Hand-assisted laparoscopic renal surgery

ADVANCEDUROLOGICLAPAROSCOPY

0094-0143/01 $15.00 + .00

HAND-ASSISTED LAPAROSCOPIC RENAL SURGERY Paul T. Fadden, M D a n d Stephen Y. N a k a d a , M D

Since the first laparoscopic nephrectomy reported by Clayman and co-workers2 in 1991, urologists have searched for ways to make laparoscopic nephrectomy less technically demanding and to shorten operative times. The introduction of hand-assisted techniques has allowed significant progress toward this end. The use of a finger through a port site by Winfield 9 and the insertion of a gloved hand by Tschadas were early examples of laparoscopic h a n d assistance. The first hand-assisted laparoscopic n e p h r e c t o m y using a sleeve was reported by Bannenburg and coworkers 2 in 1996 in an experimental porcine model. Shortly thereafter, the authors reported the first clinical cases using the P n e u m o Sleeve (Dexterity, Blue Bell, PA). 6 The same year, Keeley and co-workers3 reported the first hand-assisted laparoscopic nephroureterectomy. To date, several groups have reported early series of hand-assisted laparoscopic nephrectomies and nephroureterectomies (Table 1). 4" 7, 10 General acceptance of the approach in the urologic community continues to grow. The addition of the intraabdominal hand has provided a significant tool for the laparoscopic urologist. Herein, the authors describe their technique, early results, and biases regarding hand-assisted laparoscopic renal surgery.

TECHNIQUE Patient Selection Hand assistance is used selectively at the author's center for laparoscopic nephrectomies that may be difficult owing to inflammation, a large-sized specimen, or multiple previous abdominal procedures. Hand assistance is also advocated in procedures requiring intact specimen removal, such as laparoscopic nephroureterectomies for transitional cell carcinoma and laparoscopic live donor nephrectomy. In addition, renal cell cancers can be removed intact without morcellation. For most other laparoscopic cases, standard laparoscopic techniques are used.

Preoperative Preparation A clean liquid diet is started from the afternoon before operation. The patient takes 8 ounces of magnesium citrate on the evening before the procedure at home. A nasogastric or orogastric tube and Foley catheter are placed in the operating room.

Approach Positioning the Patient The patient is positioned with the flank over the kidney rest, but the latter is only

F r o m the D e p a r t m e n t of Surgery, Division of Urology, U n i v e r s i t y of W i s c o n s i n Medical School, Madison, W i s c o n s i n

U R O L O G I C CLINICS OF N O R T H A M E R I C A VOLUME 28 ° NUMBER 1 ° FEBRUARY 2001

167

168

FADDEN& NAKADA

Table 1. COMPARISON DATA ON EARLY SERIES OF HAND-ASSISTED LAPAROSCOPIC NEPHRECTOMIES Group (number of patients)

Shichman et al7 (30) McGinnis et al4 (22) Wolf et al1° (13)

Procedure

Operating Room Time (minutes)

Nephrectomy Nephroureterectomy Nephrectomy (18) Nephroureterectomy (4) All (13) Nephrectomy (11) Nephroureterectomy (2)

minimally raised to decrease the risk for neuralgia or pressure injuries. The trunk is posit i o n e d s u c h t h a t the u m b i l i c u s is d i r e c t e d slightly anteriorly, and the table is slightly flexed. In this position, the bowel will fall away, and the kidney is easily accessible. The patient can be rotated from a supine to a lateral position as the table is rolled from one side to the other.

Selecting Locations for the Pneumo Sleeve Template and Trocars The base template is typically placed in the midline, above the umbilicus, allowing the surgeon to insert his or her nondominant hand (Fig. 1). The incision is well t o l e r a t e d and allows the surgeon access to the hilum and kidney. Some r i g h t - h a n d e d s u r g e o n s m a y place the template at McBurney's point or below the umbilicus in the midline w h e n per-

........................., . / ....

218.5 292.1 244.0 -240.0 221.0 345.0

Hospital Stay Estimated Blood Loss (days) (mL)

3.5 4.3 4.2 -3.1 ---

203.6 205.0 242.0 -340.0 289.0 625.0

forming a right nephrectomy. Other surgeons have placed the template in the subcostal location. The disadvantage of the subcostal location is that it involves a muscle-splitting technique and m a y be more painful postoperatively. The entire p r o c e d u r e can be p e r f o r m e d with a 12-mm camera port and one to two working ports (12 mm, 5 mm). The 12-mm camera port is placed in the midclavicular line lateral to the rectus and slightly above the umbilicus. The first instrument port (12 mm) is placed in the midaxillary line at the level of the umbilicus, and the second instrument port (5 mm, if needed) is placed in the midclavicular line in the subcostal region. Typical trocar locations are different for a leftor right-handed surgeon (Fig. 1). The location of the template must be kept in mind w h e n placing the trocars. The authors always hold the template on the a b d o m e n w h e n planning port site locations.

............................. ......

",

J ......

"'.j

BO

OA

o, •

I

'-.::L/

................................ ~:S::::S::j;:;:::""

right nephrectomy

left nephrectomy

Figure 1. Port placement and incision location for right and left nephrectomy. One 12-mm port (filled circle) and a second port, A or B (open circle) are utilized. Port A (open circle, right-handed surgeon) or B (open circle, left-handed surgeon) is used depending on the side being treated. Occasionally, an axillary line 5-mm port is used for additional retraction. The surgeon inserts his/her nondominant hand.

HAND-ASSISTED LAPAROSCOPIC RENAL SURGERY: THE PNEUMO SLEEVE

Attaining Pneumoperitoneum and Placing the Initial Trocar Pneumoperitoneum is obtained using lateral insufflation with a Veress needle7 The location of the template must be planned in accordance with placement of the initial trocar. The use of endoscopically guided access trocars allows safe and efficient closed insufflation and initial trocar placement. The open Hasson technique is used in patients with prior abdominal surgery. The pneumoperitoneum pressure is set at 20 mm Hg. The laparoscope is inserted, and the abdomen is inspected for the presence of adhesions. Once safe entry has been verified, the pneumoperitoneum pressure is lowered to 15 mm Hg.

169

The length of the incision in centimeters is the same as the surgeon's glove size. The authors recommend opening the entire incision down to the level of the fascia before opening the p e r i t o n e u m because, once the peritoneal cavity is opened, the pneumoperitoneum is lost. The blue portion of the protractor retractor is placed inside fl~e abdomen. The white plastic ring is then twisted several times until enough tension is achieved. Twisting of the white portion of the protractor retractor is simplified b y forming a compressed loop with the white plastic ring and then inverting that loop to complete the twisting motion (Fig. 3). Once in position, the protractor retractor protects the wound and simplifies placement of the surgeon's hand (Fig. 4).

Attaching the Template Base The length and location of the midline incision are marked off on the abdomen. The surgeon should ensure that the template seal is away from the umbilicus. The template is then attached to the abdomen, pressing it down all around with a dry sponge. The inner seal on the template is particularly critical to maintain the pneumoperitoneum.

Making the Incision Once the template is attached and secured, the incision is made in the midline (Fig. 2).

Inserting the Sleeved Hand and Reestablishing Pneumoperitoneum The surgeon carefully passes each finger of his or her nondominant hand through the tip or hand portion of the sleeve. A second dark glove is then placed on the surgeon's hand over his sleeve. The gloved hand is well lubricated and inserted through the protractor retractor into the abdomen. It is important to ascertain by careful palpation that no loop of intestine is caught in this protractor retractor. The sleeve is then attached to the template, and the surgeon pulls his or her hand back,

q..-. ""~.

;-.

Figure 2. Pneumoperitoneum is obtained using lateral insufflation, the Pneumo Sleeve (Dexterity, Blue Bell, PA) template is placed on the abdomen, and the vertical midline incision approximately 7 cm in diameter is being performed,

170

FADDEN & NAKADA

~

.....

...... ,~..... .

.~.._.

~= -,-•

•.,~,

~ .......

. ~::~ :S.:~/:~

~•ii~:. ¸

~i11:

•

~

!!i~~

41~

•

/

=

~

.

~

i~ •

4.•: --

. =~

..-

==

Figure 3. The blue portion of the protractor retractor is inserted intra-abdominally and the surgeon is in the process of twisting the outer portion of the protractor retractor to achieve an adequate seal around the wound.

:i~,

"::::':!i!

~: . ji i

:;

•

~{

"

~

:

== >~

'::%;!!:;:.4: ~ p~; : ::i :

: ~~!

:,i!iiii' 1:;

:4

...

....

Figure 4. The protractor retractor place in the wound.

:ij ~'~'~!iii¸ " i i '

¸

HAND-ASSISTED

LAPAROSCOPIC

RENAL SURGERY: THE PNEUMO

i

171

:'~ili :¢ ili 14ii",~'

f

....; ¢ % :

:ii~

SLEEVE

d'

! [

ii

~:!ii,

;

", :::, .....

,,

'.

6~~:,,,. ~ , ~ '~'~" )

...... ~

G

'

~

i!

-f :i

'",);i.i ' . . . .

i J:

:, ~~ ' a :', ::; ;, ~,r,i~'.~ ~ i , ~ "

r

/

', "

,,J' "i/

~., ~::2111' .i

'411),iL" Figure 5. Right hand-assisted laparoscopic nephrectomy in progress. Two working ports are typically used for the entire procedure,

creating a seal. With the sleeve attached to the template, the pneumoperitoneum can be reestablished, and the remainder of the working ports can be inserted under endoscopic guidance.

Incising the Line of Toldt Dissection begins once the surgeon's hand is inserted into the abdomen and a w-orking port and camera port have been placed (Fig. 5). The line of ~[bldt is incised using an Endoshear dissector down to the level of the iliac vessels (Fig. 6). The surgeon uses his or her hand to identify the extrafascial plane and quickly completes this part of the procedure in a bloodless manner. The colon should be mobilized fully and brought medially to identify the correct plane of dissection for the remainder of the kidney.

Freeing Superior and Lateral Attachments to the Kidney The surgeon must free the superior and lateral attachments to the kidney early in the procedure. During a left n e p h r e c t o m y the kidney is separated completely from its splenic attachments. The authors have often used the 5-mm curved attachment for the h a r m o n i c scalpel (Ethicon, E n d o s u r g e r y ,

Cinncinati, OH) for this purpose. A 30 ° lens and hook electrode are also useful during this segment of the procedure. Tile lateral attachments are freed in an inferior to superior direction starting at the lower pole of the kidney: The posterior attachments are left intact early in the procedure to allow the kidney to remain relatively stable.

Identifying and Securing the Ureter Early identification and division of the ureter are considered advantageous in the performance of radical nephrectomy. Once the ureter is divided, it can be used to retract the kidney. The ureters are not stinted preoperatively for this procedure to conserve time, and the surgeon's hand can be used to identify and aid in the dissection of the ureter. The ureter is divided between 11-mm clips. During the dissection, the gonadal vein is usually identified. During a left nephrectomy, the surgeon can follow the gonadal vein to the renal hilum. For a nephroureterectomy, the ureter is left intact until the nephrectomy is completed.

Dissecting the Lower Pole of the Kidney The lower pole of the kidney is now dissected using electrocautery and hand assistance. The posterior and lateral aspects are

172

FADDEN

& NAKADA

i

:. ~:'.C'.".~. J-:.'."

.,,;~,~'~;i..~ ,.... ;,~,~ ~'."'~'": '"

Figure 6, Dissection of the upper pole of the kidney is performed.

freed first, followed by dissection toward the hilum. Dissection should be cautious along the medial aspect of the lower pole because lower pole arteries are often encountered.

Identifying and Dissecting the Renal Artery and Vein Dissection of the renal vessels is similar to an open procedure. The renal vein is identified first, and the renal artery can usually be palpated at a plane, The renal vein and artery are then dissected free (Fig. 7). A 30 ° lens is often helpful during this portion of the procedure. In patients who have complex anatomic variations, it may be necessary to dis-

"\,

sect the posterior attachments to the kidney and flip the kidney anteriorly to identify the renal artery from the posterior aspect. Early posterior ligation of the renal artery has been useful when performing nephrectomy. In addition, in difficult dissections, simply clipping the main renal artery will make the kidney smaller and easier to manipulate.

Freeing the Posterior Attachments The posterior attachments should be completely freed after the renal artery and vein have been identified. The kidney should be mobile superiorly, inferiorly, laterally, and posteriorly. The only remaining attachments

.~"

" 7£

¢

Figure 7. Identification of the renal hilum, The laparoscopic right angle is preferred for dissection around the hilum along with the hook electrode and the 5-ram harmonic scalpel.

HAND-ASSISTEDLAPAROSCOPICRENALSURGERY:THE PNEUMOSI,EEVE

173

!

t

•

°=r;,

."

• ,...;.

• ..

:

"

,.',

Figure 8. The entire renal hilum has been freed and is between the fingers of the surgeon, should be the renal hilum, and any cephalad attachments to the kidney, such as the adrenal gland (Fig, 8).

Division of the Renal Hilum The renal hilum is divided in two steps. The renal artery is clipped with a total of four 11-mm clips, two proximal and two distal, and divided (Fig. 9). The renal vein is stapled using vascular loads only. It is crucial that the surgeon ensure that the stapler is well beyond the distal aspect of the renal vein before sta~ pling the vein. The intra-abdominal hand has a key role in these maneuvers by assisting with the application of the stapler and clip applier.

Completing the Nephrectomy With the renal hilum divided, the only remaining attachments are medial and cephalad and usually related to the adrenal gland. An en bloc resection of the adrenal gland is performed for radical nephrectomies for upper pole tumors. The adrenal is left in situ for simple nephrectomies and radical nephrectomy for lower pole cancer. The remaining attachments can be freed using clips and cautery.

Lowering Pneumoperitoneum and Assessing for Bleeding The p n e u m o p e r i t o n e u m is l o w e r e d to 5 mm Hg, and the renal fossa is inspected for

bleeding (Fig. 10). Once the surgeon is satisfied that there is no significant bleeding, the specimen is manuevered in an entrapment sac and r e m o v e d after disengaging this sleeve. The plastic dome or surgeon's glove is then reinserted, and the p n e u m o p e r i t o neum is reestablished for port closure.

Closing the Ports and Abdominal Incision Closure devices are helpful for closing port sites, particularly in obese patients. Endoscopic guidance should be used during closure to avoid inclusion of omentum and intraperitoneal contents. The abdominal incision is closed in a standard fashion using interr u p t e d 0 polyglycolic acid sutures. Skin wounds are closed with absorbable subcuticular sutures.

HAND-ASSISTED LAPAROSCOPIC NEPHROURETERECTOMYmSPECIAL CONSIDERATIONS Hand-assisted laparoscopic nephroureterectomy is performed in the same manner as hand-assisted n e p h r e c t o m y except that the ureter is dissected down to the level of the bladder. Numerous techniques have been described for managing the distal ureter. Some surgeons staple the ureter distally, and then perform resectoscopic fulgeration of the ureteral office at the conclusion of the procedure.

174

EADDEN& NAKADA

",lmml~/R , "~."." ~ : ~ ; ' ~. q J~Y "..:. ";'¢~',4,[~.~,' ...~.x... t~i~m~JBr,~:,..~,: " !'.~5",:': ' ',' ~':. . ;, , -..~.~:;[~ . '~ ,.,. ~.

~rlmNiinmg~::~!.

I•

.,:

~. ";.; '~,.. ."

;

.

,..

~.'

[,

I

Figure 9. An accessory renal artery has been ligated just below the renal vein and the main renal artery has been quadruply ligated with titanium clips.

The author typically uses a 24-F resectoscopic and Collins knife and frees the ureter b y transurethrally resecting the ureteral orifice, tunnel, and intramural ureter into the peri.vesical fat. Hemostasis is achieved with cautery, and a Foley catheter is placed in the bladder. Some surgeons laparoscopically ligate the ureter within the bladder to prevent tumor spillage. The surgeon can now pluck the ureter cephalad during the laparoscopic portion of the procedure. The drawback to this approach is the possibility of draining malignant cells into the retroperitoneum. A

Foley catheter is left in place for 10 days postoperatively. A cystogram is performed in the office before catheter removal.

POSTOPERATWE

CARE

Patients start a clear liquid diet on the evening of surgery. Early ambulation is encour; age& Most patients are discharged on the third or fourth postoperative day once tolerating a regular diet and with adequate pain

o .,...

.~

i"

Figure 10, Following removal of the nephrectomy specimen the staple line of the renal vein and the remaining clips from the renal artery are identified without evidence of any bleeding.

HAND-ASSISTED LAPAROSCOPIC RENAL SURGERY: THE PNEUMO SLEEVE

control. A return to normal activity typically occurs 10 to 14 days postoperatively.

RESULTS Shichman and McGinnis and their colleagues have p u b l i s h e d excellent results performing hand-assisted laparoscopic nephrectomy and nephroureterectomy with reasonable operative times (Table 1). 4' 7 The authors' combined series demonstrate that patients u n d e r g o i n g hand-assisted laparoscopic renal surgery have similar convalescence to patients undergoing standard laparoscopic procedures. ~° The authors' most recent short-term data indicate that hand-assisted laparoscopic radical nephrectomy and laparoscopic nephroureterectomy continue to be a time-conserving approach with reasonable convalescence. The authors have performed 17 hand-assisted radical nephrectomies in a mean total operative time of 222 minutes, with a mean estimated blood loss of 171 mL, a mean hospital stay of 3.9 days, and a mean return to normal nonstrenuous activity of 16 days. Five nephroureterectomies for transitional cell carcinoma have been performed with a mean hospital stay of 5 days and a mean return to nonstrenuous normal activity at 2.5 weeks. Further long-term data with regard to cancer follow-up are pending in all series. 4, 7,10,11

COMMENT The evolution of laparoscopic urology continues. Although some may view hand-assisted laparoscopic surgery as a step backward, h a n d assistance really b r o a d e n s the scope of laparoscopy and increases the potential surgeon pool. Because many of the skills required for hand-assisted laparoscopic surgery are already mastered by many urologists, this approach may be more readily accepted by more urologists. Advanced laparoscopy should not be a skilt limited to only a small fraction of urologists. For the newer laparoscopist, hand-assisted laparoscopic surgery is a way to begin performing laparoscopic renal procedures with more confidence. Urologists have often lacked adequate training cases, requiring many urologists to begin training with nephrectomies. Hand-assisted laparoscopic surgery should

175

encourage more urologists to undertake laparoscopic nephrectomy. Hand-assisted laparoscopic surgery offers sufficient benefits in postoperative convalescence as compared with traditional open surgery. Hand-assisted laparoscopic surgery is associated with rapid dissection and a significantly shorter learning curve when compared with traditional laparoscopy. For the experienced laparoscopist, hand-assisted laparoscopic surgery is an additional option in more complex cases, allowing the surgeon to convert to hand assistance. The authors prefer this approach for laparoscopic partial nephrectomy. Laparoscopic donor nephrectomies are being performed at numerous institutions using hand assistance. Although currently used hand-assisted devices are improved ergonomically, easier to deploy, and maintain p n e u m o p e r i t o n e u m better than the prototype used in 1996, there is room for improvement. At the time of this writing, four companies produce a hand-assist device. Technology must continue to move forward as the techniques of hand-assisted laparoscopic surgery are refined. With more widespread acceptance and increased patient data, hand assistance should have a significant role in minimally invasive urology for a long time to come. References 1. Bannenburg JJG, Maijer DW, Bannenburg JH, et ah Hand-assisted laparoscopic nephrectomy in the pig: Initial report. Minim Invas Ther Allied Tech 5:483, 1996 2. Clayman RV, Kavoussi LR, Soper NJ, et al: Laparoscopic nephrectomy: Initial case report. J Uro1146:278282, 1991 3. Keeley FX, Sharma NK, Tolley DA: Hand-assisted laparoscopic nephroureterectomy [abstract 1565]. J Urol 157:399A, 1997 4. McGinnis DE, Trabulsi E, Gomella LG, et ah Handassisted laparoscopic nephrectomy (HALN): A promising technique [abstract PSA-9]. J Endourol 13:$1A63, 1999 5. Nakada SY, McDougall EM, Clayman RV: Renal Surgery. In Smith AD, Badlani GH, Bagley DH, et al (eds): Smith's Textbook of Endourology, vol 2. St. Louis, Quality Medical Publishing, 1996, pp 907-908 6. Nakada SY, Moon TD, Gist M, et al: Use of the Pneumo Sleeve as an adjunct in laparoscopic nephrectomy. Urology 49:612-613, 1996 7. Shichman SJ, Wong JE, Sosa E, et al: Hand-assisted laparoscopic radical nephrectomy and nephroureterectomy: A new standard for the 21st century [abstract 76]. J Urol 161:23, 1999 8. Tschada RK, Rassweiler JJ, Schmeller N, et ah Laparoscopic tumor nephrectomy--the German experiences [abstract 1003]. J Urol 153(suppl):479A, 1995

176

FADDEN & NAKADA

9. Winfield HN, Chen RN, Donovan JF: Laparoscopic tricks of the trade: How to overcome lack of tactile feedback [abstract 513]. J Endourol 10:$189, 1996 10. Wolf JS Jr, Moon TD, Nakada SY: Hand-assisted la-

paroscopic nephrectomy: Comparison to standard nephrectomy. J Urol 160:22-27, 1998 11. Fadden P, Moon TD, Nakada SY: Hand-assisted radical nephrectomy: Wisconsin experience. J Endo 14:A31, 2000

Address reprint requests to Stephen Y. Nakada, MD Department of Surgery, Division of Urology Section of Endourology and Stone Disease University of Wisconsin Medical School G5/343 Clinical Science Center 600 Highland Avenue Madison, W! 53792