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Indian Journal of Surgery, Vol. 66, No. 1, Jan-Feb, 2004, pp. 51-52 Case Report Hand assisted laparoscopic radical nephrectomy for large renal cell carcinoma with renal vein involvement D. D. Gaur, J. N. Kulkarni, S. Trivedi, M. R. Prabhudesai
Department of Urology, Bombay Hospital Institute of Medical Sciences, 19 Marine
Lines, Mumbai - 400020, India.
Paper Received: December 2002. Paper Accepted: October 2002. Source of Support: Nil. Code Number: is04015 ABSTRACT A 45-year-old male with a 12 cm by 10 cm grade 2 left renal cell carcinoma involving the proximal half of the renal vein was successfully treated by hand assisted laparoscopic radical nephrectomy. To minimize the risk of tumor embolism, the renal vein was dissected only after hooking it up with the index finger just beyond the tumor thrombus after ligating and dividing the renal artery. KEY WORDS Hand assisted, Radical nephrectomy, Renal cell carcinoma, Laparoscopic nephrectomy. How to cite this article: Gaur DD, Kulkarni JN, Trivedi S, Prabhudesai MR. Hand assisted laparoscopic radical nephrectomy for large renal cell carcinoma with renal vein involvement. Indian J Surg 2004;66:52-4. INTRODUCTION Though, numerous articles on laparoscopic radical nephrectomy have recently appeared in the medical literature, there is only a single report of the procedure having been performed for a renal vein involvement.1 During laparoscopic surgery, due to the renal pedicle control being less reliable, there is a greater risk of tumor embolism compared to an open procedure. Though, the usefulness of hand in laparoscopic surgery has been well established since it was first reported by Wolf et al in 1997, not more than half a dozen papers have been published so far on its use for laparoscopic radical nephrectomy.2-4 However, none of these patients in these series had any tumor thrombus extending into the renal vein. We herein, describe our successful experience of the use of hand for doing laparoscopic radical nephrectomy in a patient with a large tumor involving the proximal half of the renal vein. CASE REPORT A 45-Year-old male presented with gross painless recurrent hematuria of 1 month's duration and a bimanually palpable mass in the left lumbar region. CT scan of the abdomen showed a normal right kidney and a 10 by 12 cm mass involving the whole of the left kidney except for the upper pole. There was bulbous dilatation of the proximal half of the renal vein due to tumor invasion, but the distal half of the renal vein and the inferior vena cava were normal (Figures 1a & b). There were no lymph nodes and no extra-Gerotal invasion. Bone scan and X-ray chest showed no evidence of metastatic disease. After an informed consent had been taken, it was decided to perform a hand assisted laparoscopic radical nephrectomy because of the size of the tumor and the renal vein involvement. The bowel preparation was limited to a simple enema in the morning of the surgery. After general anesthesia had been administered cefotaxime 1 gm was given intravenously and a nasogastric tube and an indwelling urethral catheter were passed. He was then placed in a 45-degree lateral tilt, was prepped and draped. A 7.5 cm long oblique hand port incision was made in the left para-umbilical area, in such a way that the medial rim of the Dexterity ring would overlie the umbilicus. After the Dexterity hand port had been established, a subcostal 10 mm camera port was established in the mid-clavicular line by digital guidance. A 12 mm anterior working port near the McBurney's point and a 10 mm posterior working port in the anterior axillary line midway between the iliac crest and the costal arch were established under vision. The parietal peritoneum was incised along the line of Toldt with scissors passed through the anterior working port and the incision was extended up around the tumor by a combination of sharp and blunt dissection. The hand was very helpful in this dissection and within half an hour the tumor was almost completely mobilized. The posterior working port was used to lift up the diaphragm during the dissection of the upper pole. The adrenal gland was left in place and was not removed. The kidney was gently lifted up by the left hand and care was taken not to compress it during its dissection. There was bleeding from the lumbar vein, which could not be controlled laparoscopically. A large sponge was passed through the hand port for applying manual pressure and the bleeding stopped within 5 minutes. The dissection, clip ligation and division of the ureter and the gonadal vein were then carried out. The laparoscope was shifted to the posterior working port at this stage to allow a better view of the renal vessels. Going from the top of the tumor the renal artery was hooked by the index finger and was then dissected. As it was more than a centimeter wide, endo-GIA was used to clip ligate and divide it. The renal vein was dissected only after hooking it up with the index finger just beyond the tumor thrombus after the renal artery had been divided. The vein was palpated between the thumb and the finger to make sure there was no tumor extension. The collapsed vein was then clip ligated using 2 locking type synthetic clips and was divided between the clips (Pilling Weck, USA). The specimen was then trapped in an endo-sac and was pulled out by enlarging the incision to 9 cm. The operative time was 150 minutes and the estimated blood loss 300 ml. He accepted oral feeds the next day and was discharged on the 6th post-operative day. The specimen weighed 680 gm and histological examination showed a grade 2 renal cell carcinoma with tumor free surgical margins. DISCUSSION Review of world literature shows that laparoscopic radical nephrectomy is recommended for T1-2 tumors up to 10 centimeters in the largest diameter.5,6 However, a recent report by Gill et al has shown that using proper precautions, it can also be performed in patients with level 1 renal vein involvement.1 But this would not have been possible in the present case without hand assistance due to the large size of the tumor. Even with hand assistance the laparoscopic procedure could have been difficult and a bit unsafe, if the tumor was on the right side. However, due to the extra length of the renal vein on the left side, we decided to go ahead with hand assisted laparoscopic radical nephrectomy. The paper shows how the hand can be used to occlude the renal vein distal to the tumor thrombus by hooking it up with the index finger to minimize the risk of tumor embolism. During process of hooking it was kept compressed between the thumb and the index finger to prevent any tumor migration. The rim of the Dexterity ring was made to overlie the umbilicus to provide some extra space for the other ports. The adrenal gland was not removed in this case as the upper pole of the kidney was not involved by the tumor. REFERENCES
© 2004 Indian Journal of Surgery. The following images related to this document are available:Photo images[is04015f1.jpg] |
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