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Simplifying laparoscopic nephrectomy: the inferior approach with en bloc stapling of the renal hilum.

Schatloff O, Nadu A, Lindner U, Ramon J - JSLS (2014 Jul-Sep)

Bottom Line: Conversion to open surgery occurred in 3.1% of patients, and 8% of the patients had a blood transfusion.Complications were recorded in 26% of the patients; 91% of them had Clavien grade scores of 1 or 2.We present a standardized technique for LN.

View Article: PubMed Central - PubMed

Affiliation: Department of Urology, Assaf HaRofeh Medical Center, Tel Aviv, Israel.

ABSTRACT

Introduction: Laparoscopic nephrectomy (LN) is likely the most common laparoscopic procedure performed by general urologists without formal laparoscopic training. The traditional technique is cumbersome because it entails making an early approach to the hilum with the risk of bleeding and need for conversion. We perform a different technique that we believe is simpler to learn and to teach. It consists of a complete dissection of the inferior and posterior aspects of the kidney, followed by en bloc stapling of the renal hilum. The present report is a detailed description of our technique including outcomes and complications.

Materials and methods: Perioperative data of 129 consecutive patients who underwent LN between November 2003 and September 2007 were prospectively collected and retrospectively reviewed. Complications were reported using the Clavien classification system, and follow-up was performed according to our institution's protocol and included physical examination, blood count, blood chemistry, and renal function tests at every visit, in addition to abdominal computed tomography scan six months after surgery. Additional imaging was scheduled according to disease stage and grade.

Results: Mean patient age, tumor size, and operative time were 63±15.6 years, 6.3±2.4 cm, and 128±41.4 minutes, respectively. Median estimated blood loss was 0 mL (0.200). Conversion to open surgery occurred in 3.1% of patients, and 8% of the patients had a blood transfusion. Complications were recorded in 26% of the patients; 91% of them had Clavien grade scores of 1 or 2.

Conclusion: We present a standardized technique for LN. Its main advantage is that postpones any manipulation of the hilum to a later step during the procedure when it is easy to identify and control. This decreases early bleeding and main vascular complications.

No MeSH data available.


Related in: MedlinePlus

Safe en bloc stapling of the hilum. The hilum is kept in tension. A, On the right side, the staple is deployed over the inferior vena cava and away from the duodenum. B, On the left side, care should be taken to stay away from the colon, splenic hilum, and tail of the pancreas.
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Figure 6: Safe en bloc stapling of the hilum. The hilum is kept in tension. A, On the right side, the staple is deployed over the inferior vena cava and away from the duodenum. B, On the left side, care should be taken to stay away from the colon, splenic hilum, and tail of the pancreas.

Mentions: Placing the kidney into tension allows the identification of the anterior wall of the renal vein, a variable bulky posterior fatty tissue containing the renal artery and a generous posterolateral window delineated by the psoas muscle and the lateral abdominal wall. A 45-mm vascular endostapler loaded with 2.5-mm titanium clips is inserted and closed, including stapling the vein and the remaining posterior hilar tissue. Correct positioning of the stapler is of maximal importance. On the right side, it is placed through a subcostal 12-mm port and runs cephalic to caudal and medial to lateral (Figure 6[A]). It is important to ensure that the stapler runs over the anterior wall of the inferior vena cava and does not catch in the duodenum. In this way, the tip reaches the already dissected posterolateral aspect of the kidney, where no elementary structures are found. On the left side, it is placed through a 12-mm port in the left lower quadrant and runs from caudal to cephalic. The direction of the jaws should be as horizontal as possible to prevent stapling the aorta and to reliably catch the renal artery that will run perpendicular to the stapler (Figure 6[B]). The tip of the staple should always be checked before firing; of special concern are the tail of the pancreas, superior mesenteric artery, splenic vessels, and part of the stomach that might descend through the lateral aspect of the spleen. After firing, a nice staple line that includes the vein and the artery is usually observed. Our preferred technique for hilar control is en bloc stapling5; however, if the thickness of the hilum does not allow safe en bloc stapling, a plane is created between the renal vein and all posterior elements to allow the entrance of one of the jaws of the stapler. One load is used to staple all posterior hilar tissue and another to staple the remaining renal vein. The remaining lateral and upper pole attachments are then released and the kidney is extracted inside a laparoscopic bag.


Simplifying laparoscopic nephrectomy: the inferior approach with en bloc stapling of the renal hilum.

Schatloff O, Nadu A, Lindner U, Ramon J - JSLS (2014 Jul-Sep)

Safe en bloc stapling of the hilum. The hilum is kept in tension. A, On the right side, the staple is deployed over the inferior vena cava and away from the duodenum. B, On the left side, care should be taken to stay away from the colon, splenic hilum, and tail of the pancreas.
© Copyright Policy - open-access
Related In: Results  -  Collection

License
Show All Figures
getmorefigures.php?uid=PMC4208890&req=5

Figure 6: Safe en bloc stapling of the hilum. The hilum is kept in tension. A, On the right side, the staple is deployed over the inferior vena cava and away from the duodenum. B, On the left side, care should be taken to stay away from the colon, splenic hilum, and tail of the pancreas.
Mentions: Placing the kidney into tension allows the identification of the anterior wall of the renal vein, a variable bulky posterior fatty tissue containing the renal artery and a generous posterolateral window delineated by the psoas muscle and the lateral abdominal wall. A 45-mm vascular endostapler loaded with 2.5-mm titanium clips is inserted and closed, including stapling the vein and the remaining posterior hilar tissue. Correct positioning of the stapler is of maximal importance. On the right side, it is placed through a subcostal 12-mm port and runs cephalic to caudal and medial to lateral (Figure 6[A]). It is important to ensure that the stapler runs over the anterior wall of the inferior vena cava and does not catch in the duodenum. In this way, the tip reaches the already dissected posterolateral aspect of the kidney, where no elementary structures are found. On the left side, it is placed through a 12-mm port in the left lower quadrant and runs from caudal to cephalic. The direction of the jaws should be as horizontal as possible to prevent stapling the aorta and to reliably catch the renal artery that will run perpendicular to the stapler (Figure 6[B]). The tip of the staple should always be checked before firing; of special concern are the tail of the pancreas, superior mesenteric artery, splenic vessels, and part of the stomach that might descend through the lateral aspect of the spleen. After firing, a nice staple line that includes the vein and the artery is usually observed. Our preferred technique for hilar control is en bloc stapling5; however, if the thickness of the hilum does not allow safe en bloc stapling, a plane is created between the renal vein and all posterior elements to allow the entrance of one of the jaws of the stapler. One load is used to staple all posterior hilar tissue and another to staple the remaining renal vein. The remaining lateral and upper pole attachments are then released and the kidney is extracted inside a laparoscopic bag.

Bottom Line: Conversion to open surgery occurred in 3.1% of patients, and 8% of the patients had a blood transfusion.Complications were recorded in 26% of the patients; 91% of them had Clavien grade scores of 1 or 2.We present a standardized technique for LN.

View Article: PubMed Central - PubMed

Affiliation: Department of Urology, Assaf HaRofeh Medical Center, Tel Aviv, Israel.

ABSTRACT

Introduction: Laparoscopic nephrectomy (LN) is likely the most common laparoscopic procedure performed by general urologists without formal laparoscopic training. The traditional technique is cumbersome because it entails making an early approach to the hilum with the risk of bleeding and need for conversion. We perform a different technique that we believe is simpler to learn and to teach. It consists of a complete dissection of the inferior and posterior aspects of the kidney, followed by en bloc stapling of the renal hilum. The present report is a detailed description of our technique including outcomes and complications.

Materials and methods: Perioperative data of 129 consecutive patients who underwent LN between November 2003 and September 2007 were prospectively collected and retrospectively reviewed. Complications were reported using the Clavien classification system, and follow-up was performed according to our institution's protocol and included physical examination, blood count, blood chemistry, and renal function tests at every visit, in addition to abdominal computed tomography scan six months after surgery. Additional imaging was scheduled according to disease stage and grade.

Results: Mean patient age, tumor size, and operative time were 63±15.6 years, 6.3±2.4 cm, and 128±41.4 minutes, respectively. Median estimated blood loss was 0 mL (0.200). Conversion to open surgery occurred in 3.1% of patients, and 8% of the patients had a blood transfusion. Complications were recorded in 26% of the patients; 91% of them had Clavien grade scores of 1 or 2.

Conclusion: We present a standardized technique for LN. Its main advantage is that postpones any manipulation of the hilum to a later step during the procedure when it is easy to identify and control. This decreases early bleeding and main vascular complications.

No MeSH data available.


Related in: MedlinePlus