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Name:
Laparoscopic Radical Nephrectomy
Description:
Laparoscopic Radical Nephrectomy
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Upload Date:
2023-10-19T00:00:00.0000000
Transcript:
Language: EN.
Segment:1 INTRODUCTION.
LEE RICHSTONE: My name is Lee Richstone. I'm the chairman of Urology at the Smith Institute for Urology at Lenox Hill, part of Northwell Health. This video will describe laparoscopic radical nephrectomy, pointing out fundamental aspects of the approach, and tips and tricks.
Segment:2 DOUBLE VERESS TECHNIQUE.
LEE RICHSTONE: Typically, I employ a Veress needle technique. This particular patient has prior surgery performed robotically on the left-hand side, so various other sites.
LEE RICHSTONE: This is something I call the double Veress technique that I developed as a method to still use the Veress technique with prior surgical incision. So in this case, a free area is the right upper quadrant in a subcostal location. There's no prior surgery there. We do an aspiration and drop test and then start developing new peritoneum. And you're looking for low opening pressures of less than 5 millimeters of mercury, which we had.
LEE RICHSTONE: So then I employ a second Veress needle and I place it in a desired location for one of our ports, a place that would work for us. And the first thing I listen for is gas return. And if you tap on the Veress needle there, you can hear gas coming through. And that gives me a sense that we're in a clear position. And then I can rotate that needle and feel, in a tactile way, is there any obstruction or adhesions or anything that is encumbering the movement of the needle?
LEE RICHSTONE: Just to point out, this is something, after thousands of cases using a typical straightforward Veress technique, these are some tips and tricks of how you can use a Veress needle in a more complex fashion and still gain access. And I've employed this method safely in many, many cases. And it is just some additional tips and tricks. But I wouldn't advise these kind of complex maneuvers or approach to this unless you have significant experience beneath your belt.
LEE RICHSTONE: So this particular case is a 50-year-old woman, and she presented with gross hematuria. On the scan, you see that she has an indeterminate adrenal mass on the right and a large, largely endophytic renal mass on the right that is heterogeneously enhancing and solid and consistent with a renal cell carcinoma until proven otherwise. The adrenal lesion was a couple of centimeters. And as I stated, it was indeterminate.
LEE RICHSTONE: It could not be definitively judged to be an adenoma. And therefore, we planned for a laparoscopic right radical nephrectomy and adrenalectomy. The size was 6 centimeters. Also notable for some central calcification and irregularity. And we begin now with access. After access is obtained, we begin with colon mobilization. I typically start off by telling my trainees to stop, look, and listen, which is what my children were told in school.
LEE RICHSTONE: Stop, look, and listen. And you're looking for the appropriate anatomy. And the things that you're looking for, in particular, you're identifying the colon. You're looking for the mesenteric fat and where that mesenteric fat becomes essentially Gerota's. And you make an incision in the peritoneum and then work cephalad and in a caudal direction to free up the colon along the white line of Toldt.
LEE RICHSTONE: So much of this dissection can be done bluntly, and I really like to open up that envelope there. I call it "opening the book" in both directions. It's kind of like opening the front cover of a book in both directions. And you can make a lot of progress before employing any energy. And you kind of dissect that all out. You know it's clear instead of just scoring along the white line in a big broad way without first dissecting out these layers.
LEE RICHSTONE: This all comes apart like a puzzle. Laparoscopic renal surgery is like taking apart a puzzle. You need to know the planes. And if you separate those planes, it'll make the easy cases easy and it'll make the hard cases easier. When everything's stuck together in an XGP case or a difficult cancer case, knowing where these planes are and how they should separate will make life much easier for you.
LEE RICHSTONE: So it's important to get the colon out of the way, to always be aware of the colon to prevent injury, and being aware of the degree of thermal spread, whether you're using a scissor, a ligature, as in this case, or a harmonic. You're ever mindful of that. As you look down into the pelvis here, you're mindful of the appendix. You can have a retrocecal appendix and you can get the appendix here, if you're not careful.
LEE RICHSTONE: So you're always kind of looking for the appendix for the colon, and then move up. Now, here, I'm going to point out the mesenteric fat and that interface between the mesenteric fat in a certain kind of yellow color there. And if you lift up and move, you can see vessels below, in the Gerota's, and then these vessels of the parietal peritoneum there. And they kind of cross over one another.
LEE RICHSTONE: And as you move it back and forth, you can get the sense of that single cell layer that you need to go through. I'm going to point that out right here. And you can appreciate the two layers. And this is kind of the stop, look, and listen. Just look. Identify that mesenteric fat. Grab it just lateral to the colon.
LEE RICHSTONE: Lift it up and towards us. And then get through that single layer without injuring or scoring or getting into Gerota's. And then once you're into that layer, that's the first real main step of this operation, is identifying that layer, getting cleanly onto Gerota's, and mobilizing the colon. And not going posteriorly, which we're pointing out there. That's the areolar plane that gets you behind the kidney.
LEE RICHSTONE: And time and time and time again, residents and trainees will want to go to that lateral areolar plane and get behind the kidney. It's like a moth to a flame. You're just drawn to it, because it seems like a plane. But you stop, look, and listen. Look for that mesenteric fat and identify that layer and get yourself right on top of Gerota's. It's the opening move.
LEE RICHSTONE: It's like the opening move of a chess game. And getting yourself right onto that plane in the beginning sets the stage for the whole subsequent set of events and steps. Again, here, I was looking back for the appendix. Now we're up towards the caudal extent of the kidney and opening the book, if you will, towards the head. And that's the liver on the right. In this particular case, we're not using a liver retractor.
LEE RICHSTONE: I often do. But you'll see how we negotiate around that. So with that right hand, grabbing the cut edge of the peritoneum and again, dissecting and spreading and opening the book and staying right on Gerota's. So you can see now we're working up towards the head. And again, we'll grasp the upper edge of the peritoneum and open the book to the right, do some blunt dissection, staying right on Gerota's.
LEE RICHSTONE: And you're looking now for the duodenum. You're looking for the adrenal gland. And you'll see right now in this patient, it's pretty thin, that you can already see the adrenal gland right there. People often talk about a nacho cheese colored yellow. But there's the adrenal gland. The second thing to point out now is as you further direct this plane, you want to go towards the triangular ligament of the liver, not over towards the gallbladder.
LEE RICHSTONE: So in that direction there. And you just continue to spread. Open up these planes. The duodenum is starting to come into view right there. This is critical. And you're thinking about the duodenum. And here, you'll see how I'm using that right hand to take advantage of the planes and retract the liver as I retract the peritoneum and the colon.
LEE RICHSTONE: And just doing that together and working up, again, towards the triangular ligament, towards the liver. And taking advantage of the natural planes here, which separate in a fairly avascular way. Now, once that's done, we'll start cauterizing the duodenum, which is seen here. The liver, the adrenal gland, and the kidney. Care must be taken, of course, to avoid any injury to the duodenum.
LEE RICHSTONE: This is done athermally and sharply. I typically just use a pair of scissors and cut 1 or 2 centimeters away from the duodenum. There's no reason to be right on the duodenal edge here. Oftentimes, the residents, I'm just telling them to step away from the duodenum. They're just a little too close. Some of these little capillaries and vessels in that single cell layer can ooze a little bit.
LEE RICHSTONE: Just tolerate it. Cut it sharply. It's never a massive amount of bleeding, and it can be tolerated. So the duodenum is seen there. And again, we'll continue to cauterize the duodenum. And this is obviously critical. Any duodenal injuries can be life-threatening. And you see here, again still some more of these vessels.
LEE RICHSTONE: Even though I see those little blood vessels there, I'm OK if they ooze a little bit. I want to be sharp here and just incise that layer. And then turn the scissors around. Use the back of the scissor and just gently sweep down and cauterize. I turned the scissors around. You've got to be facile with the instrument and have your forefinger able to just do that quickly.
Segment:3 IDENTIFYING URETER AND PSOAS MUSCLE.
LEE RICHSTONE: So now we'll move forward to the second main step of the operation. The first is colon mobilization. The second is utereral identification. Once you've mobilized the colon and the duodenum medially, and we're seeing the vascular structures there, the gonadal and the cava will come into view-- once that's been medialized, then you start picking up the lower pole.
LEE RICHSTONE: So the left hand can-- in this case, on a right-sided kidney, the lower pole can be lifted up, and you're starting to look at where you want to go under. In this particular case, the ureter is visible right away. Oftentimes, there's fat and you won't see it, or you'll see the gonadal first. Most cases, what I'd like to do is get the ureter up and keep the gonadal down. You usually don't need-- on the right side, if you're underneath the gonadal and you go up towards the hilum, you'll risk avulsing the gonadal, and you're just too medial.
LEE RICHSTONE: And on the left side, you're not going to avulse it off the cava, but you're going to be very medial, unnecessarily medial. So in this case, it's pretty apparent. And this is called a hand under hand technique, so gentle lifting up anteriorly, and then the other hand comes up, et cetera. And hand under hand. And you want to keep the psoas fascia down.
LEE RICHSTONE: If you raise the psoas fascia off the muscle-- and you can see, the psoas fascia is real and it often is a very well-defined layer, almost looks like a little hernia sac of tissue. But you want to keep that down, and you don't want to injure any of the structures on the psoas to cause numbness or any neuromuscular injuries or sensations to the patient. So this is the second critical step.
LEE RICHSTONE: Colon mobilization, and then getting under the ureter. Now, I call this the neutral position, and so I'll refer to that. This is the neutral position, meaning that the kidney is up. You're under the ureter. And the renal hilum will then be in that location, as depicted. And you need to open up Gerota's to identify the hilum and march to the hilum. So I call the next step, the third step, the march to the hilum.
LEE RICHSTONE: And so you grasp that layer of Gerota's and dissect underneath it. And then take it. And so here, you lift it up and you kind of back down. And again, opening up the layers. These layers exist. And take advantage of them. And then you take them with some energy, and you open up this whole area on the march to the hilum.
LEE RICHSTONE: You start seeing the gonadal. You don't have a single layer anymore of Gerota's, but you have fat that can be dissected, made into fascicles, and you can approach the hilum. The next step of the operation is dissecting the renal hilum.
Segment:4 DISSECTING THE RENAL HILUM.
LEE RICHSTONE: And once you've opened up Gerota's, renal vein is usually seen fairly readily with some sweeping and blunt dissection. And again, beneath the hilum or inferior caudal to the hilum, there's some fatty tissue.
LEE RICHSTONE: You're looking for a renal artery or accessory vessels in that area in all of this tissue here. Usually, we find the renal artery immediately lateral to the vein. And typically, we'll take the inferior hand-- so on a right-sided case, that's the left hand. And that hand is poised to hug behind the vein and parallel to the great vessels. And hug behind the vein and dissect out the artery.
LEE RICHSTONE: In this particular case, as you'll see, the artery is in a cephalad position. It's found well above the renal vein, so it's a little bit different. So I'm going to show you now a little bit. What we would typically do here is with the right hand, we would lift up the kidney, because that's not going to get you behind the vein. This left hand will get you behind the vein, parallel to the great vessels.
LEE RICHSTONE: Now, there's a couple of different ways to elevate the kidney. In this particular case, you could just retract up with a grasper or with the suction. Anything can lean up on the kidney. It's not that fatty. Some kidneys are big and floppy, a lot of fat or a huge tumor, and you can lean into the kidney with an open laparoscopic Debakey, as seen here.
LEE RICHSTONE: So you can lift under, you can lean in, or you can grasp the perinephric fat and just pull up. So that's a teaching point. There's three ways to raise up the kidney and get retraction. Now, again, this is that inferior hand hugging behind the vein, looking for the artery. And usually, it's right behind and you can insert the sucker, gently dissect in between the vein and the artery.
LEE RICHSTONE: In this particular case, the artery is closer to the head in a cephalad position. So we're going to drop the kidney down and start dissecting cephalad to the vein in order to identify the artery, which you see there. So you have renal vein. We clip the gonadal. In this case, to the left of the screen. And now, we're going to work on the artery.
LEE RICHSTONE: So this case is a little bit easier in that the artery is so medial and above the vein. So some blunt dissection between the artery and vein. Again, that right hand is using a laparoscopic Debakey. That is my instrument of choice. I always use that. I do prefer a Ligasure. That big 10 Ligasure is a big, heavy instrument that allows for great anterior retraction of the kidney.
LEE RICHSTONE: You can take all that lateral tissue and upper pole tissue with-- you can take a lot of, tissue and it gets great hemostasis and great bulk to the instrument for dissection. So again, we continue to dissect out the renal artery with spreading, and we've gotten our fascicle above and below. A stapler is employed to take the renal hilum, ensuring that we have a vascular load with the appropriate staple size.
LEE RICHSTONE: I upsized my right hand here. Usually, there's a 5-millimeter port for the right hand, but I upsized it, just because I had a great angle for the renal artery that was safe. So we take the artery. Try to limit the amount of torque on the instrument as we fire. And then in sequence, we then take the renal vein with another load of the stapler, as seen here.
LEE RICHSTONE: We ensure that we see the tips. We ensure that this vessel is going to the kidney, nowhere else. We don't want to be taking any of the great vessels or the SMA or the SMV, or any other kind of vessels. So they're going to the kidney. They're clearly defined. We see the tips of the stapler. And we know what we're taking.
LEE RICHSTONE: So now, we're going to march up. And in this case, again, there was an indeterminate adrenal lesion. So the adrenal gland is going to be taken. And you can see that right here. You see the adrenal lesion. So we're going to hug the cava and work up the cava. The adrenal vein is identified here, which will be clipped. We've already dissected off some of the adrenal gland medially, and we're going to continue to work that medial plane, as well as the cephalad plane underneath the liver.
LEE RICHSTONE: Now, I've done a lot of these cases, so I'm able to get away without a liver retractor here. Obviously, this would be made easier by having a liver retractor, so I often employ one. I don't endorse obviating a liver retractor in all cases. But in this case, we didn't use one. And as you see here now, the Ligasure is employed to get some of the stellate blood supply to the adrenal gland, keeping the cava in view, obviously, and ensuring that this is not taking the cava in any way.
LEE RICHSTONE: The cava is clearly seen more medially there to the right of the screen. And then we kind of work up the rest of the attachments between the upper aspect of the adrenal gland, and just take this on block with the kidney. And again, you see here how the 10-millimeter Ligasure is a great instrument. It just gets excellent hemostasis, and you can take a lot of tissue at any one time.
LEE RICHSTONE: It also is meaty enough to help retract down both the adrenal gland and the liver with that downward force, because it's got the force to do so. And so then the specimen is completely liberated there. And you see the hilum well controlled, using a little bit of fibular here just in the adrenal bed. And we have a nice, dry field. And that leaves the lateral attachments and it leaves the transection of the ureter as the sole remaining attachments here.
LEE RICHSTONE: And so we'll go through that now, the lateral attachments
Segment:5 LATERAL ATTACHMENTS AND URETERAL DISSECTION.
LEE RICHSTONE: and utereral dissection. And then we'll be able to bag our specimen. So the ureter here is clipped. And the Ligasure, again, is an excellent instrument to go through all of this tissue and do it expeditiously and with excellent hemostasis. So the ureter is taken.
LEE RICHSTONE: The lateral attachments and inferior attachments are taken, making sure to stay outside of Gerota's, and perform a radical nephrectomy in that manner, outside of Gerota's. And we'll continue that dissection. The specimen is bagged in an Endo Catch bag. It's extremely important that this is done under direct visualization.
LEE RICHSTONE: You don't want anything else in there. You don't want to get loops of bowel or anything incorporated in there. And then you close the metal loop, also under view. So you can see here that we have a dry field. The field is inspected. The specimen is extracted. It is always good practice to re-insufflate after the specimen is extracted.
LEE RICHSTONE: Directly visualize from a laparoscopic view your extraction sites, and ensure that no bowel or other visceral structures is incorporated into the enclosure. This also allows you to view the operative field, the dissection field, after the release of pneumoperitoneum for several minutes while you're extracting the specimen. There's no pneumoperitoneum to tamponade bleeding. You then re-insufflate, reexamine the field, and ensure that there's been no accumulation of blood products or any other evidence of injury.
LEE RICHSTONE: Pathology revealed a T1b clear cell renal cell carcinoma, Fuhrman grade 3. The adrenal lesion was a benign adenoma. In this video, we've presented the fundamental steps for a laparoscopic radical nephrectomy. To review, this begins with safe access. The first step of the operation is incision along the white line of Toldt and colon mobilization. The second step of the operation is getting under the ureter and anteriorly retracting the kidney and lower pole.
LEE RICHSTONE: The next step of the operation is the "march to the hilum," beginning with an incision of the anterior leaflet of Gerota's fascia, and identifying the renal artery and vein. This is followed by safe ligation of the artery and vein with a stapler, and then proceeding finally with the upper pole and lateral attachments. We hope that this was educational, and wish you safe and enjoyable adventures with renal laparoscopy.
LEE RICHSTONE: Thank you.
Segment:1 INTRODUCTION.
LEE RICHSTONE: My name is Lee Richstone. I'm the chairman of Urology at the Smith Institute for Urology at Lenox Hill, part of Northwell Health. This video will describe laparoscopic radical nephrectomy, pointing out fundamental aspects of the approach, and tips and tricks.
Segment:2 DOUBLE VERESS TECHNIQUE.
LEE RICHSTONE: Typically, I employ a Veress needle technique. This particular patient has prior surgery performed robotically on the left-hand side, so various other sites.
LEE RICHSTONE: This is something I call the double Veress technique that I developed as a method to still use the Veress technique with prior surgical incision. So in this case, a free area is the right upper quadrant in a subcostal location. There's no prior surgery there. We do an aspiration and drop test and then start developing new peritoneum. And you're looking for low opening pressures of less than 5 millimeters of mercury, which we had.
LEE RICHSTONE: So then I employ a second Veress needle and I place it in a desired location for one of our ports, a place that would work for us. And the first thing I listen for is gas return. And if you tap on the Veress needle there, you can hear gas coming through. And that gives me a sense that we're in a clear position. And then I can rotate that needle and feel, in a tactile way, is there any obstruction or adhesions or anything that is encumbering the movement of the needle?
LEE RICHSTONE: Just to point out, this is something, after thousands of cases using a typical straightforward Veress technique, these are some tips and tricks of how you can use a Veress needle in a more complex fashion and still gain access. And I've employed this method safely in many, many cases. And it is just some additional tips and tricks. But I wouldn't advise these kind of complex maneuvers or approach to this unless you have significant experience beneath your belt.
LEE RICHSTONE: So this particular case is a 50-year-old woman, and she presented with gross hematuria. On the scan, you see that she has an indeterminate adrenal mass on the right and a large, largely endophytic renal mass on the right that is heterogeneously enhancing and solid and consistent with a renal cell carcinoma until proven otherwise. The adrenal lesion was a couple of centimeters. And as I stated, it was indeterminate.
LEE RICHSTONE: It could not be definitively judged to be an adenoma. And therefore, we planned for a laparoscopic right radical nephrectomy and adrenalectomy. The size was 6 centimeters. Also notable for some central calcification and irregularity. And we begin now with access. After access is obtained, we begin with colon mobilization. I typically start off by telling my trainees to stop, look, and listen, which is what my children were told in school.
LEE RICHSTONE: Stop, look, and listen. And you're looking for the appropriate anatomy. And the things that you're looking for, in particular, you're identifying the colon. You're looking for the mesenteric fat and where that mesenteric fat becomes essentially Gerota's. And you make an incision in the peritoneum and then work cephalad and in a caudal direction to free up the colon along the white line of Toldt.
LEE RICHSTONE: So much of this dissection can be done bluntly, and I really like to open up that envelope there. I call it "opening the book" in both directions. It's kind of like opening the front cover of a book in both directions. And you can make a lot of progress before employing any energy. And you kind of dissect that all out. You know it's clear instead of just scoring along the white line in a big broad way without first dissecting out these layers.
LEE RICHSTONE: This all comes apart like a puzzle. Laparoscopic renal surgery is like taking apart a puzzle. You need to know the planes. And if you separate those planes, it'll make the easy cases easy and it'll make the hard cases easier. When everything's stuck together in an XGP case or a difficult cancer case, knowing where these planes are and how they should separate will make life much easier for you.
LEE RICHSTONE: So it's important to get the colon out of the way, to always be aware of the colon to prevent injury, and being aware of the degree of thermal spread, whether you're using a scissor, a ligature, as in this case, or a harmonic. You're ever mindful of that. As you look down into the pelvis here, you're mindful of the appendix. You can have a retrocecal appendix and you can get the appendix here, if you're not careful.
LEE RICHSTONE: So you're always kind of looking for the appendix for the colon, and then move up. Now, here, I'm going to point out the mesenteric fat and that interface between the mesenteric fat in a certain kind of yellow color there. And if you lift up and move, you can see vessels below, in the Gerota's, and then these vessels of the parietal peritoneum there. And they kind of cross over one another.
LEE RICHSTONE: And as you move it back and forth, you can get the sense of that single cell layer that you need to go through. I'm going to point that out right here. And you can appreciate the two layers. And this is kind of the stop, look, and listen. Just look. Identify that mesenteric fat. Grab it just lateral to the colon.
LEE RICHSTONE: Lift it up and towards us. And then get through that single layer without injuring or scoring or getting into Gerota's. And then once you're into that layer, that's the first real main step of this operation, is identifying that layer, getting cleanly onto Gerota's, and mobilizing the colon. And not going posteriorly, which we're pointing out there. That's the areolar plane that gets you behind the kidney.
LEE RICHSTONE: And time and time and time again, residents and trainees will want to go to that lateral areolar plane and get behind the kidney. It's like a moth to a flame. You're just drawn to it, because it seems like a plane. But you stop, look, and listen. Look for that mesenteric fat and identify that layer and get yourself right on top of Gerota's. It's the opening move.
LEE RICHSTONE: It's like the opening move of a chess game. And getting yourself right onto that plane in the beginning sets the stage for the whole subsequent set of events and steps. Again, here, I was looking back for the appendix. Now we're up towards the caudal extent of the kidney and opening the book, if you will, towards the head. And that's the liver on the right. In this particular case, we're not using a liver retractor.
LEE RICHSTONE: I often do. But you'll see how we negotiate around that. So with that right hand, grabbing the cut edge of the peritoneum and again, dissecting and spreading and opening the book and staying right on Gerota's. So you can see now we're working up towards the head. And again, we'll grasp the upper edge of the peritoneum and open the book to the right, do some blunt dissection, staying right on Gerota's.
LEE RICHSTONE: And you're looking now for the duodenum. You're looking for the adrenal gland. And you'll see right now in this patient, it's pretty thin, that you can already see the adrenal gland right there. People often talk about a nacho cheese colored yellow. But there's the adrenal gland. The second thing to point out now is as you further direct this plane, you want to go towards the triangular ligament of the liver, not over towards the gallbladder.
LEE RICHSTONE: So in that direction there. And you just continue to spread. Open up these planes. The duodenum is starting to come into view right there. This is critical. And you're thinking about the duodenum. And here, you'll see how I'm using that right hand to take advantage of the planes and retract the liver as I retract the peritoneum and the colon.
LEE RICHSTONE: And just doing that together and working up, again, towards the triangular ligament, towards the liver. And taking advantage of the natural planes here, which separate in a fairly avascular way. Now, once that's done, we'll start cauterizing the duodenum, which is seen here. The liver, the adrenal gland, and the kidney. Care must be taken, of course, to avoid any injury to the duodenum.
LEE RICHSTONE: This is done athermally and sharply. I typically just use a pair of scissors and cut 1 or 2 centimeters away from the duodenum. There's no reason to be right on the duodenal edge here. Oftentimes, the residents, I'm just telling them to step away from the duodenum. They're just a little too close. Some of these little capillaries and vessels in that single cell layer can ooze a little bit.
LEE RICHSTONE: Just tolerate it. Cut it sharply. It's never a massive amount of bleeding, and it can be tolerated. So the duodenum is seen there. And again, we'll continue to cauterize the duodenum. And this is obviously critical. Any duodenal injuries can be life-threatening. And you see here, again still some more of these vessels.
LEE RICHSTONE: Even though I see those little blood vessels there, I'm OK if they ooze a little bit. I want to be sharp here and just incise that layer. And then turn the scissors around. Use the back of the scissor and just gently sweep down and cauterize. I turned the scissors around. You've got to be facile with the instrument and have your forefinger able to just do that quickly.
Segment:3 IDENTIFYING URETER AND PSOAS MUSCLE.
LEE RICHSTONE: So now we'll move forward to the second main step of the operation. The first is colon mobilization. The second is utereral identification. Once you've mobilized the colon and the duodenum medially, and we're seeing the vascular structures there, the gonadal and the cava will come into view-- once that's been medialized, then you start picking up the lower pole.
LEE RICHSTONE: So the left hand can-- in this case, on a right-sided kidney, the lower pole can be lifted up, and you're starting to look at where you want to go under. In this particular case, the ureter is visible right away. Oftentimes, there's fat and you won't see it, or you'll see the gonadal first. Most cases, what I'd like to do is get the ureter up and keep the gonadal down. You usually don't need-- on the right side, if you're underneath the gonadal and you go up towards the hilum, you'll risk avulsing the gonadal, and you're just too medial.
LEE RICHSTONE: And on the left side, you're not going to avulse it off the cava, but you're going to be very medial, unnecessarily medial. So in this case, it's pretty apparent. And this is called a hand under hand technique, so gentle lifting up anteriorly, and then the other hand comes up, et cetera. And hand under hand. And you want to keep the psoas fascia down.
LEE RICHSTONE: If you raise the psoas fascia off the muscle-- and you can see, the psoas fascia is real and it often is a very well-defined layer, almost looks like a little hernia sac of tissue. But you want to keep that down, and you don't want to injure any of the structures on the psoas to cause numbness or any neuromuscular injuries or sensations to the patient. So this is the second critical step.
LEE RICHSTONE: Colon mobilization, and then getting under the ureter. Now, I call this the neutral position, and so I'll refer to that. This is the neutral position, meaning that the kidney is up. You're under the ureter. And the renal hilum will then be in that location, as depicted. And you need to open up Gerota's to identify the hilum and march to the hilum. So I call the next step, the third step, the march to the hilum.
LEE RICHSTONE: And so you grasp that layer of Gerota's and dissect underneath it. And then take it. And so here, you lift it up and you kind of back down. And again, opening up the layers. These layers exist. And take advantage of them. And then you take them with some energy, and you open up this whole area on the march to the hilum.
LEE RICHSTONE: You start seeing the gonadal. You don't have a single layer anymore of Gerota's, but you have fat that can be dissected, made into fascicles, and you can approach the hilum. The next step of the operation is dissecting the renal hilum.
Segment:4 DISSECTING THE RENAL HILUM.
LEE RICHSTONE: And once you've opened up Gerota's, renal vein is usually seen fairly readily with some sweeping and blunt dissection. And again, beneath the hilum or inferior caudal to the hilum, there's some fatty tissue.
LEE RICHSTONE: You're looking for a renal artery or accessory vessels in that area in all of this tissue here. Usually, we find the renal artery immediately lateral to the vein. And typically, we'll take the inferior hand-- so on a right-sided case, that's the left hand. And that hand is poised to hug behind the vein and parallel to the great vessels. And hug behind the vein and dissect out the artery.
LEE RICHSTONE: In this particular case, as you'll see, the artery is in a cephalad position. It's found well above the renal vein, so it's a little bit different. So I'm going to show you now a little bit. What we would typically do here is with the right hand, we would lift up the kidney, because that's not going to get you behind the vein. This left hand will get you behind the vein, parallel to the great vessels.
LEE RICHSTONE: Now, there's a couple of different ways to elevate the kidney. In this particular case, you could just retract up with a grasper or with the suction. Anything can lean up on the kidney. It's not that fatty. Some kidneys are big and floppy, a lot of fat or a huge tumor, and you can lean into the kidney with an open laparoscopic Debakey, as seen here.
LEE RICHSTONE: So you can lift under, you can lean in, or you can grasp the perinephric fat and just pull up. So that's a teaching point. There's three ways to raise up the kidney and get retraction. Now, again, this is that inferior hand hugging behind the vein, looking for the artery. And usually, it's right behind and you can insert the sucker, gently dissect in between the vein and the artery.
LEE RICHSTONE: In this particular case, the artery is closer to the head in a cephalad position. So we're going to drop the kidney down and start dissecting cephalad to the vein in order to identify the artery, which you see there. So you have renal vein. We clip the gonadal. In this case, to the left of the screen. And now, we're going to work on the artery.
LEE RICHSTONE: So this case is a little bit easier in that the artery is so medial and above the vein. So some blunt dissection between the artery and vein. Again, that right hand is using a laparoscopic Debakey. That is my instrument of choice. I always use that. I do prefer a Ligasure. That big 10 Ligasure is a big, heavy instrument that allows for great anterior retraction of the kidney.
LEE RICHSTONE: You can take all that lateral tissue and upper pole tissue with-- you can take a lot of, tissue and it gets great hemostasis and great bulk to the instrument for dissection. So again, we continue to dissect out the renal artery with spreading, and we've gotten our fascicle above and below. A stapler is employed to take the renal hilum, ensuring that we have a vascular load with the appropriate staple size.
LEE RICHSTONE: I upsized my right hand here. Usually, there's a 5-millimeter port for the right hand, but I upsized it, just because I had a great angle for the renal artery that was safe. So we take the artery. Try to limit the amount of torque on the instrument as we fire. And then in sequence, we then take the renal vein with another load of the stapler, as seen here.
LEE RICHSTONE: We ensure that we see the tips. We ensure that this vessel is going to the kidney, nowhere else. We don't want to be taking any of the great vessels or the SMA or the SMV, or any other kind of vessels. So they're going to the kidney. They're clearly defined. We see the tips of the stapler. And we know what we're taking.
LEE RICHSTONE: So now, we're going to march up. And in this case, again, there was an indeterminate adrenal lesion. So the adrenal gland is going to be taken. And you can see that right here. You see the adrenal lesion. So we're going to hug the cava and work up the cava. The adrenal vein is identified here, which will be clipped. We've already dissected off some of the adrenal gland medially, and we're going to continue to work that medial plane, as well as the cephalad plane underneath the liver.
LEE RICHSTONE: Now, I've done a lot of these cases, so I'm able to get away without a liver retractor here. Obviously, this would be made easier by having a liver retractor, so I often employ one. I don't endorse obviating a liver retractor in all cases. But in this case, we didn't use one. And as you see here now, the Ligasure is employed to get some of the stellate blood supply to the adrenal gland, keeping the cava in view, obviously, and ensuring that this is not taking the cava in any way.
LEE RICHSTONE: The cava is clearly seen more medially there to the right of the screen. And then we kind of work up the rest of the attachments between the upper aspect of the adrenal gland, and just take this on block with the kidney. And again, you see here how the 10-millimeter Ligasure is a great instrument. It just gets excellent hemostasis, and you can take a lot of tissue at any one time.
LEE RICHSTONE: It also is meaty enough to help retract down both the adrenal gland and the liver with that downward force, because it's got the force to do so. And so then the specimen is completely liberated there. And you see the hilum well controlled, using a little bit of fibular here just in the adrenal bed. And we have a nice, dry field. And that leaves the lateral attachments and it leaves the transection of the ureter as the sole remaining attachments here.
LEE RICHSTONE: And so we'll go through that now, the lateral attachments
Segment:5 LATERAL ATTACHMENTS AND URETERAL DISSECTION.
LEE RICHSTONE: and utereral dissection. And then we'll be able to bag our specimen. So the ureter here is clipped. And the Ligasure, again, is an excellent instrument to go through all of this tissue and do it expeditiously and with excellent hemostasis. So the ureter is taken.
LEE RICHSTONE: The lateral attachments and inferior attachments are taken, making sure to stay outside of Gerota's, and perform a radical nephrectomy in that manner, outside of Gerota's. And we'll continue that dissection. The specimen is bagged in an Endo Catch bag. It's extremely important that this is done under direct visualization.
LEE RICHSTONE: You don't want anything else in there. You don't want to get loops of bowel or anything incorporated in there. And then you close the metal loop, also under view. So you can see here that we have a dry field. The field is inspected. The specimen is extracted. It is always good practice to re-insufflate after the specimen is extracted.
LEE RICHSTONE: Directly visualize from a laparoscopic view your extraction sites, and ensure that no bowel or other visceral structures is incorporated into the enclosure. This also allows you to view the operative field, the dissection field, after the release of pneumoperitoneum for several minutes while you're extracting the specimen. There's no pneumoperitoneum to tamponade bleeding. You then re-insufflate, reexamine the field, and ensure that there's been no accumulation of blood products or any other evidence of injury.
LEE RICHSTONE: Pathology revealed a T1b clear cell renal cell carcinoma, Fuhrman grade 3. The adrenal lesion was a benign adenoma. In this video, we've presented the fundamental steps for a laparoscopic radical nephrectomy. To review, this begins with safe access. The first step of the operation is incision along the white line of Toldt and colon mobilization. The second step of the operation is getting under the ureter and anteriorly retracting the kidney and lower pole.
LEE RICHSTONE: The next step of the operation is the "march to the hilum," beginning with an incision of the anterior leaflet of Gerota's fascia, and identifying the renal artery and vein. This is followed by safe ligation of the artery and vein with a stapler, and then proceeding finally with the upper pole and lateral attachments. We hope that this was educational, and wish you safe and enjoyable adventures with renal laparoscopy.
LEE RICHSTONE: Thank you.
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