nephrectomy Vs Open Donor Nephrectomy
Current series show complication rate higher during early part of experience. Later on there is no statistical
difference
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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
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Laparoscopic Nephrectomy for Renal cell carcinoma
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Issues – Lap Nephrectomy for RCC
Prolonged operating time
Complication rates
Specimen Extraction
Potential for Tumour Spread
Port site Recurrence
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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)
Issues – Lap Nephrectomy for RCC
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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
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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
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Tele-mentoring
Tele-mentoring is guiding surgical and
other clinical procedure from a remote
distance by a mentor
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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
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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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THANK YOUTHANK YOU