Nephrectomy

Definition
A nephrectomy is a surgical procedure for the removal of a kidney or section of a kidney.

Description
Nephrectomy may involve removing a small portion of the kidney or the entire organ and surrounding tissues. In partial nephrectomy, only the diseased or infected portion of the kidney is removed. Radical nephrectomy involves removing the entire kidney, a section of the tube leading to the bladder (ureter), the gland that sits atop the kidney (adrenal gland), and the fatty tissue surrounding the kidney. A simple nephrectomy performed for living donor transplant purposes requires removal of the kidney and a section of the attached ureter.

Indication
 Cancer- T1 and T2 renal cell carcinoma (most common)  Wilms' tumor-(childhood cancer)  Transitional cell cancer-upper urinary tract urothelial cancer  Symptomatic hydronephrosis-the distention and dilation of the renal pelvis  Chronic infection  Polycystic kidney disease-a genetic disorder characterized by the growth of fluid-filled cysts in the kidney that over time replace enough kidney mass to decrease kidney function ending in renal failure  Ischemic nephropathy-result of inadequate blood flow to the kidneys that leads to progressive loss of kidney function and kidney atrophy (shrinkage)  Hypertension  Renal calculus  Traumatic injury

Procedure
A laparoscopic nephrectomy is usually a 3- to 4-hour procedure performed under general anesthesia and is usually indicated for tumor removal, chronic infection, or to remove a healthy kidney from a donor for transplantation. A simple nephrectomy removes just the kidney, and a radical nephrectomy removes the adrenal gland and possibly the lymph nodes. A partial nephrectomy is the removal of a small renal tumor, preserving the remaining portion of the kidney. Both radical and partial nephrectomies can be performed laparoscopically. There are three types of laparoscopic nephrectomy techniques: retroperitoneal, transperitoneal, and hand-assisted. The retroperitoneal approach exposes the kidney without entering the peritoneal cavity. The trans-peritoneal approach (through the

abdominal cavity) gives the surgeon the ideal operating space and provides the best identifiable anatomical landmarks. The transperitoneal approach can be done purely laparoscopically, or as a hand-assisted procedure. The laparoscopic hand-assisted approach allows the surgeon to utilize his or her hand to help with dissection, retraction, and removal of the kidney through the hand port incision. In the hand-assisted laparoscopic procedures, the surgeon's hand port replaces one of the ports typically used for laparoscopic instrumentation. Hand-assisted laparoscopic technique has potential advantages over pure laparoscopic technique since the surgeon has the ability to manipulate the tissues with the hand inserted through the operative port. There are distinct advantages associated with the hand-assisted technique. For surgeons learning the laparoscopic techniques, the hand-assisted technique helps ease the transition from open technique to pure laparoscopic techniques. A disadvantage of the hand-assisted procedure is the larger incision, usually about 6 to 8 cm, which may result in more pain for the patient and a longer time to recover from the surgery. One of the surgeon's considerations when selecting the surgical approach is the renal structure(s) to be removed and type of procedure planned (partial nephrectomy versus radical nephrectomy). Some surgeons consider the retroperitoneal approach to be a faster way to dissect through to the renal hilum. Others believe the retroperitoneal approach affords a smaller working area and presents increased challenges transferring the kidney into the entrapment sac (Endo-Catch). Advocates of transperitoneal approach appreciate its familiarity; it offers a similar view of the anatomy as during open procedures. The operative area is also more spacious. Disadvantages of the transperitoneal approach include the potential for injury to the bowel and that the transperitoneal approach usually results in a longer surgical time. The surgeon may also consider how the specimen is to be removed from the patient. If the desire is to remove the entire kidney intact without morcellating, the hand-assisted procedure allows the kidney to be removed through the hand port itself.

Pre-procedure considerations
Following induction of general anesthesia and endotracheal tube placement, a nasogastric tube and urinary catheter are inserted prior to surgical positioning. A preprocedure cystoscopy and placement of one or two ureteral stents may also be performed. Anti-embolism stockings and sequential compression devices should be applied to maintain blood flow to the lower legs and reduce the risk of thromboembolism. The OR staff should be prepared with instrumentation ready in case the procedure needs to be converted to an open nephrectomy. The surgical skin prep should include a prepped area large enough for an open procedure and the patient should also be draped in a manner that could allow an open procedure to be performed as well. Protocols for proper timing of antibiotic administration to prevent surgical site infection should be followed.

Intra-operative
The operative procedure begins with three to four small incisions for port placements to insert a laparoscope and laparoscopic instruments. The surgeon then establishes pneumoperitoneum with CO2. Placement of endoscopic trocars include one for insufflation, another below the costal margin, and one below the umbilicus. Typically, a 10 mm port is placed with a camera introduced through the port. Under direct visualization, the surgeon makes additional incisions: usually one 10 or 12 mm port at the midclavicular line just below the costal margin; a 5mm trocar below the umbilicus, and two more 5 mm trocars each at the anterior axillary line, one near the umbilicus, and one in the subcostal region. These two trocars may be secured by Prolene or Vicryl sutures.

Laparoscopic bowel graspers and scissors will be inserted to manipulate the bowel and open the retroperitoneum. The ureter is then dissected down to the lower pole of the kidney. An atraumatic grasper is used to help with retraction while dissecting the tissue around the kidney, leaving the adrenal gland untouched. Endoscopic clips are placed on the renal veins and arteries (two clips distally and two to three clips proximally) then divided by laparoscopic scissors. Endoscopic surgical stapling devices can also be used as an alternate way to ligate and divide the renal vessels. Once the ureter is incised between the clips, the kidney is free. An end catch or lap-sac is placed into the operative site and the kidney is manipulated into the bag. The kidney may be morcellated while in the entrapment sac or removed intact through a handassist port. The endoscopic trocars are removed under vision to ensure that any bleeding is under control. The port sites are then closed with Vicryl (polyglactin) and Monocryl sutures and incision dressings are applied. Injury to a vessel can occur during the procedure, and can usually be managed with surgical clips, a surgical stapler, or pressure application using a Foley catheter balloon over the bleeding area. If major bleeding occurs, the surgeon may need to convert to an open procedure emergently.

Post-op management (Nsg. Responsibilities)

In the immediate postoperative period, the patient should be assessed for signs of any tissue injury pot-entially caused by surgical positioning devices. The perioperative nurse should communicate concerns regarding the patient's skin condition and areas of concern for potential skin breakdown to the post-anesthesia care unit (PACU) staff. The immediate postanesthesia assessment is performed by the PACU nurse. Vital signs, oxygen saturation, and cardiac rhythm are monitored. The patient's level of pain is assessed and pain medication is administered. The patient is assessed for any postoperative complications including bleeding, nausea, vomiting, and abdominal distension. The patient's urinary output must be carefully monitored to ensure that the remaining kidney is functioning. Insufflation of the abdomen with carbon dioxide can cause some discomfort for the patient, if the CO2 gas isn't removed as much as possible before the procedure is completed. Other postoperative complications can include deep vein thrombosis, myocardial infarction, surgical site infection and pulmonary embolism.

Medications
Most patients will be prescribed a strong painkiller. The biggest complaint of most people experience is constipation associated with pain medication. Keep your stool soft. You should be able to continue with your usual medications. Blood thinners may increase the risk of bleeding after surgery. Keflex (250, 500) 1 tab by mouth every 8 hours Levaquin (250, 500, 750) mg 1 tab by mouth every 24 hours Cipro (250,500) mg 1 tab per mouth every 12 hours Lortab (5, 7.5, 10/500) mg 1 tab by mouth every 6 hours as needed for pain Percocet (5, 7.5, 10/325) mg 1 tab by mouth every 6 hours as needed for pain Darvocet (50, 100) mg 1 tab by mouth every 6 hours for pain Ibuprofen (400, 600, 800) mg 1 tab by mouth every 6 hours with food for pain