Overview
Definition:
Retroperitoneal laparoscopic nephrectomy (RPLN) is a minimally invasive surgical technique to remove a kidney without entering the peritoneal cavity
This approach utilizes the retroperitoneal space, offering distinct advantages in terms of patient recovery and avoidance of visceral complications.
Epidemiology:
RPLN is increasingly adopted for various renal pathologies, including benign and malignant tumors, non-functioning kidneys, and donor nephrectomies
Its incidence is rising globally as laparoscopic surgery becomes the standard of care for many urological conditions.
Clinical Significance:
RPLN provides excellent visualization of the kidney and surrounding structures while minimizing bowel manipulation
It leads to reduced postoperative pain, faster recovery, shorter hospital stays, and improved cosmesis compared to open surgery
Understanding optimal access and positioning is crucial for surgical success and patient safety, particularly for residents preparing for complex DNB and NEET SS scenarios.
Indications
Benign Conditions:
Severe hydronephrosis, non-functioning kidney secondary to obstruction or infection, symptomatic renal cysts, nephrolithiasis refractory to conservative management, essential hypertension (unilateral nephrectomy).
Malignant Conditions:
Renal cell carcinoma (RCC) stage T1-T2, transitional cell carcinoma of the renal pelvis, metastatic disease to the kidney.
Donor Nephrectomy:
Laparoscopic nephrectomy for living kidney donation, enabling faster recovery for the donor.
Other Indications:
Traumatic kidney injury requiring nephrectomy, intractable renal colic, suspected renal tuberculosis.
Access Ports
Port Placement Principles:
Strategic placement of ports is essential for adequate triangulation and instrument maneuverability
Ports are typically placed in the lumbar or flank region, avoiding major vascular structures and the psoas muscle.
Three Port Technique:
A common approach involves three ports: one primary working port (10-12 mm) for the dissecting instrument and grasper, and two secondary ports (5 mm) for the camera and suction/irrigation
The primary port is usually placed at the tip of the 11th or 12th rib.
Four Port Technique:
In certain complex cases or for better triangulation, a fourth port may be utilized
This can enhance visualization and instrument control, especially during dissection around major vessels or in obese patients.
Port Variations:
Modified port placements may be employed based on patient anatomy, the side of surgery (left vs
right), and the specific pathology
Left-sided approaches may involve placing ports slightly more anteriorly due to anatomical landmarks.
Patient Positioning
Prone Position:
The most common position for RPLN, offering excellent exposure of the retroperitoneal space
The patient is placed in a modified flank position, with the kidney-bearing side elevated by beanbags or supports
This position stretches the flank muscles, widening the intercostal spaces and facilitating port placement.
Lateral Decubitus Position:
Less frequently used, but can be an alternative in specific situations
Requires careful attention to prevent pressure sores and ensure adequate venous return.
Supine Position:
Rarely used for standard RPLN, but might be employed for specific variations or combined procedures
Generally offers inferior visualization and access to the retroperitoneal space for nephrectomy.
Anesthesia Considerations:
General anesthesia with endotracheal intubation is standard
Careful attention to fluid management, blood pressure, and oxygenation is crucial, especially in the prone position where venous pressure can increase.
Dissection And Mobilization
Initial Incision And Entry:
A small skin incision is made, and the retroperitoneal space is entered by blunt dissection or using a balloon trocar
Careful dissection avoids injury to the peritoneum and its contents.
Exposure Of Kidney:
The Gerota's fascia is incised to expose the kidney
The plane between the kidney and the perinephric fat is carefully dissected using laparoscopic instruments.
Mobilization Of Kidney:
The kidney is mobilized from surrounding structures, including the adrenal gland (if not involved), spleen (left side), colon (left side), and duodenum (right side)
Careful dissection of the renal hilum is performed.
Dissection Of Renal Vasculature:
The renal artery and vein are identified, dissected, and secured
Stapling devices or clips are commonly used to ligate these vessels
The order of ligation (artery first for malignancy) is critical and depends on the indication.
Key Points
Exam Focus:
Understanding the anatomical boundaries of the retroperitoneal space is paramount for port placement
Knowledge of nerve and vascular structures at risk is critical for avoiding complications during dissection
The choice of patient position significantly impacts surgical exposure and potential complications.
Clinical Pearls:
Maintain adequate insufflation pressure to ensure working space
Always identify and dissect the renal hilum early
For malignant tumors, consider ligation of the renal artery first to devascularize the tumor before manipulation
Be mindful of the spleen and colon on the left, and the duodenum and liver on the right.
Common Mistakes:
Inadequate port placement leading to poor triangulation
Injury to the peritoneum, intestines, spleen, colon, or major vessels
Failure to identify or properly ligate the renal artery and vein
Insufficient mobilization of the kidney, leading to tearing of the renal capsule or inadequate specimen extraction.