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Laparoscopic

Renal Surgery

Dr. Zia
TMO
HMC, Surgery
Laparoscopic Surgery
Big Surgeon! Big Incision! Big
Success!
What’s Laparoscopic
Surgery?

► Minimally
invasive surgery

► Gas-inflated
abdomen
► Laparoscope
and tools
HISTORY
Video laparoscopic surgery
The beginning-1990
Media and lay public hype

• “Key-hole surgery”
• “Laser surgery”
• “Cure that’s quicker by tube”
• “World’s smartest operation
Major excitement amongst surgeons
Why Laparoscopic Surgery?
 Small incision, minimal scar, improved cosmesis

 Improved visualization via telescopic
magnification and minimal bleeding

 Shorter recovery times

 Minimal post-operative pain

 Less chance of infection
Compare !

Today Yesterday
General contraindications
► Severe COPD or Cardiac Disease

► Grade II or III Shock

► Generalized peritonitis

► Previous extensive abdominal surgery

► Previous generalized inflammatory disease or irridaiation

► Hyper or Hypo-coagulable states

► Advanced stage of pregnancy

► Suspected Carcinoma
Intra operative Monitoring

► ECG
► Blood Pressure
► Airway pressure monitor
► Pulse oximeter
► Endotracheal CO2 concentration
(PETCO2) monitor
► Peripheral nerve stimulator
► Body temperature probe
Recent advances

► Robotic surgery
► Tele robotic surery
► Incisionless surgery
 Trans vaginal cholecystectomy
► Gasless surgery
What is NOTES?

Natural Orifice Translumenal Endoscopic Surgery:
-Intentional puncture of one of the viscera (e.g., stomach,
rectum, vagina, urinary bladder) to access the abdominal
cavity
-With an endoscope (flexible or stiff)
-To perform an intraabdominal operation

Pearl JP, Ponsky JL: J Gastrointest Surg. 2007 Dec 5
NOTES in humans: perhaps 300
cases world-wide
 Hydrabad: Appendectomy, liver biopsy, tubal ligation: 22 cases.
 Brazil: : Endoscopically-assisted transgastric and transvaginal
laparoscopic cholecystectomy 10 cases.
 4 transvaginal cholecystectomies and a transgastric laparoscopy
for cancer
 Ohio: Transgastric peritoneoscopy
 New York: lap-assisted transvaginal chole
 Oregon Transgastric cholecystectomy
 Argentina and San Diego Transvaginal cholecystectomy (n=4)
Transgastric cholecystectomy (n=2) Transgastric appendicectomy
(n=2)
 Mayo Clinic Transvesical (urinary bladder) peritoenoscopy
 Chicago Transgastric cholecystectomy
 Brazil. Transvaginal hybrid nephrectomy (n=1)
data base of 150 cases in South America mostly cholecystectomy
Laparoscopy in renal diseases
Laparoscopic Nephrectomy was
first performed in 1991 by
Clayman, Kavoussi et al, where
they removed the Right kidney
from a patient diagnosed with
Renal Oncocytoma
 Equivalent oncological efficacy compared
to open approach, with advantages of:
►Lower morbidity
►Improved cosmesis
►Shorter hospitalization
►Quicker recovery
Laparoscopic approaches to kidneys

► Retroperitoneal approach

► Trans peritoneal approach

Hand assisted surgery
Transperitoneal Approach Retroperitoneal Approach
Transperitoneal approach
Anatomy
Renal hilum left
Renal
hilum
right
Relations Right Kidney
Relations left kidney
Laparoscopic nephrectomy
The team
Patient position
LANDMARKS
Patient position
Trocar placement
Trocar insertion
Mobilization of colon
Mobilization of colon
Identifying Ureter
Identifying Ureter
DISSECTION
Renal artery
Renal vein
Ureter and Gonadal Vein
DISSECTION LUMBAR
FOSSA
Extraction
Post op care
► NG tube removed
► Orally allowed on post op day 1
► Drain removed if output less than
50cc/24hr
► Normal diet on day 2 post op.
► 1st follow up after 1 month
► Abdominal u/s and renal profile
performed
HALN

► HANDASSISTED LAPAROSCOPIC
NEPHRECTOMY
What is Hand-assisted
Laparoscopic Nephrectomy
► “HALN” stands for hand-assisted
laparoscopic nephrectomy

► Surgeon removes kidney
laparoscopically with the assistance of
the hand through a small 4 inch
incision near the umbilicus

► Kidney removed intact through hand
port
Why Hand assisted
Laparoscopic Nephrectomy

“Del iver y of kid ney a nywa y r equ ir es a
6 t o 9 c m inc isio n a t t he en d. S o it i s
on ly l ogi cal t o us e t his i nc is ion a s a
port t o h el p wi th r et ract ion a nd
di ss ect ion of t he o rga n r igh t fr om s ta rt
of t he s ur ger y”
Why Laparoscopic Hand-Assisted Nephrectomy

HAND IS THE MOST VERSATILE
INSTRUMENT
( To Feel, to dissect, To Retract & For Knot-Tying)

‘Endohand’ for laparoscopy - undergoing trial ( Jackman – 1999)
Laparoscopic Hand Assisted Nephrectomy
Versus Conventional Laparoscopic Nephrectomy

I. No difference in:
a. Post operative Pain
b. Return of Bowel function
c. Duration of Convalescence
II. Less number of complications
III. Operation time less by 85 min (Wolf - 1997)
Our experience

Supra renal masses 4
Radical nephrectomy 8
Non- Atrophic
4
functioni kidneys
ng Hydronephro
6
tic
Renal cysts 4
Pyeloplasties 4
Total 30
► Procedure abandoned 3 cases

► Complications No

► Patient orally allowed 1st POD

► Drain Out 2nd POD

► Back to Home 3rd POD
Thank You
Our Team

Prof. Dr. Mazhar Khan
Asst. Prof. Dr. Zahid Aman
Registrar. Dr. Siddique
SMO. Dr. Aziz Khan
SMO. Dr. Sarfaraz Khan

TMO’s

Dr. Zia
Dr. Navid Anwar Dr. Yousaf
Dr. Zahid Wazir Dr. Waqas
Dr. Rizwan Kundi Dr. Ahmed Din
“Every day you may make
progress. Every step may be
fruitful....You know you will
never get to the end of the
journey. But this, so far from
discouraging, only adds to
the joy and glory of the
climb.”

Sir Winston Churchill
British politician (1874 - 1965)