0022-534 7/91/1462-0278$03.00/0 THE JOURNAL OF UROLOGY Copyright© 1991 by AMERICAN UROLOGICAL ASSOCIATION, INC.
Vol. 146, 278�282 August 1991 Printed in U.S.A.
LAPAROSCOPIC NEPHRECTOMY: INITIAL CASE REPORT RALPH V. CLAYMAN, LOUIS R. KAVOUSSI, NATHANIEL J. SOPER, STEPHEN M. DIERKS, SHIMON MERETYK, MICHAEL D. DARCY, FREDERICK D. ROEMER, EDWARD D. PINGLETON, PAUL G. THOMSON AND STEPHENIE R. LONG From the Departments of Surgery (Division of Urologic Surgery) and Radiology, and Division of General Surgery, Mallinckrodt Institute of Radiology, Washington University School of Medicine, St. Louis, Missouri, and Cook Urological, Inc., Spencer, Indiana
ABSTRACT
A tumor-bearing right kidney was completely excised from an 85-year-old woman using a laparoscopic approach. A newly devised method for intra-abdominal organ entrapment and a recently developed laparoscopic tissue morcellator made it possible to deliver the 190 gm. kidney through an 11 mm. incision. KEY WORDS:
kidney neoplasms, nephrectomy, laparoscopy, carcinoma
Although major advances in laparoscopic surgery have been made in the area of gynecology, its application in the realm of general surgery and urology has been limited.1 Recently, with the development of laparoscopic cholecystectomy, more interest in minimally invasive laparoscopic procedures has occurred.2 The advantages of this approach are obvious to the patient and surgeon, including shorter hospitalization, lower morbidity and more rapid convalescence. However, while small lesions (dimin utive uterine myomas) or small hollow organs (appendix or gallbladder) can be removed laparoscopically, there have been 3 deterrents to the spread of laparoscopy into other areas of traditional abdominal surgery: 1) the need for extensive tissue dissection and vascular control, 2) the requirement for proper organ isolation to preclude abdominal contamination with bac teria or cancerous cells from the diseased organ and 3) the development of an instrument to allow for the safe and rapid removal of tissue through an 11 mm. laparoscopic port. We describe how each of these problems was addressed to accom plish a modified radical nephrectomy using laparoscopic tech niques.
FIG. 1. Preoperative CT scan reveals 3 cm. renal mass (arrows) occupying lateral border of mid portion of right kidney. Right kidney measures 6.5 X 8.5 X 6.5 cm.
CASE HISTORY
An 85-year-old white woman presented with an asympto matic 3 cm. solid right renal mass serendipitously diagnosed when she underwent a computerized tomogram (CT) of the abdomen after suffering a fall. The study revealed no intra abdominal pathology. However, a 3 cm. renal mass was noted along the lateral border of the mid portion of the right kidney (fig. 1). Medical history was significant for an appendectomy performed through a lower midline abdominal incision in 1950 and right total hip replacement in 1988. The only medications were a daily tablet of alprazolam and an aspirin every other day. On physical examination she weighed 50 kg. and was 5 feet 1 inch tall, afebrile, with a blood pressure of 154/70 and pulse 60 per minute. The right kidney was not palpable and there was no right costovertebral angle tenderness. Serum chemistry studies revealed a blood urea nitrogen level of 13 mg./dl. and a creatinine level of 1.0 mg./dl. The serum electrolytes, liver function studies, coagulation studies (pro thrombin time, partial thromboplastin time and bleeding time), white blood count and platelet count were all within normal limits. The admission hemoglobin was slightly depressed (11.4 gm./dl.) but all of the red blood cell indexes were normal. Urine culture was sterile. A chest radiograph and a radionuclide bone scan were nega tive for metastatic disease. Likewise, on the CT scan there was Accepted for publication March 15, 1991. 278
no evidence of renal hilar lymphadenopathy, inferior vena caval tumor thrombus or hepatic metastases. Preoperatively, the patient underwent a bowel preparation (1 gm. erythromycin base and 1 gm. neomycin orally at 4, 5 and 10 p.m., and 3 1. GoLYTELY). Preoperative antibiotics consisted of 1 gm. intravenous ampicillin and 70 mg. gentamicin. On the morning of June 25, 1990 right renal arteriography revealed a single right renal artery that bifurcated as it exited from beneath the inferior vena cava (fig. 2). Five segmental renal arteries were identifiable on the radiographs. The renal mass appeared to be well perfused and there was no involve ment of the renal vein. The right renal artery was embolized by injection of 8 cc absolute ethanol. Then, 2½ hours after the embolization, the patient underwent the operation. Due to her age and a history of postoperative tachycardia after hip surgery (ASA class 3) a Swan-Ganz catheter was placed via the right jugular vein. A nasogastric tube was also positioned. With the patient in a supine position flexible cystoscopy was performed and a 0.035-inch guide wire along with a 5F angiographic end hole catheter were passed to the renal pelvis. A urethral cath eter was also placed. A Veress needle was inserted supraumbilically in the midline. A pneumoperitoneum was achieved with carbon dioxide: 10 mm. Hg pressure with 4.5 1. instilled. Two 11 mm. trocars were then placed: 1 approximately 2 inches above the umbilicus in the midline and 1 in the mid clavicular line approximately 4
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FIG. 2. Preoperative angiogram reveals single renal artery with 5 segmental branches (small arrows) supplying kidney and vascularized renal mass (large arrows).
inches above the umbilicus. Two 5 mm. trocars were then positioned: 1 in the mid clavicular line approximately 1 inch below the umbilicus and 1 in the mid clavicular line 2 inches above the umbilicus (on a line with the initially placed 11 mm. trocar). The patient was then turned to a left lateral decubitus position to displace the bowel medially and another trocar (11 mm.) was placed in the anterior axillary line 2 inches above the umbilicus (on a line with the initially placed 11 mm. trocar). Using an electrocautery dissecting probe and several different types of grasping forceps, the right line of Toldt lateral to the ascending colon was grasped and incised. The right colon was
reflected medially, thereby exposing the retroperitoneum and Gerota's fascia. The ureter was identified by inoving the ret rograde ureteral catheter within the ureter. The ureter was then dissected and secured by a 5 mm. grasping forceps (lower most 5 mm. port). Lateral traction on the ureter placed the renal hilus on slight tension. By dissecting along the tented up ureter, the renal pelvis and renal vessels could be identified. Due to the prox imity of the dissection to the medial border of the kidney the vascular structures were smaller in size but multiple in number. Each of 5 segmental renal arteries was subsequently dissected and secured with ligature clips: 2 clips on the renal side and 2 or 3 on the vascular stump. The secured vessels were transected with a 5 mm. hook scissors. The upper pole of the kidney was dissected and the adrenal gland was left in place. The rest of the kidney, including the perirenal fat and Gerota's fascia over the lower pole and mid portion of the kidney, was dissected from the abdominal sidewall. Lastly, the previously placed retrograde ureteral guide wire and catheter were removed from the ureter. The ureter was secured with 2 ligature clips, and then incised, thereby completely freeing the kidney within the abdomen (fig. 3, A). At that point a tough, flexible, 6 X 9-inch, impermeable sterile sack with a drawstring (patent pending*) was inserted into the abdomen via the midline 11 mm. laparoscopy sheath. The sack was opened in the abdomen and the kidney was then maneuvered into the sack (fig. 3, B). Through the midline 11 mm. port a 5 mm. grasping forceps was used to grasp the mouth of the sack and pull it part way into the 11 mm. sheath. The sheath was removed and the mouth of the sack then lay on the exterior of the anterior abdominal wall. A tissue morcellating device in combination with a vacuum (patent pending*) was then introduced into the kidney-contain ing sack. The kidney was morcellated and aspirated from within the impermeable sack (7 minutes). The then empty sack was pulled from the abdominal cavity. Inspection of the abdomen revealed no active bleeding. The abdominal fascia underlying * Cook OB/GYN, Inc., Spencer, Indiana.
Gr1;1sping forceps suspending kidney from ureter
"'-'--f'"cf--f-Kk:lney wlthln entrapment s.ock
FIG. 3. A intraoperative view of kidney completely freed from its retroperitoneal attachments and vascular supply. Kidney is suspended from renal hilus v'ia 5 mm. grasper passed through 1 abdominal sheath. B, intraoperative view of kidney placed into nylon surgical sack.
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each of the 11 mm. laparoscopic sites was closed with 1-zero polyglactin. The skin of each 11 mm. port and of the 5 mm. ports was closed with 5-zero polyglycolic acid placed in a subcuticular fashion. The total operative time was 6 hours 45 minutes. The esti mated blood loss was 300 cc. A total of 41. intravenous crystal loid was given. Throughout the procedure there was no decrease in blood pressure and the central venous pressure varied be tween 6 and 11 cm. water. The specimen weighed 190 gm. (fig. 4). Pathological evalua tion of the morcellated kidney revealed an oncocytoma of the kidney (grade 1 granular cell renal cancer). No surgical margins could be discerned. No lymph node tissue was noted. The. nasogastric tube was removed within 12 hours postop eratively and the patient began oral intake in less than 36 hours. Antibiotic coverage with ampicillin, gentamicin and metronidazole hydrochloride was continued for 48 hours fol lowed by cefazolin sodium for another 3 days. The hematocrit drifted downward from 28% immediately postoperatively to 24.8% on postoperative day 2. Therefore, 1 unit of blood was transfused. A CT scan of the abdomen revealed only a scant amount of ascites but there were small bilateral pleural effusions (fig. 5). Auscultation of the chest revealed rales bilaterally. The patient was given a bolus of 20 mg. furosemide and a brisk diuresis ensued (2,150 cc in 8 hours). Another 10 mg. dose of parenteral furosemide was given the
Fm. 4. Gross specimen of right kidney. Specimen weighed 190 gm. Renal parenchyma is to left side and suspected fragments of tumor are on right side.
Fm. 5. On postoperative day 2 CT scan at level of lower pole of left kidney (arrow) reveals absence of right kidney and minimal amount of intraperitoneal fluid. Abdominal wall on right side is mildly thickened.
next day. With this combined therapy the hematocrit increased to 31%. Throughout the postoperative period the temperature ranged from 36.5 to 37.5C. The white blood count initially increased to 15,000 cells per mm.a but by postoperative day 5 it had returned to normal (8,000 cells per mm.a). During the postoperative period the patient experienced min imal discomfort. One dose of morphine sulfate (4 mg.) was given intravenously 5 hours after the procedure. No other analgesics, either parenteral or oral, were requested or admin istered. The patient was discharged on the morning of postop erative day 6. She resumed normal preoperative activities by postoperative day 10 (fig. 6). DISCUSSION
For the last 50 years laparoscopy has been largely the prov ince of the gynecologist. 1 With this minimally invasive means to access the female pelvis, the gynecologist has used the laparoscope to diagnose successfully a variety of conditions, and to perform biopsies and minor operations, including tubal ligation, excision of small subserous myomas, ovarian biopsy, treatment of tubal pregnancy, excision of an ovarian cyst, oophorectomy, adhesiolysis and peritoneal biopsy. Although the abdomen is common territory for the gynecologist, general surgeon and urologist, laparoscopy has been little used in these other specialties. In general surgery the laparoscope was ini tially used by only a few surgeons to aid in the diagnosis of the acute abdomen.a However, the recent advent of laparoscopic cholecystectomy has moved laparoscopy into generally accepted surgical practice.2 In urology, the laparoscope has been used most commonly to diagnose the location of a cryptorchid testicle to plan a subse quent open operation.4• 5 More recently, the laparoscope has been used at 1 hospital to perform pelvic lymph node dissection before planned therapy for localized prostate cancer.6 Indeed, the chief beneficiary of this technology is the patient; hospital stay (outpatient or overnight), convalescence (1 to 3 days) and morbidity are minimal compared to a traditional open opera tion. To date, there has been 1 major practical drawback to lapa roscopy, that is the tissue removed, of necessity, had to be limited in size to that of the largest laparoscopic port inserted (11 mm.). To apply laparoscopic technology to the removal of larger tissues 3 problems had to be overcome: 1) tissue dissec tion, 2) tissue evacuation and 3) organ entrapment. With regard to tissue dissection, the advent of electrocautery probes with aspiration and irrigation capabilities, and the development of
FIG. 6. Abdomen 10 days after laparoscopic nephrectomy. Long arrow denotes umbilicus. Closed arrows show 5 mm. trocar sites. Open arrows show 11 mm. trocar sites.
LAPAROSCOPIC NEPHRECTOMY
rapid load metal clip appliers have been of great benefit. The former greatly facilitates tissue dissection, while the latter allows for rapid and secure occlusion of vascular structures. This precludes the necessity of passing suture and tying surgical knots through the laparoscope, which is difficult and tedious. To remove larger structures via the 11 mm. laparoscopic incision it is necessary to have available an effective tissue morcellator. While a hand operated tissue morcellator is avail able, it is used predominantly on small amounts of tissue. Other surgical tissue aspirators have recently become available: a surgical tissue liquidizer and an ultrasonic aspirator. 7• 8 How ever, neither has been developed for use via the laparoscope. Therefore, a serviceable electrical tissue morcellator for lapa roscopic use was developed during our initial studies of lapa roscopic nephrectomy in pigs. 9 The clinical prototype rapidly fragments and evacuates tissue without destroying the histology of the kidney. The last impediment to approaching larger organs laparo scopically was the concern that in handling or removing the diseased tissue, bacteria or cancerous cells could be released into the abdomen. Certainly, an infected or tumor-bearing organ could not be fragmented and removed in situ, since tumor cells or bacteria would be released as the tissue was morcellated. Therefore, a method to isolate the diseased organ from the rest of the abdomen was devised. Specifically, by placing the tissue directly into an impermeable nylon sack, the tissue was effec tively sequestered such that subsequent morcellation would not release the c6ntents of the organ into the abdominal cavity. The approach for laparoscopic nephrectomy could conceiva bly be done in either a direct retroperitoneal manner or an indirect transabdominal fashion. However, earlier attempts at direct retroperitoneal renal laparoscopy by Wickham and Miller were largely unsuccessful. 10 In human cadavers they used a direct retroperitoneal approach but because of the ret roperitoneal fat a satisfactory pneumoretroperitoneum could not be achieved. Similarly, the first reported attempt at using a minimally invasive operation to remove a kidney in an animal model was that of Weinberg and Smith and, again, a direct retroperitoneal approach was used. 1 1 In 1 pig a percutaneous nephrostomy tube was placed into the kidney directly through the retroperitoneum. An endoscopic ultrasonic aspirator was used to remove the kidney from the inside outward. At autopsy, the renal pedicle and a stump of renal parenchyma remained intact despite preoperative embolization of the renal artery and renal vein. 1 1 Given these difficulties, we elected to approach the kidney transabdominally via the laparoscope. This approach had not been previously reported in either animals or humans. The aforementioned methods were initially developed in the labo ratory using 100 pound female pigs. 8 From this study the techniques to dissect the kidney and entrap it in a sack were refined. In addition, further changes were made in the tissue morcellator and the entrapment sack, thereby allowing for more rapid morcellation without injury to the sack itself. The pro cedure was completed in each of 7 pigs within 1.5 to 3 hours. In each case the kidney was successfully dissected and freed from its renal pedicle. In 6 of 7 pigs the kidney was successfully delivered via the sack. Given our favorable laboratory experience, we elected to apply this method for nephrectomy to a patient. A favorable factor in our patient was the small size (3 cm.) amd location of the right renal tumor making it amenable to simple or even partial nephrectomy. 12-15 Therefore, only a modified radical nephrectomy encompassing the perirenal fat and fascia over lying the tumor was planned. The ipsilateral adrenal gland was not removed. However, adrenalectomy in patients with con fined midsection or lower pole renal carcinoma probably is unnecessary. 12 In this initial case our method for laparoscopic nephrectomy succeeded, although the operative time was ex cessive. Difficulty in identifying and securing the ureter ac-
counted for almost half of the operative time. Similarly, the investment of the kidney and hilar structures in fat also con tributed to the difficulty and duration of the dissection. None theless, the patient tolerated the lengthy procedure well, with out any clinically significant hemodynamic changes. Convalescence was complicated by the need for 1 unit of blood and mild fluid overload. The nasogastric tube was re moved within 12 hours and oral feedings were begun 36 hours after the procedure. Interestingly, only a single injection for discomfort was needed; no other parenteral nor oral analgesics were given during the rest of the hospital stay. The patient was discharged from the hospital 6 days postoperatively. One group of individuals to whom this patient can be com pared are those undergoing donor nephrectomy. In general, these patients are middle aged and healthy. As such, it is of interest that while the operative time for donor nephrectomy is brief (1.5 to 2.2 hours) the hospital stay is still lengthy (6.9, 10.2 and 10.5 days as reported in several large series 16-18). In addition, most patients require nasogastric suction for 24 hours and are not able to begin oral intake for 48 to 72 hours. 1 Furthermore, a minor complication rate of 14 to 30% and a major complication rate of O to 3.5% have been reported. 16-18 Many complications are secondary to the surgical wound itself (infection, fasciitis and herniation). Other problems are secondary to injuries from the retraction of the wound and surrounding organs and tissues (pleurotomy or pneumonia in 4 to 12% of the cases and incidental splenectomy in O to 2.3%). 16-18 Furthermore, in none of the reports on donor ne phrectomy is the total dosage of pain medication recorded nor the duration of convalescence addressed. In our initial case laparoscopic nephrectomy resulted in minimal morbidity, a short hospital stay and brief convalescence. With additional physician experience and further refinements in instrumenta tion, the operative time for laparoscopic nephrectomy probably will decrease as will the length of hospitalization. Aside from obvious patient benefits, significant cost savings should also be realized. However, presently there are several disadvantages to this technique. Transient drawbacks include the need for operator experience, expense of the laparoscopic equipment and in creased operative time for nephrectomy. These problems should all be overcome as the technique is acquired and refined by other urologists. A potentially more serious and irresolvable problem is that the specimen is fragmented rather than re moved intact. While this is of little concern when nephrectomy is performed for benign disease (renal hypertension, end stage renal disease or chronic pyelonephritis), it may be a problem with a tumor-bearing kidney. While histological confirmation of the renal cancer can be obtained, there can be no or scant commentary regarding the depth of tumor invasion. Finally, lymph node involvement can be assessed only if a lymph node dissection is performed either immediately before or after re moval of the kidney. This tissue then can be sent separately for analysis to determine the presence or absence of nodal metastases. Lastly, we believe this initial report of laparoscopic nephrec tomy has broad implications that go well beyond the urological realm. The practice of laparoscopy, organ entrapment and intra-abdominal, albeit contained, morcellation could conceiv ably apply to any tissue within the abdominal cavity that can be dissected laparoscopically. As such, splenectomy, ovariec tomy for ovarian cancer, colon resection, small bowel resection, diseased appendixes, thick-walled, infected gallbladders, and other intra-abdominal and pelvic processes of either an infec tious or cancerous nature may eventually be removed using a minimally invasive laparoscopic technique. ADDENDUM
Since June 25, 1990 we have successfully completed 8 con secutive laparoscopic nephrectomies using the aforementioned
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techniques. The 7 subsequent patients have all required ne phrectomy for benign disease: renovascular hypertension, chronic obstruction, recurrent infection and associated flank pain. Currently, we believe that these techniques are best applied to patients with benign renal disease; among otherwise healthy patients with upper tract malignancy, a standard open surgical procedure remains the treatment of choice. In these patients present concerns over possible tumor dissemination and the lack of surgical margins preclude a laparoscopic ap proach. Drs. Beth Brunts and Louis Dehner, Department of Pathol ogy, Washington University School of Medicine and Dr. Kurt Semm, Director of the Women's Hospital at Christian Al brechts University, Kiel, Germany, provided expertise and sup port. 1. 2. 3. 4. 5.
REFERENCES Semm, K.: Operative Manual forEndoscopic Abdominal Surgery. Chicago: Year Book Medical Publishers, Inc., 1987. Reddick, E. J. and Olsen, D. 0.: Laparoscopic laser cholecystec tomy. A comparison with mini-lap cholecystectomy. Surg. En dosc., 3: 131, 1989. Wood, D., Berci, G., Morgenstern, L. and Paz-Partlow, M.: Mini laparoscopy in blunt abdominal trauma. Surg. Endosc., 2: 184, 1988. Cortesi, N., Ferrari, P., Zambarda,E., Manenti, A., Baldini, A. and Morano, F. P.: Diagnosis of bilateral abdominal cryptorchidism by laparoscopy.Endoscopy, 8: 33, 1976. Manson, A. L., Terhune, D., Jordan, G., Auman, J. R., Peterson, N. and MacDonald, G.: Preoperative laparoscopic localization of the nonpalpable testis. J. Urol., 134: 919, 1985.
6. Schuessler, W. and Griffith, D. P.: Personal communication. 7. Coptcoat, M. J., Ison, K. T. and Wickham, J.E. A.: Endoscopic tissue liquidization and surgical aspiration. J.Endourol., 2: 321, 1988. 8. Chopp, R. T., Shah, B. B. and Addonizio, J. C.: Use of ultrasonic surgical aspirator in renal surgery. Urology, 22: 157, 1983. 9. Clayman, R. V., Kavoussi, L. R., Long, S. R., Dierks, S. M., Meretyk, S. and Soper, N. J.: Laparoscopic nephrectomy: initial report of pelviscopic organ ablation in the pig. J. Endourol., 4: 247, 1990. 10. Wickham, J. E. A. and Miller, R. A.: Percutaneous renal access. In: Percutaneous Renal Surgery. New York: Churchill Living stone, chapt. 2, pp. 33-39, 1983. 11. Weinberg, J. J. and Smith, A. D.: Percutaneous resection of the kidney: preliminary report. J.Endourol., 2: 355, 1988. 12. Robey,E. L. and Schellhammer, P. F.: The adrenal gland and renal cell carcinoma: is ipsilateral adrenalectomy a necessary compo nent of radical nephrectomy? J. Urol., 135: 453, 1986. 13. Graham, S. D., Jr. and Glenn, J. F.:Enucleative surgery for renal malignancy. J. Urol., 122: 546, 1979. 14. Topley, M., Novick, A. C. and Montie, J. E.: Long-term results following partial nephrectomy for localized renal adenocarci noma. J. Urol., 131: 1050, 1984. 15. Novick, A. C.: Partial nephrectomy for renal cell carcinoma. Urol. Clin. N. Amer., 14: 419, 1987. 16. Weinstein, S. H., Navarre, R. J., Jr., Loening, S. A. and Corry, R. J.:Experience with live donor nephrectomy. J. Urol., 124: 321, 1980. 17. DeMarco, T., Amin, M. and Harty, J. I.: Living donor nephrectomy: factors influencing morbidity. J. Urol., 127: 1082, 1982. 18. Ruiz, R., Novick, A. C., Braun, W.E., Montague, D. K. and Stewart, B. H.: Transperitoneal live donor nephrectomy. J. Urol., 123: 819, 1980.
Vol. 146, 278�282 August 1991 Printed in U.S.A.
LAPAROSCOPIC NEPHRECTOMY: INITIAL CASE REPORT RALPH V. CLAYMAN, LOUIS R. KAVOUSSI, NATHANIEL J. SOPER, STEPHEN M. DIERKS, SHIMON MERETYK, MICHAEL D. DARCY, FREDERICK D. ROEMER, EDWARD D. PINGLETON, PAUL G. THOMSON AND STEPHENIE R. LONG From the Departments of Surgery (Division of Urologic Surgery) and Radiology, and Division of General Surgery, Mallinckrodt Institute of Radiology, Washington University School of Medicine, St. Louis, Missouri, and Cook Urological, Inc., Spencer, Indiana
ABSTRACT
A tumor-bearing right kidney was completely excised from an 85-year-old woman using a laparoscopic approach. A newly devised method for intra-abdominal organ entrapment and a recently developed laparoscopic tissue morcellator made it possible to deliver the 190 gm. kidney through an 11 mm. incision. KEY WORDS:
kidney neoplasms, nephrectomy, laparoscopy, carcinoma
Although major advances in laparoscopic surgery have been made in the area of gynecology, its application in the realm of general surgery and urology has been limited.1 Recently, with the development of laparoscopic cholecystectomy, more interest in minimally invasive laparoscopic procedures has occurred.2 The advantages of this approach are obvious to the patient and surgeon, including shorter hospitalization, lower morbidity and more rapid convalescence. However, while small lesions (dimin utive uterine myomas) or small hollow organs (appendix or gallbladder) can be removed laparoscopically, there have been 3 deterrents to the spread of laparoscopy into other areas of traditional abdominal surgery: 1) the need for extensive tissue dissection and vascular control, 2) the requirement for proper organ isolation to preclude abdominal contamination with bac teria or cancerous cells from the diseased organ and 3) the development of an instrument to allow for the safe and rapid removal of tissue through an 11 mm. laparoscopic port. We describe how each of these problems was addressed to accom plish a modified radical nephrectomy using laparoscopic tech niques.
FIG. 1. Preoperative CT scan reveals 3 cm. renal mass (arrows) occupying lateral border of mid portion of right kidney. Right kidney measures 6.5 X 8.5 X 6.5 cm.
CASE HISTORY
An 85-year-old white woman presented with an asympto matic 3 cm. solid right renal mass serendipitously diagnosed when she underwent a computerized tomogram (CT) of the abdomen after suffering a fall. The study revealed no intra abdominal pathology. However, a 3 cm. renal mass was noted along the lateral border of the mid portion of the right kidney (fig. 1). Medical history was significant for an appendectomy performed through a lower midline abdominal incision in 1950 and right total hip replacement in 1988. The only medications were a daily tablet of alprazolam and an aspirin every other day. On physical examination she weighed 50 kg. and was 5 feet 1 inch tall, afebrile, with a blood pressure of 154/70 and pulse 60 per minute. The right kidney was not palpable and there was no right costovertebral angle tenderness. Serum chemistry studies revealed a blood urea nitrogen level of 13 mg./dl. and a creatinine level of 1.0 mg./dl. The serum electrolytes, liver function studies, coagulation studies (pro thrombin time, partial thromboplastin time and bleeding time), white blood count and platelet count were all within normal limits. The admission hemoglobin was slightly depressed (11.4 gm./dl.) but all of the red blood cell indexes were normal. Urine culture was sterile. A chest radiograph and a radionuclide bone scan were nega tive for metastatic disease. Likewise, on the CT scan there was Accepted for publication March 15, 1991. 278
no evidence of renal hilar lymphadenopathy, inferior vena caval tumor thrombus or hepatic metastases. Preoperatively, the patient underwent a bowel preparation (1 gm. erythromycin base and 1 gm. neomycin orally at 4, 5 and 10 p.m., and 3 1. GoLYTELY). Preoperative antibiotics consisted of 1 gm. intravenous ampicillin and 70 mg. gentamicin. On the morning of June 25, 1990 right renal arteriography revealed a single right renal artery that bifurcated as it exited from beneath the inferior vena cava (fig. 2). Five segmental renal arteries were identifiable on the radiographs. The renal mass appeared to be well perfused and there was no involve ment of the renal vein. The right renal artery was embolized by injection of 8 cc absolute ethanol. Then, 2½ hours after the embolization, the patient underwent the operation. Due to her age and a history of postoperative tachycardia after hip surgery (ASA class 3) a Swan-Ganz catheter was placed via the right jugular vein. A nasogastric tube was also positioned. With the patient in a supine position flexible cystoscopy was performed and a 0.035-inch guide wire along with a 5F angiographic end hole catheter were passed to the renal pelvis. A urethral cath eter was also placed. A Veress needle was inserted supraumbilically in the midline. A pneumoperitoneum was achieved with carbon dioxide: 10 mm. Hg pressure with 4.5 1. instilled. Two 11 mm. trocars were then placed: 1 approximately 2 inches above the umbilicus in the midline and 1 in the mid clavicular line approximately 4
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FIG. 2. Preoperative angiogram reveals single renal artery with 5 segmental branches (small arrows) supplying kidney and vascularized renal mass (large arrows).
inches above the umbilicus. Two 5 mm. trocars were then positioned: 1 in the mid clavicular line approximately 1 inch below the umbilicus and 1 in the mid clavicular line 2 inches above the umbilicus (on a line with the initially placed 11 mm. trocar). The patient was then turned to a left lateral decubitus position to displace the bowel medially and another trocar (11 mm.) was placed in the anterior axillary line 2 inches above the umbilicus (on a line with the initially placed 11 mm. trocar). Using an electrocautery dissecting probe and several different types of grasping forceps, the right line of Toldt lateral to the ascending colon was grasped and incised. The right colon was
reflected medially, thereby exposing the retroperitoneum and Gerota's fascia. The ureter was identified by inoving the ret rograde ureteral catheter within the ureter. The ureter was then dissected and secured by a 5 mm. grasping forceps (lower most 5 mm. port). Lateral traction on the ureter placed the renal hilus on slight tension. By dissecting along the tented up ureter, the renal pelvis and renal vessels could be identified. Due to the prox imity of the dissection to the medial border of the kidney the vascular structures were smaller in size but multiple in number. Each of 5 segmental renal arteries was subsequently dissected and secured with ligature clips: 2 clips on the renal side and 2 or 3 on the vascular stump. The secured vessels were transected with a 5 mm. hook scissors. The upper pole of the kidney was dissected and the adrenal gland was left in place. The rest of the kidney, including the perirenal fat and Gerota's fascia over the lower pole and mid portion of the kidney, was dissected from the abdominal sidewall. Lastly, the previously placed retrograde ureteral guide wire and catheter were removed from the ureter. The ureter was secured with 2 ligature clips, and then incised, thereby completely freeing the kidney within the abdomen (fig. 3, A). At that point a tough, flexible, 6 X 9-inch, impermeable sterile sack with a drawstring (patent pending*) was inserted into the abdomen via the midline 11 mm. laparoscopy sheath. The sack was opened in the abdomen and the kidney was then maneuvered into the sack (fig. 3, B). Through the midline 11 mm. port a 5 mm. grasping forceps was used to grasp the mouth of the sack and pull it part way into the 11 mm. sheath. The sheath was removed and the mouth of the sack then lay on the exterior of the anterior abdominal wall. A tissue morcellating device in combination with a vacuum (patent pending*) was then introduced into the kidney-contain ing sack. The kidney was morcellated and aspirated from within the impermeable sack (7 minutes). The then empty sack was pulled from the abdominal cavity. Inspection of the abdomen revealed no active bleeding. The abdominal fascia underlying * Cook OB/GYN, Inc., Spencer, Indiana.
Gr1;1sping forceps suspending kidney from ureter
"'-'--f'"cf--f-Kk:lney wlthln entrapment s.ock
FIG. 3. A intraoperative view of kidney completely freed from its retroperitoneal attachments and vascular supply. Kidney is suspended from renal hilus v'ia 5 mm. grasper passed through 1 abdominal sheath. B, intraoperative view of kidney placed into nylon surgical sack.
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each of the 11 mm. laparoscopic sites was closed with 1-zero polyglactin. The skin of each 11 mm. port and of the 5 mm. ports was closed with 5-zero polyglycolic acid placed in a subcuticular fashion. The total operative time was 6 hours 45 minutes. The esti mated blood loss was 300 cc. A total of 41. intravenous crystal loid was given. Throughout the procedure there was no decrease in blood pressure and the central venous pressure varied be tween 6 and 11 cm. water. The specimen weighed 190 gm. (fig. 4). Pathological evalua tion of the morcellated kidney revealed an oncocytoma of the kidney (grade 1 granular cell renal cancer). No surgical margins could be discerned. No lymph node tissue was noted. The. nasogastric tube was removed within 12 hours postop eratively and the patient began oral intake in less than 36 hours. Antibiotic coverage with ampicillin, gentamicin and metronidazole hydrochloride was continued for 48 hours fol lowed by cefazolin sodium for another 3 days. The hematocrit drifted downward from 28% immediately postoperatively to 24.8% on postoperative day 2. Therefore, 1 unit of blood was transfused. A CT scan of the abdomen revealed only a scant amount of ascites but there were small bilateral pleural effusions (fig. 5). Auscultation of the chest revealed rales bilaterally. The patient was given a bolus of 20 mg. furosemide and a brisk diuresis ensued (2,150 cc in 8 hours). Another 10 mg. dose of parenteral furosemide was given the
Fm. 4. Gross specimen of right kidney. Specimen weighed 190 gm. Renal parenchyma is to left side and suspected fragments of tumor are on right side.
Fm. 5. On postoperative day 2 CT scan at level of lower pole of left kidney (arrow) reveals absence of right kidney and minimal amount of intraperitoneal fluid. Abdominal wall on right side is mildly thickened.
next day. With this combined therapy the hematocrit increased to 31%. Throughout the postoperative period the temperature ranged from 36.5 to 37.5C. The white blood count initially increased to 15,000 cells per mm.a but by postoperative day 5 it had returned to normal (8,000 cells per mm.a). During the postoperative period the patient experienced min imal discomfort. One dose of morphine sulfate (4 mg.) was given intravenously 5 hours after the procedure. No other analgesics, either parenteral or oral, were requested or admin istered. The patient was discharged on the morning of postop erative day 6. She resumed normal preoperative activities by postoperative day 10 (fig. 6). DISCUSSION
For the last 50 years laparoscopy has been largely the prov ince of the gynecologist. 1 With this minimally invasive means to access the female pelvis, the gynecologist has used the laparoscope to diagnose successfully a variety of conditions, and to perform biopsies and minor operations, including tubal ligation, excision of small subserous myomas, ovarian biopsy, treatment of tubal pregnancy, excision of an ovarian cyst, oophorectomy, adhesiolysis and peritoneal biopsy. Although the abdomen is common territory for the gynecologist, general surgeon and urologist, laparoscopy has been little used in these other specialties. In general surgery the laparoscope was ini tially used by only a few surgeons to aid in the diagnosis of the acute abdomen.a However, the recent advent of laparoscopic cholecystectomy has moved laparoscopy into generally accepted surgical practice.2 In urology, the laparoscope has been used most commonly to diagnose the location of a cryptorchid testicle to plan a subse quent open operation.4• 5 More recently, the laparoscope has been used at 1 hospital to perform pelvic lymph node dissection before planned therapy for localized prostate cancer.6 Indeed, the chief beneficiary of this technology is the patient; hospital stay (outpatient or overnight), convalescence (1 to 3 days) and morbidity are minimal compared to a traditional open opera tion. To date, there has been 1 major practical drawback to lapa roscopy, that is the tissue removed, of necessity, had to be limited in size to that of the largest laparoscopic port inserted (11 mm.). To apply laparoscopic technology to the removal of larger tissues 3 problems had to be overcome: 1) tissue dissec tion, 2) tissue evacuation and 3) organ entrapment. With regard to tissue dissection, the advent of electrocautery probes with aspiration and irrigation capabilities, and the development of
FIG. 6. Abdomen 10 days after laparoscopic nephrectomy. Long arrow denotes umbilicus. Closed arrows show 5 mm. trocar sites. Open arrows show 11 mm. trocar sites.
LAPAROSCOPIC NEPHRECTOMY
rapid load metal clip appliers have been of great benefit. The former greatly facilitates tissue dissection, while the latter allows for rapid and secure occlusion of vascular structures. This precludes the necessity of passing suture and tying surgical knots through the laparoscope, which is difficult and tedious. To remove larger structures via the 11 mm. laparoscopic incision it is necessary to have available an effective tissue morcellator. While a hand operated tissue morcellator is avail able, it is used predominantly on small amounts of tissue. Other surgical tissue aspirators have recently become available: a surgical tissue liquidizer and an ultrasonic aspirator. 7• 8 How ever, neither has been developed for use via the laparoscope. Therefore, a serviceable electrical tissue morcellator for lapa roscopic use was developed during our initial studies of lapa roscopic nephrectomy in pigs. 9 The clinical prototype rapidly fragments and evacuates tissue without destroying the histology of the kidney. The last impediment to approaching larger organs laparo scopically was the concern that in handling or removing the diseased tissue, bacteria or cancerous cells could be released into the abdomen. Certainly, an infected or tumor-bearing organ could not be fragmented and removed in situ, since tumor cells or bacteria would be released as the tissue was morcellated. Therefore, a method to isolate the diseased organ from the rest of the abdomen was devised. Specifically, by placing the tissue directly into an impermeable nylon sack, the tissue was effec tively sequestered such that subsequent morcellation would not release the c6ntents of the organ into the abdominal cavity. The approach for laparoscopic nephrectomy could conceiva bly be done in either a direct retroperitoneal manner or an indirect transabdominal fashion. However, earlier attempts at direct retroperitoneal renal laparoscopy by Wickham and Miller were largely unsuccessful. 10 In human cadavers they used a direct retroperitoneal approach but because of the ret roperitoneal fat a satisfactory pneumoretroperitoneum could not be achieved. Similarly, the first reported attempt at using a minimally invasive operation to remove a kidney in an animal model was that of Weinberg and Smith and, again, a direct retroperitoneal approach was used. 1 1 In 1 pig a percutaneous nephrostomy tube was placed into the kidney directly through the retroperitoneum. An endoscopic ultrasonic aspirator was used to remove the kidney from the inside outward. At autopsy, the renal pedicle and a stump of renal parenchyma remained intact despite preoperative embolization of the renal artery and renal vein. 1 1 Given these difficulties, we elected to approach the kidney transabdominally via the laparoscope. This approach had not been previously reported in either animals or humans. The aforementioned methods were initially developed in the labo ratory using 100 pound female pigs. 8 From this study the techniques to dissect the kidney and entrap it in a sack were refined. In addition, further changes were made in the tissue morcellator and the entrapment sack, thereby allowing for more rapid morcellation without injury to the sack itself. The pro cedure was completed in each of 7 pigs within 1.5 to 3 hours. In each case the kidney was successfully dissected and freed from its renal pedicle. In 6 of 7 pigs the kidney was successfully delivered via the sack. Given our favorable laboratory experience, we elected to apply this method for nephrectomy to a patient. A favorable factor in our patient was the small size (3 cm.) amd location of the right renal tumor making it amenable to simple or even partial nephrectomy. 12-15 Therefore, only a modified radical nephrectomy encompassing the perirenal fat and fascia over lying the tumor was planned. The ipsilateral adrenal gland was not removed. However, adrenalectomy in patients with con fined midsection or lower pole renal carcinoma probably is unnecessary. 12 In this initial case our method for laparoscopic nephrectomy succeeded, although the operative time was ex cessive. Difficulty in identifying and securing the ureter ac-
counted for almost half of the operative time. Similarly, the investment of the kidney and hilar structures in fat also con tributed to the difficulty and duration of the dissection. None theless, the patient tolerated the lengthy procedure well, with out any clinically significant hemodynamic changes. Convalescence was complicated by the need for 1 unit of blood and mild fluid overload. The nasogastric tube was re moved within 12 hours and oral feedings were begun 36 hours after the procedure. Interestingly, only a single injection for discomfort was needed; no other parenteral nor oral analgesics were given during the rest of the hospital stay. The patient was discharged from the hospital 6 days postoperatively. One group of individuals to whom this patient can be com pared are those undergoing donor nephrectomy. In general, these patients are middle aged and healthy. As such, it is of interest that while the operative time for donor nephrectomy is brief (1.5 to 2.2 hours) the hospital stay is still lengthy (6.9, 10.2 and 10.5 days as reported in several large series 16-18). In addition, most patients require nasogastric suction for 24 hours and are not able to begin oral intake for 48 to 72 hours. 1 Furthermore, a minor complication rate of 14 to 30% and a major complication rate of O to 3.5% have been reported. 16-18 Many complications are secondary to the surgical wound itself (infection, fasciitis and herniation). Other problems are secondary to injuries from the retraction of the wound and surrounding organs and tissues (pleurotomy or pneumonia in 4 to 12% of the cases and incidental splenectomy in O to 2.3%). 16-18 Furthermore, in none of the reports on donor ne phrectomy is the total dosage of pain medication recorded nor the duration of convalescence addressed. In our initial case laparoscopic nephrectomy resulted in minimal morbidity, a short hospital stay and brief convalescence. With additional physician experience and further refinements in instrumenta tion, the operative time for laparoscopic nephrectomy probably will decrease as will the length of hospitalization. Aside from obvious patient benefits, significant cost savings should also be realized. However, presently there are several disadvantages to this technique. Transient drawbacks include the need for operator experience, expense of the laparoscopic equipment and in creased operative time for nephrectomy. These problems should all be overcome as the technique is acquired and refined by other urologists. A potentially more serious and irresolvable problem is that the specimen is fragmented rather than re moved intact. While this is of little concern when nephrectomy is performed for benign disease (renal hypertension, end stage renal disease or chronic pyelonephritis), it may be a problem with a tumor-bearing kidney. While histological confirmation of the renal cancer can be obtained, there can be no or scant commentary regarding the depth of tumor invasion. Finally, lymph node involvement can be assessed only if a lymph node dissection is performed either immediately before or after re moval of the kidney. This tissue then can be sent separately for analysis to determine the presence or absence of nodal metastases. Lastly, we believe this initial report of laparoscopic nephrec tomy has broad implications that go well beyond the urological realm. The practice of laparoscopy, organ entrapment and intra-abdominal, albeit contained, morcellation could conceiv ably apply to any tissue within the abdominal cavity that can be dissected laparoscopically. As such, splenectomy, ovariec tomy for ovarian cancer, colon resection, small bowel resection, diseased appendixes, thick-walled, infected gallbladders, and other intra-abdominal and pelvic processes of either an infec tious or cancerous nature may eventually be removed using a minimally invasive laparoscopic technique. ADDENDUM
Since June 25, 1990 we have successfully completed 8 con secutive laparoscopic nephrectomies using the aforementioned
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techniques. The 7 subsequent patients have all required ne phrectomy for benign disease: renovascular hypertension, chronic obstruction, recurrent infection and associated flank pain. Currently, we believe that these techniques are best applied to patients with benign renal disease; among otherwise healthy patients with upper tract malignancy, a standard open surgical procedure remains the treatment of choice. In these patients present concerns over possible tumor dissemination and the lack of surgical margins preclude a laparoscopic ap proach. Drs. Beth Brunts and Louis Dehner, Department of Pathol ogy, Washington University School of Medicine and Dr. Kurt Semm, Director of the Women's Hospital at Christian Al brechts University, Kiel, Germany, provided expertise and sup port. 1. 2. 3. 4. 5.
REFERENCES Semm, K.: Operative Manual forEndoscopic Abdominal Surgery. Chicago: Year Book Medical Publishers, Inc., 1987. Reddick, E. J. and Olsen, D. 0.: Laparoscopic laser cholecystec tomy. A comparison with mini-lap cholecystectomy. Surg. En dosc., 3: 131, 1989. Wood, D., Berci, G., Morgenstern, L. and Paz-Partlow, M.: Mini laparoscopy in blunt abdominal trauma. Surg. Endosc., 2: 184, 1988. Cortesi, N., Ferrari, P., Zambarda,E., Manenti, A., Baldini, A. and Morano, F. P.: Diagnosis of bilateral abdominal cryptorchidism by laparoscopy.Endoscopy, 8: 33, 1976. Manson, A. L., Terhune, D., Jordan, G., Auman, J. R., Peterson, N. and MacDonald, G.: Preoperative laparoscopic localization of the nonpalpable testis. J. Urol., 134: 919, 1985.
6. Schuessler, W. and Griffith, D. P.: Personal communication. 7. Coptcoat, M. J., Ison, K. T. and Wickham, J.E. A.: Endoscopic tissue liquidization and surgical aspiration. J.Endourol., 2: 321, 1988. 8. Chopp, R. T., Shah, B. B. and Addonizio, J. C.: Use of ultrasonic surgical aspirator in renal surgery. Urology, 22: 157, 1983. 9. Clayman, R. V., Kavoussi, L. R., Long, S. R., Dierks, S. M., Meretyk, S. and Soper, N. J.: Laparoscopic nephrectomy: initial report of pelviscopic organ ablation in the pig. J. Endourol., 4: 247, 1990. 10. Wickham, J. E. A. and Miller, R. A.: Percutaneous renal access. In: Percutaneous Renal Surgery. New York: Churchill Living stone, chapt. 2, pp. 33-39, 1983. 11. Weinberg, J. J. and Smith, A. D.: Percutaneous resection of the kidney: preliminary report. J.Endourol., 2: 355, 1988. 12. Robey,E. L. and Schellhammer, P. F.: The adrenal gland and renal cell carcinoma: is ipsilateral adrenalectomy a necessary compo nent of radical nephrectomy? J. Urol., 135: 453, 1986. 13. Graham, S. D., Jr. and Glenn, J. F.:Enucleative surgery for renal malignancy. J. Urol., 122: 546, 1979. 14. Topley, M., Novick, A. C. and Montie, J. E.: Long-term results following partial nephrectomy for localized renal adenocarci noma. J. Urol., 131: 1050, 1984. 15. Novick, A. C.: Partial nephrectomy for renal cell carcinoma. Urol. Clin. N. Amer., 14: 419, 1987. 16. Weinstein, S. H., Navarre, R. J., Jr., Loening, S. A. and Corry, R. J.:Experience with live donor nephrectomy. J. Urol., 124: 321, 1980. 17. DeMarco, T., Amin, M. and Harty, J. I.: Living donor nephrectomy: factors influencing morbidity. J. Urol., 127: 1082, 1982. 18. Ruiz, R., Novick, A. C., Braun, W.E., Montague, D. K. and Stewart, B. H.: Transperitoneal live donor nephrectomy. J. Urol., 123: 819, 1980.
