103 Laparoscopic Surgery of the Kidney

103 LAPAROSCOPIC SURGERY OF THE KIDNEY Jay T. Bishoff, MD Louis R. Kavoussi, MD Historical Overview Procedure Autosomal Dominant Polycystic Kidney Disease Patient Evaluation and Preparation Postoperative Management Surgical Approaches Results Transperitoneal Nephropexy Retroperitoneal Indications Hand-Assisted Procedure Simple Nephrectomy Results Indications and Contraindications Pyelolithotomy Patient Positioning Insufflation and Trocar Placement Calyceal Diverticulectomy Procedure Indications Postoperative Management Procedure Results Results Laparoscopic Transperitoneal Donor Nephrectomy Laparoscopy for Renal Malignancy Patient Selection Operative Preparation Radical Nephrectomy Patient Positioning Indications and Contraindications Procedure Preoperative Evaluation Alternative Approaches Positioning and Trocar Placement Procedure Renal Biopsy Results Indications Conclusion Patient Positioning Procedure Partial Nephrectomy Postoperative Considerations Laparoscopic Ablative Techniques Results Cryosurgery Renal Cystic Disease Radiofrequency Interstitial Tissue Ablation Indications Complications of Laparoscopic Renal Surgery Patient Preparation Patient Positioning Conclusions HISTORICAL OVERVIEW though these changes have been made possible through advances in video technology and instrumentation design, Since the mid-1990s, there has been an evolution in the primary driver has been an increasingly educated pa- surgical practice from traditional open approaches toward tient population seeking less painful means of treatment. minimally invasive means of treating operative lesions. Al- Over a century ago, our gynecologic colleagues introduced 3645 3646 LAPAROSCOPIC SURGERY OF THE KIDNEY Table 103–1. LAPAROSCOPIC NEPHRECTOMY Conver- OR LOH sion Compli- Author Approach Indication Time (Min) (days) EBL (%) cations Morcellation Intact Rassweiler et al, Transperitoneal Benign N 20 239 (115–300) 6 16 16% 4/24 83% 20/24 17% 4/24 1993b N 24 Malignant N 4 Kerbl et al, 1994 Transperitoneal Benign N 20 343 (100–700) 4 343 ml 4 20% 5/24 87% 21/24 13% 3/24 N 23 Malignant N 4 Retroperitoneal N 1 Eraky et al, 1994 Transperitoneal Benign N 60 210 (132–288) 3 10 6% 4/60 N 60 Nicol et al, 1994 Transperitoneal Benign N 5 180 (120–300) 3 0 100% 5/5 N 5 Perez et al, 1994 Transperitoneal Benign N 12 145 (105–360) 3 8 16% 2/12 0 100% 12/12 N 12 Parra et al, 1995 Transperitoneal Benign N 12 145 (105–360) 4 140 8 16% 2/12 8% 1/12 92% 11/12 N 12 Rassweiler et al, Transperitoneal Benign N 18 206 7 1996 N 18 Malignant N 17 6 Retroperitoneal N 17 Higashihara et al, Benign N 51 298 (168–428) 239 16 1998 Malignant N 12 390 8 Keeley and Tolley, Transperitoneal Benign N 76 146 4 na 5 18% 18/100 0 100% 100/100 1998 N 79 Malignant N 24 Retroperitoneal N 23 Rassweiler et al, Transperitoneal Benign N 444 188 (50–400) 5 9 6% 29/482 1998 N 344 Malignant N 38 10 6% 29/482 Retroperitoneal N 138 Rozenberg et al, Transperitoneal Malignant N 17 116 13 13% 4/30 1999 N 30 Benign N 13 Desgrandchamps Transperitoneal Benign N 12 119 (70–180) 5 50 ml 0 7% 1/14 0 100% 14/14 et al, 1999 N 14 Malignant N 2 EBL, estimated blood loss; LOH, length of hospitalization; na, not applicable; OR, operating room. laparoscopic surgery, primarily as a diagnostic tool. Only 1996; Rassweiler et al, 1998; Rozenberg et al, 1999; He- recently has it become a practical and acceptable alterna- mal, et al 1999). tive to treat complex surgical diseases. The development of the laparoscopic pelvic lymphade- nectomy for patients with prostate cancer inaugurated the PATIENT EVALUATION AND role of laparoscopy in treating urologic lesions (Griffith et PREPARATION al, 1990). In June 1990, Clayman and coworkers at Wash- ington University overcame the barriers to laparoscopic Patient preparation for laparoscopic kidney surgery is solid organ removal by performing the first laparoscopic similar to that for comparable open procedures. Informed nephrectomy (Clayman et al, 1991). In less than 7 hours, consent must be obtained with a discussion of possible an elderly patient with a 3-cm solid renal mass underwent complications including adjacent organ injury and un- laparoscopic radical nephrectomy through five trocar sites. recognized bowel injury (Bishoff et al, 1999). The pa- This accomplishment represents one of the milestones in tient should be informed that conversion to open sur- minimally invasive surgery because it provided the solution gery might be necessary to safely complete the planned for removing a large solid organ without the need for an procedure. incision. In order for the surgeon to determine any contraindica- Since this report, many institutions have verified the util- tions to laparoscopic surgery or conditions that may alter ity of a laparoscopic approach to address benign and ma- the laparoscopic approach, the preoperative evaluation must lignant diseases of the kidney. Advances in instrument include a careful history and detailed physical examination. technology and surgical techniques have also allowed com- Laparoscopic kidney surgery requires a general anes- plex renal reconstruction to be performed laparoscopically. thetic. Consequently, patients who are not candidates The result for patients has been markedly less morbidity for a general anesthetic should not undergo laparo- than open flank surgery. The benefits of laparoscopic ne- scopic surgery (Monk and Weldon, 1992). Prior abdomi- phrectomy include a lower requirement for pain medi- nal surgery may alter the choice between transperito- cation, a shorter hospital stay, reduced convalescence, neal or retroperitoneal approaches, patient positioning, and a more rapid return to full activity (Table 103– 1) and the placement site of trocars but is not a contrain- (Copcoat et al, 1992; Kavoussi et al, 1993; Kerbl et al dication to laparoscopic surgery (Chen et al, 1998; Ca- 1993a, 1993b; Rassweiler et al, 1993; Kerbl et al, 1994; deddu et al, 1999). Severe cardiac or pulmonary disease Nicol et al, 1994; Perez et al, 1994; Parra et al, 1995; may place the patient at risk for complications due to the Baba et al, 1996; Doublet et al, 1996; Rassweiler et al, pneumoperitoneum, which can compromise ventilation and JAY T. BISHOFF AND LOUIS R. KAVOUSSI 3647 limit venous return (Arthure, 1970; Hodgson et al, 1970; result in difficulty with orientation, visualization, trocar Nunn, 1987; Lew et al, 1992). Patients with chronic ob- spacing, and organ entrapment. Even though this provides structive pulmonary disease may not be able to compensate an extraperitoneal operation, injury can occur to intra-ab- for hypercarbia induced by the pneumoperitoneum and may dominal organs, and a hernia can be created during balloon require lower insufflation pressures or conversion to open dilatation of the extraperitoneal space (Adams et al, 1996). surgery (Monk and Weldon, 1992; Adams et al, 1995). Compared with a transperitoneal approach, a retroperi- Laboratory and imaging studies are obtained as indi- toneal approach results in complication rates, pain med- cated. An electrocardiogram and a chest radiograph are ication requirements, lengths of hospital stay, and times obtained before surgery. Pulmonary function studies are to return to normal activity after surgery similar to performed only in those patients with known respiratory those of the retroperitoneal route (McDougall and Clay- disease or those at high risk based on the history and man, 1996; Rassweiler et al, 1998a). There are patients in physical examination. All patients should have their blood whom retroperitoneal access is preferred over the transperi- typed and screened, and in advanced procedures, cross- toneal approach. Patients with a history of multiple abdom- matched blood should be available. Bowel preparation var- inal surgical procedures or peritonitis may benefit from this ies according to the procedure and the physician’s prefer- approach. Initial retroperitoneal access can be achieved ence. with subsequent opening of the peritoneum as indicated Anticoagulated patients are managed in cooperation with (Cadeddu et al, 1999). Also, patients with abnormality on their primary physician. Patients with bleeding disorders the posterior surface of the kidney (exophytic cyst or mass) should have 2 to 4 units of packed red blood cells cross- may be better served through retroperitoneal access. Con- matched before the start of the procedure. Fresh frozen sequently, the laparoscopic surgeon should be familiar plasma can be given if needed just before the procedure. with both transperitoneal and retroperitoneal ap- Patients with thrombocytopenia can receive platelets 30 proaches (Barreto et al, 1995; Doublet et al, 1996; Gas- minutes before the incision to increase their platelet count man et al, 1996; Rassweiler et al, 1998b; Gill and Ras- to greater than 50,000/ml. Additional platelet transfusion sweiler, 1999; Hsu et al, 1999 (see Chapter 100). should not be necessary in the absence of symptomatic bleeding. Uremic patients may benefit from desmopressin acetate treatment to improve platelet function. Hand-Assisted A preoperative abdominal CT scan is useful in evalu- ating the location, size, and abnormality of the kidney In an effort to facilitate learning of laparoscopic tech- to be addressed. Areas of perinephric stranding discov- niques, hand-assisted endoscopic techniques have been in- ered on CT may indicate significant inflammation and troduced. The hand-assisted devices offer a bridge between adhesions, increasing the chance for conversion to an laparoscopic and open surgery and may help surgeons open

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