Standardized or programmed surgical approach is the basic condition to reduce surgical trauma
Laparoscopic radical kidney cancer resection has replaced open surgery as the gold standard for TI and T2 stage kidney cancer surgery and has become a routine surgical approach in large hospitals in China, which is a basic skill that every urologist must master. Compared with open surgery, the advantage is minimally invasive. How to minimize trauma during surgery? Clear anatomical thinking, concise surgical sequence, avoiding unnecessary repetitive movements and “no backtracking” are the prerequisites, and standardization or programming of surgery is the best way to reduce surgical differences between operators. In the case of posterior laparoscopic radical nephrectomy, we adopt the anatomical sequence of dorsal-ventral-inferior pole-upper pole to disconnect the renal artery and vein as early as possible, and after the artery is disconnected, the kidney is in an ischemic state, and the ischemic plane is formed between the perirenal fascia and the surrounding tissues, which makes the separation easier, less bleeding, and the operation is quick and convenient It is easier to separate, less bleeding, quicker and more convenient, and more conducive to patient recovery.
The steps of preparing the retroperitoneal cavity, cleaning the extraperitoneal fat, and opening the lateral fascia are no different from other surgeries.
I. Separation of the dorsal side and search for the renal tip
After opening the lateral vertebral fascia, it is freed along the surface of the psoas muscle and between the perirenal fascia, up to the subdiaphragm and down to the iliac fossa. From the subdiaphragm to the iliac fossa, the whole body is advanced to avoid “digging a well”, which I have beautifully called “the figure is poor and the kidney tip is present”, and the right side usually reveals the inferior vena cava.
The method of finding the renal hilum is as follows.
1, after the overall separation from the subdiaphragm to the iliac fossa, the location with high tissue protrusion and tension is the renal tip.
2. Sometimes the site with much blood leakage is the renal tip. (As shown in the figure)
Figure 1 Overall separation from the diaphragm to the iliac fossa along the surface of the psoas muscle
Figure 2 Protrusion and more blood is the location of the renal tuberosity
Separation and ligation of the renal hilum
When the location of renal artery and vein is not completely determined, for the sake of safety, the method of blunt stripping while suctioning is more often used to prevent vascular injury. After roughly understanding the location of the vessel, the ultrasonic knife is applied to clamp, lift, cut off the lymphatic vessels of the renal tip and open the arterial sheath, the renal artery is mostly a trunk, and in some cases, two or more branches are separated before entering the kidney, generally, the right renal artery is behind the inferior vena cava The left side is separated above the renal vein-semichoroid vein-lumbar vein complex, this plane of artery is generally one, here the advantages of freeing the renal tip also include simultaneous regional lymph node dissection, two proximal and one distal Hom-lock clamps after complete freeing, Hom-lock clamps of the renal artery have individual arterial Hom-lock clamping of the renal artery has been reported to cause isolated arterial tears, and one titanium clip proximally in elderly and calcified arteries may prevent fatal bleeding due to arterial tears. The left renal vein has more branches, including genital vein, venous complex and adrenal vein, which should be operated gently with ultrasonic knife to prevent bleeding caused by tearing of the branch vein, resulting in blurring of the operative field, and the angle between the vein and the inferior vena cava (one near and one far) should be observed after separation of the right vein to prevent injury to the inferior vena cava during clamping. The vein wall is relatively weak and blunt separation of the vein wall surface can lead to tearing and bleeding.
Figure 3 Relationship between inferior vena cava and renal vein (two clamping angles)
Third, ventral separation of the kidney
The key at this level is to correctly find the anatomical gap between the peritoneum and the perirenal fascia. On the dorsal side of the retroperitoneal fold, the ultrasonic knife is used to transect the lateral vertebral fascia, revealing the perirenal fascia and peritoneum, and separating between the perirenal fascia and the peritoneum toward the ventral renal surface. Starting from the mid-superior pole of the kidney, it was progressively moved from top to bottom, from distal (dorsal) to proximal (hilum), with attention to the pancreas, splenic artery and descending colon on the left side; ascending colon and duodenum on the right side.
Figure 4 Gradual separation of the ventral side from the middle and upper pole to the hilum and lower pole
IV. Handling the upper and lower pole of the kidney
The lower pole of the kidney can be separated first with the help of the sling effect of the upper pole of the kidney, and then the upper pole can be handled to facilitate the visualization. At the level of iliac vessels, the fatty tissue and ureter of the lower pole are cut off with ultrasonic knife, and the part of the upper pole connected with the subdiaphragmatic fascia is cut off along the surface of the adrenal gland, and according to the location of the tumor, the adrenal gland is decided whether to perform adrenalectomy, and the lower pole and upper pole are free towards the hilum respectively, paying attention to the possible existence of the collateral renal artery.
Figure 5 Dissection of lower pole and ureter with the help of upper pole sling
Figure 6 Dissection of the upper pole of the kidney
V. Specimen removal
In China, the whole specimen is usually removed by enlarging the incision. After removal, pay attention to the damage of the subcostal vessels, and observe carefully when suturing, because the incision is small, the exposure is not sufficient, and there are reports of secondary surgery due to bleeding of the subcostal vessels, and we should not take it lightly or forget about it because the kidney is beautifully cut.