Simplifying Laparoscopic Nephrectomy: The Inferior Approach with En Bloc Stapling of the Renal Hilum

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.

Laparoscopic nephrectomy: Moroccan experience of 68 cases

“…Blood loss in published series ranged from 0 to 828 ml. The lowest losses recorded by Oscar Schatloff et al [6] in a retrospective study including 129 patients admitted for laparoscopic nephrectomy, and the highest by Hee Youn Kim et al [7] in a comparative study of the retroperitoneal (34 patients) and transperitoneal (30 patients) pathways of laparoscopic radical nephrectomy for large solid renal tumors (> 7 cm).…”

A comparison of renal vascular control techniques during laparoscopic nephrectomy

“…[ 7 12 14 ] After surgical and technological improvements, AVF formation was evaluated by contemporary studies. [ 3 4 5 6 7 8 12 13 14 ] To our knowledge, there is no study showing the association between en bloc ligation of the renal hilum and AVF formation. However, average time from nephrectomy to AVF formation may be another risk factor.…”

“…Dissection of the renal hilum during the LN requires the laparoscopic experience and skills that may not be developed in the learning curve or novice laparoscopic surgeon. [ 4 ] In these situations, separation of the renal hilum can lead to massive haemorrhage due to vessel injury.…”

Utility of Anteroposterior Diameter Ratio of Tumor and Abdomen for Laparoscopic Approach for Radical Nephrectomy in Large Renal Masses

“…Whether or not these two factors have a significant impact on the outcomes of the surgery remains to be proven, with none of the large series of LRN for large renal masses stating their impact (5, 18). Moreover, a hilar tumor can be successfully managed laparoscopically by subtle technical modifications such as inferior and posterior dissection of the kidney followed by en bloc stapling of the hilum (28). Further validation of the APROTA is desirable in a larger sample size.…”