Surgery Illustrated Surgical Atlas. Samuel P. Sterrett and Stephen Y. Nakada University of Wisconsin, Division of Urology, Madison, Wisconsin, USA

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1 STERRETT nd NAKADA Left HALRN Anesthesi Left HALRN Monitor Monitor Surgeon 2nd Assistnt Assistnt Cutery Genertor OR Instrument tble b b Right HALRN Retrctor Cmer Working Port Gelport Incision Left HALRN Gelport Incision Working Port Cmer STERRETT nd NAKADA BJUI BJU INTERNATIONAL Surgery Illustrted Surgicl Atls Hnd-ssisted rdicl lproscopic nephrectomy Smuel P. Sterrett nd Stephen Y. Nkd University of Wisconsin, Division of Urology, Mdison, Wisconsin, USA ILLUSTRATIONS by STEPHAN SPITZER, PLANNING AND PREPARATION INDICATIONS Rdicl nephrectomy (RN) hs been the minsty for treting loclized RCC since first described by Robson in 1969 [1]. The lproscopic RN (LRN) hs introduced new stndrd of cre to urology, nd is n dvnced procedure requiring trining in lproscopic techniques. An intr-bdominl hnd gives improved tctile feedbck to the urologist, thereby mking LRN less dunting. Hnd-ssisted lproscopy (HAL) lso provides yet nother tool to help urologists perform more complex RNs. RN is the procedure of choice for loclized RCC not menble to prtil nephrectomy. HALRN cn be used for lmost ny ptient who requires RN nd cn lso be used in ptients with metsttic disese, either for plliting symptoms or for potentil combintion with djuvnt immunotherpy. b PATIENT SELECTION There re no bsolute contrindictions to HALRN but there re mny circumstnces tht increse the potentil for morbidity, including bowel obstruction, peritonitis, bdominl wll infection, previous inflmmtion, previous surgery, nd presence of inferior ven cv tumour thrombi [2]. Ech surgeon must set limits ccording to his or her experience nd confidence. SPECIFIC EQUIPMENT/MATERIALS Non-disposble: Two monitors, flt screen; 5-mm or 10-mm 30 lproscope; 5-mm or 10-mm 0 lproscope; High-flow insuffltor; Three-chip lproscopic cmer; 5-mm Mrylnd dissector; 5-mm trumtic grsper; 404 JOURNAL COMPILATION 2008 BJU INTERNATIONAL 102, doi: /j x x

2 SURGERY ILLUSTRATED 5-mm scissors, curved nd stright bldes; 5-mm suction/irrigtion system (Nehzt); Crter-Thomson closure device (Inlet Medicl, Eden Pririe, MN, USA); 5-mm curved hrmonic sclpel (Ethicon Endo-Surgery, Cincinnti, OH, USA). Disposble: Hnd-ccess device (Gelport, Applied Medicl, Rncho Snt Mrgrit, CA, USA); Non-blded trocrs, one 5-mm, two 10-mm (Visiport, Ethicon); Port reducers (Ethicon); LpSc (Cook Urologicl, Spencer, IN, USA); Endo-GIA stpler, vsculr lod (10 mm) (Ethicon); Sutures, 1 polydioxnone for fscil closure of hnd port; 0 polyglctin for 10-mm ports; 4 0 polyglctin for skin closure. SPECIFIC PATIENT PREPARATION All ptients should hve metsttic survey, including n nteroposterior nd lterl chest X-ry or chest CT, serum clcium, serum lkline phosphtse, nd bdominl CT; the lst is lso useful to ssist in surgicl plnning. A bone scn is dvised for ptients with elevted serum clcium levels, elevted lkline phosphtse, or bone pin [3]. In ddition, renl function should be evluted by serum cretinine levels; if high, or if rdiologicl imging revels n bnorml contrlterl kidney, differentil renogrphy cn be considered. Ptients with renl insufficiency or compromised contrlterl renl function might need further considertion for renl-spring surgery. All ptients re instructed to discontinue nticogultion medictions 5 dys before surgery. Bowel preprtion comprises cler liquids nd one bottle of mgnesium citrte in the fternoon before surgery. The ptient is instructed to tke nothing by mouth fter midnight. A first-genertion cephlosporin is given before surgery. JOURNAL COMPILATION 2008 BJU INTERNATIONAL 405

3 STERRETT nd NAKADA SPECIFIC PATIENT POSITIONING Figure 1 The ptient is plced in modified flnk position. The kidney rest is rised minimlly to void neuromusculr injuries, nd the tble is minimlly flexed (<20 ). The downwrd leg is flexed, nd the knee nd nkle re well pdded. The upwrd leg is stright nd well supported with pillows. The lower rm is well pdded t the elbow nd wrist, nd n xillry roll is plced. The upper rm cn be suspended or plced on pdded Myo stnd. Wide cloth tpe ffixed to the bed nd plced over the shoulder nd greter trochnter increse stbility. Tpe blisters re voided by plcing towels or Tegderm between the cloth tpe nd skin. The ptient's entire bdomen nd flnk is then prepped nd drped. SPECIFIC ROOM POSITIONING Left HALRN Figure 1b The surgeon nd ssistnt stnd together on the opposite side from the kidney to be removed. The surgeon is closest to the hed of the ptient, to fcilitte hnd-port nd working-port ccess. The ssistnt stys closer to the feet to run the cmer nd, if necessry, n dditionl retrctor. The surgicl technicin stys on the sme side s the surgeons, closer towrd the foot of the bed. The surgicl instrument tbles re on the side of the surgeon t the feet nd behind the surgeons, nd the power genertors (i.e. cutery, hrmonic sclpel) re cross the tble from the surgeons. Monitors re plced t the level of the ptients' shoulders on both sides of the ptient if second ssistnt is present. An open instrument set should lwys be vilble should conversion to n open procedure be necessry. Cutery Genertor 2nd Assistnt Monitor Anesthesi OR Surgeon Assistnt Monitor Instrument tble b Left HALRN 406 JOURNAL COMPILATION 2008 BJU INTERNATIONAL

4 SURGERY ILLUSTRATED HAND-ACCESS DEVICES Figure 2 Although severl devices re vilble, ech ccess device mintins the pneumoperitoneum while llowing the hnd to sty in the bdomen. We currently use the GelPort, which uses soft gel-type cp with smll slit through which the surgeon plces hnd. The GelPort llows trnsfer of the hnd in nd out of the port without loss of pneumoperitoneum. b JOURNAL COMPILATION 2008 BJU INTERNATIONAL 407

5 STERRETT nd NAKADA SURGICAL STEPS STEP 1. PLACING THE HAND PORT AND TROCARS To obtin pneumoperitoneum, Veress needle is inserted into the ipsilterl lower qudrnt long the midclviculr line lterl to the rectus muscle. The bdomen is insufflted to 15 mmhg using crbon dioxide. We introduce 0 lproscope through 5- or 10-mm Visiport under direct vision. This feture llows us to crefully identify ech lyer of nterior bdominl wll nd ensure correct entry into the pneumoperitoneum. The bdomen is then surveyed to evlute for metsttic disese nd dhesions. The hnd device nd remining ports re then typiclly plced under direct vision. Figure 3 Left HALRN Gelport Incision Working Port Cmer For right-hnded surgeon performing left HALRN, we recommend the hnd port be plced in midline incision just bove the umbilicus (Fig. 3). For right-hnded surgeon performing right HALRN, we recommend the hnd port be plced in Gibson incision in the right lower qudrnt (Fig. 3b). Alterntively, for right HALRN right-hnded surgeon could use the mirror imge set-up s on the left side, nd work with his or her dominnt hnd in the bdomen. In ddition to the hnd port, two or three trocrs re typiclly required; one 5-mm or 10-mm cmer, one 10-mm working port, nd sometimes n dditionl 5-mm working port for dditionl retrction, prticulrly on the liver for right sided tumours. When performing HALRN through midline Gelport incision, the 10-mm working port should be plced in the mid xillry line in position more crnil thn the cmer port. If needed for retrction, n dditionl 5-mm working port cn be plced lterlly in the subcostl region, somewhere between the mid-xillry line nd the mid-clviculr line, or wherever the surgeon considers it to be of the best use. b Right HALRN Retrctor Cmer Working Port Gelport Incision For obese ptients, plcing the hnd-ccess device in the usul loction might put the hnd port t n uncomfortble distnce from the kidney, mking dissection difficult. We recommend plcing the hnd-ccess device lterl to the midline, to sty closer to the kidney. Trocr positioning should lso be djusted to llow for the more lterl loction of the hnd ccess device. 408 JOURNAL COMPILATION 2008 BJU INTERNATIONAL

6 SURGERY ILLUSTRATED STEP 2. INCISE THE WHITE LINE OF TOLDT AND MOBILIZE THE COLON Figure 4 The intr-bdominl hnd should be used to plce medil trction on the colon to clerly delinete the line of Toldt. After n incision is mde on this fscil plne, finger cn be inserted in the plne behind the fsci to push the colon wy nd expose bloodless plne through the peritonel ttchments. These ttchments re then incised from the ilic vessels to the heptic or splenic flexure, to free the colon from the lterl bdominl wll. For right nephrectomy, the liver is relesed from the side-wll by incising the tringulr ligment, to llow it to be retrcted superiorly. Once the duodenum is identified, the Kocher mnoeuvre should be performed to reflect the duodenum medilly nd expose the inferior ven cv. For left nephrectomy, the splenic flexure between the colon nd spleen is left intct so tht fter the spleen is relesed, the plne between the spleen nd upper pole of the kidney cn be developed to llow both the spleen nd colon to fll wy medilly. The dissection should be close to the spleen to void perforting the diphrgm. One should lso keep in mind tht the stomch cn come round the lterl spect of the spleen, thus creting the potentil for injury. STEP 3. FREE THE LATERAL AND SUPERIOR ATTACHMENTS TO THE KIDNEY With the nterior surfce of Gerot's fsci visible fter medil reflection of the colon, ttention is turned to mobilizing the lterl nd superior ttchments of the kidney. The lterl spect is freed from the lower pole towrd the upper pole. The upper-pole ttchments re liberted medilly to the drenl. The 30 lens fcilittes dissection of the upper nd lterl pole ttchments. The posterior ttchments should be left intct t the point in the cse. JOURNAL COMPILATION 2008 BJU INTERNATIONAL 409

7 STERRETT nd NAKADA STEP 4. LOCATE AND CONTROL THE URETER, AND MANAGE THE GONADAL VEIN Figure 5 The ureter should be identified erly nd divided between clips, or with the vsculr stpler. The ureter typiclly lies medil to the psos, longside the gondl vein. During dissection of the ureter, cre should be tken to void dmging the gondl vein, to void troublesome bleeding. During the left nephrectomy, the gondl vein cn be followed crnilly to the renl vein. On the right side the surgeon should be creful not to vulse the gondl vein off the ven cv. Rther, the gondl vein should be relesed wy from the ureter nd llowed to return medilly. Even slight trction on the gondl vein cn cuse the gondl vein to ter. After division, the proximl ureteric stump cn be used to ssist with retrction of the kidney. The lower pole of the kidney cn now be freed in lterl to medil direction, with cre tken medilly to void indvertent injury to unrecognized lower pole vessels. 410 JOURNAL COMPILATION 2008 BJU INTERNATIONAL

8 SURGERY ILLUSTRATED STEP 5. IDENTIFY AND MOBILIZE THE RENAL VEIN AND ARTERY Figure 6 The nterior surfce of the vein should be identified nd crefully clened. On the left side, the drenl nd gondl vein brnches should be locted. The rtery should be locted by plption. The renl vein nd rtery should be dissected free. This dissection is fcilitted by freeing the posterior ttchments to the kidney nd flipping the kidney nteriorly for posterior pproch to the renl rtery. STEP 6. FREE THE POSTERIOR ATTACHMENTS TO THE KIDNEY After the renl vein nd rtery hve been identified, the posterior ttchments to the kidney should be freed. The only remining ttchments re t the hilum nd superiorly t the drenl glnd. JOURNAL COMPILATION 2008 BJU INTERNATIONAL 411

9 STERRETT nd NAKADA STEP 7. DIVIDE THE RENAL ARTERY AND VEIN Figures 7 nd 8 The renl rtery is divided with vsculr stpler using posterior rtery control [4,5]. This involves flipping the kidney medilly to expose the renl rtery. The renl vein cn then be stpled with vsculr stpler. It is impertive to confirm tht the stpler extends cross the entire renl vein. Alwys puse fter deploying the stpler, to llow dequte seting of the stple rows. Stpling over clips cn cuse stple misfire, often resulting in unnecessry hemorrhge. STEP 8. FREE THE REMAINING MEDIAL ATTACHMENTS After dividing the renl rtery nd vein, medil lymphtics nd dipose tissue might remin. These cn be tken down with the hrmonic sclpel or cutery, keeping in mind tht n berrnt vessel cn be hidden in this tissue. STEP 9. SPARE OR REMOVE THE ADRENAL If the drenl is to be spred, the plne between the upper pole of the kidney nd drenl should be developed. Cre should be tken to sty lterl nd inferior to the drenl to void most of the vessels supplying nd drining the drenl. We prefer to spre the drenl for ipsilterl upper pole tumours, s long s distinct plne is evident; ggressive dissection is key. If the drenl is not to be spred, it should be removed en bloc. The drenl vein on the respective side should first be identified nd divided between clips. One must tke cre when clipping either drenl vein, s the right vein is typiclly quite short nd the left vein clips cn interfere with the stpler due to its origin off the renl vein. STEP 10. LOWER THE PNEUMOPERITONEUM AND ASSESS FOR BLEEDING Working insuffltion pressures (15 mmhg) cn tmponde venous bleeding. We routinely lower the insuffltion pressure to 5 mmhg nd survey the hilr re, upper pole, nd lower pole res to ssess for bleeding before or fter specimen removl. 412 JOURNAL COMPILATION 2008 BJU INTERNATIONAL

10 SURGERY ILLUSTRATED JOURNAL COMPILATION 2008 BJU INTERNATIONAL 413

11 STERRETT nd NAKADA STEP 11. REMOVING THE SPECIMEN Figure 9 Before removl the specimen must be plced into bg to prevent potentil tumour seeding of the wound. We use the LpSc (Cook Urologicl) which is currently the only extrction bg tht is impenetrble to tumour cells. To fcilitte plcing the specimen into the bg, one side of the open end should be grsped with n instrument, nd the other held open with finger. After the specimen is crefully plced into the opening, the drwstring is pulled to close the bg, which cn be extrcted through the hnd-port site. Occsionlly, lrge tumours might necessitte extension of the hnd-ccess incision to extrct the specimen. b 414 JOURNAL COMPILATION 2008 BJU INTERNATIONAL

12 SURGERY ILLUSTRATED STEP 12. CLOSE THE PORT SITES AND HAND-ACCESS SITE We routinely close ll 10-mm port sites in dults nd ll 5-nd 10-mm port sites in children, to prevent hernition of omentum or bowel. We use the Crter Thomsen device (Inlet Medicl, Eden Pririe, MN, USA) to plce our suture under direct vision. After ll sutures re plced, the lproscope is used to visulize the removl of ll ports, nd the sutures re tied. POSTOPERATIVE CARE All incisions re closed with subcuticulr suture nd dressed with liquid dhesive (Mstisol, Ferndle Lbs, Inc. Ferndle, MI, USA) nd sterile strips. A smll non-occlusive dressing is plced over the hnd-ccess incision nd bnd ids re plced over the port incisions. A first-genertion cephlosporin is given for the first 24 h fter surgery. Ptients wer sequentil compression devices on the lower extremities until mbulting well. Ambultion is begun on the night of surgery. Ptients re offered cler liquids the morning of the first dy fter surgery. Diet is dvnced s tolerted. Ptients re typiclly dischrged on the second or third dy fter surgery. FROM SURGEON TO SURGEON LRN remins the modern stndrd of cre for treting loclized renl cncer. HAL surgery represents prgmtic development in urologicl lproscopy. For mny urologists, HAL surgery is the only pproch they will hve the time nd resources to lern. HALRN hstens lerning for the surgeon gining experience in lproscopy, due to the fmilirity nd confidence gined with the dvntges of tctile senstion. When performing ny RN, hnd ssistnce with intct removl hs confirmed benefits for the ptient nd surgeon. REFERENCES 1 Robson CJ. The results of rdicl nephrectomy for renl cell crcinom. J Urol 1969; 101: Sundrm CP, Rehmn J, Lndmn J et l. Hnd ssisted lproscopic rdicl nephrectomy for renl cell crcinom with inferior ven cvl thrombus. J Urol 2002; 168: Novick AC. Surgery of the kidney. In Cmpbell's Urology 9th edn. Phildelphi: WB Sunders,2006: Nkd SY. Techniques in endourology: hnd-ssisted lproscopic nephrectomy. J Endourol 1999; 13: Nkd SY, Fdden P, Jrrrd DF et l. Hnd-ssisted lproscopic rdicl nephrectomy: comprison to open rdicl nephrectomy. Urology 2001; 58: Correspondence: Stephen Y. Nkd, Chirmn, Division of Urology, G5/339 Clinicl Science Center, 600 Highlnd Drive, Mdison, WI , USA. e-mil: nkd@surgery.wisc.edu Abbrevition: HAL(RN), hnd-ssisted lproscopic (rdicl nephrectomy). JOURNAL COMPILATION 2008 BJU INTERNATIONAL 415