Bilateral Hand-Assisted Laparoscopic Renal Surgery in the Supine Position: The Spleen at Risk.

2011·0.16 MB·English

by  Brown, James A.

S P
CIENTIFIC APER
Bilateral Hand-Assisted Laparoscopic Renal Surgery
in the Supine Position: The Spleen at Risk
James A. Brown, MD, Kashif Siddiqi, MD
ABSTRACT INTRODUCTION
Objective:Weevaluatedthesafetyofsimultaneousbilat- During the last decade, multiple investigators have re-
eral renal procedures performed using hand-assisted lap- ported that bilateral hand-assisted laparoscopic ne-
aroscopy (HAL) with the patient in the supine position. phrectomy is feasible and safe, even for patients with
autosomal dominant polycystic kidney disease (AD-
Materials and Methods: After securely strapping the
PKD) (Table 1).1-10 Other investigators have further
patient to the table, a hand-port device is placed via a
reported that single-setting bilateral HAL partial ne-
7-cmsupraumbilicalorperi-umbilicalincisionwithtwoto
phrectomy, ureterolysis, and nephroureterectomy are
four 5-mm to 12-mm trocars placed bilaterally. During a
also feasible and safe.11-14 Although some surgeons in
3-year period, 8 bilateral HAL renal operations were ini-
these prior series repositioned the patient to maintain
tiated(upperpolepartialnephrectomies,3nephroureter-
the advantage of performing laparoscopy with the pa-
ectomies, 3 bilateral nephrectomies, and right nephrec-
tientin the lateral decubitus position, most positioned
tomy with left adrenalectomy).
the patient supine (dorsal decubitus) and rolled the
Results:Meanpatientagewas41years.Onepatientwith table from side to side, elevating the kidney 30° to 45°,
ADPKD required conversion to open due to failure to to operate on each kidney without the need to reposi-
progress secondary to excessive perirenal fat and 22-cm tion the patient.
kidneys. The other 7 were completed successfully with a
Inflammatory renal conditions added to the difficulty
mean operative time of 417 minutes and mean EBL of
336cc. Two patients received transfusions. Two small and operative time.6,8 Bilateral nephrectomies to re-
move large ADPKD were the most challenging proce-
splenic lacerations, managed conservatively, were the
dures overall, with the longest operative times and the
only complications.
greatest chance for open conversion.8,10 All of these
Conclusions: Bilateral hand-assisted laparoscopic renal prior investigators concluded that bilateral HAL renal
surgerywiththepatientinthesupineposition(rollingthe surgery was safe, even with the patients positioned
table side to side) is feasible in the majority of patients. supine throughout the procedure and rolled or “air-
However, very large kidneys (eg, ADPKD) may be better planed” in each direction to operate on each kidney.
approached with the patient in the lateral decubitus po- While it would seem probable that bowel mobilization
sition or via an open subcostal incision. Importantly, the would be more difficult in this latter situation, to our
spleen appears to be at increased risk for capsular injury knowledge, no prior investigators have reported an
due to apparent increased difficulty of left colon mobili- increased rate of splenic capsule injury. The aim of this
zation in the “rolled” or “airplaned” supine position. study was to evaluate our experience with performing
simultaneous renal procedures using HAL with the pa-
Key Words: Laparoscopy, Kidney, Supine position.
tient in the supine position, specifically focusing on
safety and occurrence of adjacent organ injury.
MATERIALS AND METHODS
Division of Urology, Medical College of Georgia, Augusta, Georgia, USA (all The patients were securely strapped to the table in the
authors).
supine position with 3-inch tape criss-crossing the chest,
Addresscorrespondenceto:JamesA.Brown,MD,UniversityofIowa,Department acrossthehips,thighs,andlowerextremities.Ahand-port
ofUrology,200HawkinsDr.,3RCP,IowaCity,IA52242-1089,USA.Telephone:
devicewasplacedviaamidline7-cmsupraumbilical(ex-
[phone],Fax:[phone],E-mail:[email protected]
tending to or skirting the upper left umbilicus) in 5 pa-
DOI:10.4293/108680810X12924466009168
tientsandviaaperi-umbilicalincision(for3nephroureter-
©2011byJSLS,JournaloftheSocietyofLaparoendoscopicSurgeons.Publishedby
theSocietyofLaparoendoscopicSurgeons,Inc. ectomy patients, Figure 1) with two to four 5-mm to
JSLS(2011)15:27–31 27
BilateralHand-AssistedLaparoscopicRenalSurgeryintheSupinePosition:TheSpleenatRisk,BrownJAetal.
Complications 0 0 1AVfistulathrombosis 1ATN;1postoppercutaneousdrainplacement;1retroperitoneaIhematoma NS NS 0 1pneumothorax;1conversion;1transfusion 1AVfistulathrombosis;1reintubation 5complications;4conversions;2transfusions (cid:5)riovenous,ATN
e
rt
MeanEstimatedBloodLoss(mL) 300(cid:2)200 400 338 100–200 NS 345 NS 203 350 (cid:5)se;AVA
a
e
s
al n) di
Tot (mi 395, ney
ctomy MeanORTime 210 330(300) 360 286 390 265 185 190 194 315 ystickid
e c
picNephr PositionAngle 60° 40–50° 90° 90° 40°(30–45°) 60° NS NS 30° NS nantpoly
o mi
Table1nd-AssistedLaparosc SupineProcedure,NoRepositioning 0 2 0 0 3 0 6 3 10 (cid:1)(cid:4)18(/gelrollunderoneflank) (cid:5)KDautosomaldo
Ha us DP
eriesofBilateral LateralDecubit(cid:1)ProcedureRepositioning 1 rd1(3case) 2 4 0 2 0 0 0 0 (cid:5)nfection,DK,A
S i
d e ct
she Casno. 1 3 2 4 3 2 6 3 10 18 tra
Publi PatientPopulation ESRD,UTI ADPKD ESRD,UTI,DK,ADPKD ADPKD ADPKD Chronicinfection ADPKD(cid:3)20cmADPKD ADPKD ADPKD (cid:5)disease,UTIunrinary(cid:5)NSnotsignificant.
Report Schmidlinetal,20001 Rehmanetal,20012 Troxel&Das,20013 Jenkinsetal,20024 Lee&Clayman,20045 Tanetal,20046 Zamanetal,20057 Tobias-Machadoetal,20058 Whittenetal,20069 Lipkeetal,200710 (cid:5)ESRDend-stagerenalacutetubularnecrosis,
28 JSLS(2011)15:27–31
mies and required open conversion due to failure to
progresssecondarytoexcessiveperirenalfatand22-cm
kidneys.
The mean preoperative serum hemoglobin was 11.4mg/dL
(median, 11.2). The mean postoperative hemoglobin
level was 9.2mg/dL (median, 8.8). Two patients re-
ceived red blood cell transfusions. The only complica-
tions identified were 2 small splenic capsular lacera-
tions, both of which were managed conservatively.
There were no other intraoperative or postoperative
complications identified.
DISCUSSION
Several prior investigators have reported that simultane-
ousbilateralHALnephrectomyissafeandeffective,even
when performed with the patient in the supine position
(Table 1).1-10 Additionally, bilateral HAL partial nephrec-
tomy and ureterolysis have been demonstrated to be fea-
Figure1.Periumbilicalhand-portandlaparoscopictrocarplace- sible and without excessive morbidity.11,12 In the partial
mentsites. nephrectomyseries,thepatientswereinthelateraldecu-
bitus position and repositioned during the operation, but
12-mm trocars placed bilaterally. The table was rolled or in the ureterolysis series, the patients was secured to the
“airplaned”maximallyside-to-sidetoallowforboweland operative table supine and the table was rolled to each
hepatic/splenic flexure mobilization and surgery in each side.
retroperitoneum.
Additionally,thefeasibilityofHALbilateralnephroureter-
We initiated 8 bilateral HAL renal operations (upper ectomy (HALBNU) has recently been demonstrated. In-
pole partial nephrectomies, 3 bilateral nephroureterec- vestigators from the National Taiwan University in Tai-
tomies, 3 bilateral nephrectomies, and a right nephrec- pei reported the first HALBNU in 2002 and
tomy with left adrenalectomy) as treatment for inconti- subsequently published a review of 33 HALBNU pa-
nence secondary to ectopic vaginal ureters, end-stage tients (compared to 16 open BNU patients) treated for
renal disease (ESRD) with left renal tumor, ESRD with clinically localized presumed upper tract transitional
vesicoureteral reflux (VUR; 3 cases), ESRD with Good- cell carcinoma.13,14 Their HALBNU cases took 38 min-
pasture’s disease and refractory hypertension, ESRD uteslongeronaverage(309vs271minutes)withlower
with neurogenic bladder and VUR and ESRD with AD- transfusion (42% vs 75%) and complication (12% vs
PKD. Resident surgeons actively participated as opera- 19%) rates. Importantly, while they positioned the pa-
tive surgeons during cases. Patient demographic data, tient supine and rolled the table rather than reposition,
operative times, estimated blood loss (EBL), blood they used alternating inflation cuffs to further elevate
transfusions, conversion rates, and complications were the flank. Additionally, the distal ureteral dissections
recorded. were performed through the 7-cm HAL incision by
using an open technique.
RESULTS
OurseriesincludespatientsundergoingbilateralHALne-
All 8 patients were female with a mean age of 41 years. phrectomy, a bilateral upper pole partial nephrectomy
Seven cases (87.5%) were completed successfully with plus 3 bilateral nephroureterectomies. The latter cases
a mean operative time of 417 minutes (median, 407) were to treat 3 patients with ESRD from vesicoureteral
and mean EBL of 336mL (median, 250). One ADPKD reflux(VUR).UnlikeChuehandcolleagues,13weusedno
patient underwent attempted bilateral HAL nephrecto- technique such as inflation devices to further elevate the
JSLS(2011)15:27–31 29
BilateralHand-AssistedLaparoscopicRenalSurgeryintheSupinePosition:TheSpleenatRisk,BrownJAetal.
flank.Additionallyintheseproceduresforbenigndisease, WhiletherearespecialsituationsinwhichbilateralHAL
theuretersweredividedatthelevelofthebladder(with- procedures are appropriate, utilization of some form of
out taking a bladder cuff) using an entirely HAL surgical left flank elevation should be strongly considered. Ad-
approach. ditionally, staged procedures, optimal lateral decubitus
repositioning of the patient between sides, and early
Our mean operative time of 417 minutes was longer
conversion to open surgery in the case of failure to
than the mean operative times of prior reports of bilat-
progressareallreasonablealternativestothedescribed
eralHALnephrectomies(194to330minutes),HALBNU
(309 minutes) and partial nephrectomies (246 min- technique.
utes).2,4,6,9,11,14 The reason for our increased operative
timesisunclear,buttherelativelylowvolumeofwidely
varying procedures and significant active resident par- CONCLUSION
ticipation in all cases were likely contributing factors.
Bilateralhand-assistedlaparoscopicrenalprocedureswith
Our mean EBL of 336mL, however, was on par with
thepatientinthesupineposition(rollingthetablesideto
prior reports ((cid:2)350mL).2,5,11 The need to transfuse 2
side)arefeasiblebutmayputthespleenatincreasedrisk
patients and to convert our large ADPKD case to open
(25% in this series) for a capsular injury. Additionally,
was also consistent with prior reports of bilateral HAL
while complex diseases may be handled, very large kid-
surgery to treat ADPKD.8,10 In these series, 1 of 3 and 4
neys(eg,ADPKD,(cid:3)20cm)areatsignificantriskforopen
of 18 ADPKD patients required open conversion.
conversion, and we believe are better approached in the
Unique to this study, however, was the occurrence of
lateral decubitus position or via an open subcostal inci-
splenic capsular lacerations in 25% (2 of 8) of the
sion. The senior author has abandoned this supine ap-
procedures. This complication, to our knowledge, has
proach and currently favors repositioning or staging the
not been previously reported and raises concern re-
renalprocedures,performedwiththepatientinthelateral
garding the safety of colonic splenic flexure mobiliza-
decubitus position.
tionwhenthepatientispositionedtotallysupineonthe
table. In this position, even with the table tilted maxi-
mally, we observed suboptimal medial bowel displace-
References:
ment and found that a greater than normal amount of
hand traction to mobilize the colon (rather than dis- 1. SchmidlinFR,IselinCE.Hand-assistedlaparoscopicbilateral
placement by gravity) was required, when subjectively nephrectomy.Urology.2000;56:153.
compared to HAL renal procedures in the full lateral
2. RehmanJ,LandmanJ,AndreoniC,McDougallEM,Clayman
decubitus position.
RV.Laparoscopicbilateralhandassistednephrectomyforauto-
We acknowledge that a significant limitation to this somal dominant polycystic kidney disease: initial experience.
study is the small number of patients and the perfor- JUrol.2001;166:42-47.
mance of several different bilateral hand-assisted pro- 3. Troxel S, Das S. Hand-assisted laparoscopic approach to
cedures. We also acknowledge that bilateral HAL sur- multiple-organremoval.JEndourol.2001;15:895-897.
gery in the nearly supine position, with a gel roll or
4. Jenkins MA, Crane JJ, Munch LC. Bilateral hand-assisted
balloon elevating the left flank 10% to 15% and re-
laparoscopic nephrectomy for autosomal dominant polycystic
movedmid-casepriortoswitchingtotherightside,can
kidney disease using a single midline HandPort incision. Urol-
besuccessfullyperformed.Further,HALandpurelapa-
ogy.2002;59:32-36.
roscopic renal surgery to the left kidney in a modified
(30°) flank position has been widely reported, and 5. Lee DI, Clayman RV. Hand-assisted laparoscopic nephrec-
although splenic injury is a known complication, the tomyinautosomaldominantpolycystickidneydisease.JEndou-
incidence is generally very low. rol.2004;18:379-382.
Therefore, we believe the main finding of this study is 6. Tan YH, Siddiqui K, Preminger GM, Albala DM. Hand-as-
sisted laparoscopic nephrectomy for inflammatory renal condi-
thatperformanceofbilateralHALrenalsurgerywiththe
tions.JEndourol.2004;18:770-774.
patient in the totally supine position (and without any
form of flank elevation) provides suboptimal exposure 7. Zaman F, Nawabi A, Abreo KD, Zibari GB. Pretransplant
to the kidneys and adrenal glands, which may lead to bilateral hand-assisted laparoscopic nephrectomy in adult pa-
longer operative times and a higher complication rate. tients with polycystic kidney disease. JSLS. 2005;9:262-265.
30 JSLS(2011)15:27–31
8. Tobias-Machado M, Tavares A, Forseto PH Jr., Zambon JP, 12. Brown JA, Garlitz CJ, Hubosky SG, Gomella LG. Hand-
Juliano RV, Wroclawski ER. Hand-assisted laparoscopic ne- assistedlaparoscopicureterolysistotreatureteralobstruction
phrectomy as a minimally invasive option in the treatment of secondarytoidiopathicretroperitonealfibrosis:assessmentof
largerenalspecimens.IntBrazJUrol.2005;31:526-533. a novel technique and initial series. Urology. 2006;68:46-49.
9. WhittenMG,VanderWerfW,BelnapL.Anovelapproach 13. Chueh SC, Chen J, Hsu WT, Hsieh MH, Lai MK. Hand
to bilateral hand-assisted laparoscopic nephrectomy for auto- assisted laparoscopic bilateral nephroureterectomy in 1 session
somal dominant polycystic kidney disease. Surg Endosc. 2006; without repositioning patients is facilitated by alternating infla-
20:679-684. tioncuffs.JUrol.2002;167:44-47.
10. Lipke MC, Bargman V, Milgrom M, Sundaram CP. Limita- 14. Tai HC, Lai MK, Chung SD, Huang KH, Chueh SC, Yu
tions of laparoscopy for bilateral nephrectomy for autosomal HJ. Intermediate-term oncological outcomes of hand-assisted
dominantpolycystickidneydisease.JUrol.2007;177:627-631. laparoscopic versus open bilateral nephroureterectomy for
dialysis and kidney transplant patients with upper urinary
11. Madi R, Wolf JS, Jr. Single-setting bilateral hand-assisted
tract urothelial carcinoma. J Endourol. 2009;23:1139-1144.
laparoscopic partial nephrectomy. J Endourol. 2009;23:929-
932.
JSLS(2011)15:27–31 31