Laparoscopic Nephrectomy

In 1901, German surgeon Kelling first used Nize cystoscopy for abdominal examination. With the improvement and development of endoscopy, laparoscopic surgery has been widely used in the diagnosis and treatment of general surgery, obstetrics and gynecology and urology. In recent years, the development of laparoscopic surgery in urology has been even more encouraging. It has the advantages of small damage, less postoperative pain, quick recovery, etc. It is more and more accepted and applied by patients and urologists. In the 1960s, laparoscopy was only used for the diagnosis of patients with intra-abdominal cryptorchidism and pseudo-hermaphroditism and high ligation of spermatic vein. In 1979, Wickman used laparoscopic retroperitoneal ureterolithotomy. In 1985, Eshghi used laparoscopic pelvic heterotopic renal incision. In the 1990s, Glayman used laparoscopic nephrectomy and Parra used abdominal cavity. Mirror pelvic lymphadenectomy and biopsy. At present, laparoscopic surgery has been widely used in the treatment of various diseases of urology, such as complete seminal vesicle resection, ureteral obstruction after gynecological surgery, bladder diverticulectomy, renal cyst drainage, renal cyst decompression, Postoperative renal cyst drainage, urinary incontinence bladder neck suspension, ureteropelvic ureteroplasty, ureteral anti-reflux surgery, nephrectomy, prostatectomy and even radical prostatectomy. Clayman in the United States successfully used laparoscopic surgery for the first time in 1990 to complete the first nephrectomy, becoming the pioneer of modern urological laparoscopic surgery, followed by Japan and other countries to carry out the operation. In 1992, the Institute of Urology of Beijing Medical University took the lead in the development of laparoscopic nephrectomy in China. At present, many hospitals have carried out this operation and accumulated many successful experiences. Treatment of diseases: renal hypoplasia Indication With the improvement of laparoscopic instruments and the improvement of surgical techniques, the indications for nephrectomy have become more and more extensive. 1. Renal benign lesions Atrophic kidneys caused by various causes, including renal hypoplasia, renal atrophy caused by arterial stenosis, hydronephrosis, and kidney atrophy caused by inflammation. 2. Renal tumor, radical nephrectomy or renal tumor resection. 3. Renal pelvis, kidney, ureter, cystectomy. 4. Renal sputum incision and stone removal. 5. Allogeneic kidney transplantation, cut the living donor kidney. 6. Renal pyeloplasty for the treatment of stenosis at the junction of the fistula of children. Contraindications 1. Have a history of abdominal surgery or a history of kidney surgery. 2. Patients with systemic hemorrhagic disease should not be treated. 3. Cardiopulmonary complications are severe and difficult to tolerate surgery. 4. Peri-infection of the kidney, pus kidney, kidney and surrounding tissue adhesion is heavier. 5. People with acute abdominal inflammation. Preoperative preparation 1. The same as the general open surgery preoperative preparation 1 hematuria routine measurement, liver and kidney function tests, urography and CT examination; 2 systemic examination and preparation, for elderly patients, poor cardiopulmonary function should improve cardiopulmonary function, correct Hypertension, heart rhythm disorder, correction of anemia and malnutrition; 3 control of infection. 2. Start eating food 1d before surgery. 3. Leave the stomach tube in the morning. 4. Intraoperative ureteral intubation on the morning of the operation makes it easier to find, dissect, and separate the ureter during surgery. 5. Patients with larger tumors may have renal artery embolization before surgery to reduce intraoperative bleeding. 6. Device preparation, standard laparoscopic instruments can be performed nephrectomy, but the automatic vascular suture incision should be used when ligation of the renal pedicle blood vessels to prevent bleeding. 7. Explain to patients and their families that they are ready for open surgery at any time. Surgical procedure 1. Transabdominal nephrectomy (1) Manufacture of pneumoperitoneum, make a transverse incision of about 1 cm on the umbilicus or 0.5 to 1 cm below the umbilicus, and cut the skin, subcutaneous tissue and anterior rectus sheath. Lift the abdominal wall and puncture the abdominal cavity with a Veress needle. CO2 was injected into the abdominal cavity, and the injection was stopped when the intra-abdominal pressure reached 1.5 to 2.1 kPa. The observation mirror was inserted into the abdominal cavity from the first cannula, and the second, third, and fourth cannula were inserted under the observation. (2) laparoscopic surgery requires 4 to 5 cannula for nephrectomy, point A is 0.5 to 1.0 cm below the umbilicus; point B is 1/3 of the line between the umbilicus and rib arch; point C is in the umbilicus and anterior Connected to the middle and outer 1/3; D point in the midline of the clavicle flat umbilicus. (3) Laparoscopic observation of the peritoneum after incision on the outside of the ascending (lowering) colon. The perirenal fat sac was cut with an electric hook to reveal the kidney. (4) Separate the front of the kidney and the lower pole of the kidney. (5) Free ureter, which indicates ureteral peristalsis, marked with a ureteral catheter or searched inside the spermatic vein. After detaching the ureter of sufficient length, clamp it with a metal clamp and cut it. (6) Carefully separate the renal pedicle artery and vein. The proximal end of the renal artery can be placed on two metal clips, one on the far side, and cut off. An automatic vascular suture incision in the renal vein makes the procedure safer. (7) Isolation of the upper pole and the dorsal side of the kidney, and cutting off the blood vessels to the adrenal gland. (8) Take out the kidney, put the kidney specimen into the organ, put it into the bag, tighten the bag mouth, enlarge the wound, pull the kidney out or crush the kidney specimen into the bag. (9) No bleeding, release CO2 gas, exit the cannula, and suture the skin incision. 2. Retroperitoneal nephrectomy (1) Position: the lateral side position, the affected side is upward, and the waist is high. (2) trocar position design: 10mm puncture cone was placed 2cm above the iliac crest line, and the laparoscope was placed. 10mm and 5mm trocars were placed at the level of the anterior and posterior iliac crests. Enter the operating device. (3) Establishment of the retroperitoneal operation gap: 1 to 2 cm above the iliac crest line, the incision muscle layer was bluntly separated to the peritoneum, and the cervical probe was introduced into the retroperitoneal space to explore the cavity. Place the balloon catheter and inject 500-700ml of water to form the retroperitoneal space. After 5 minutes of compression and hemostasis were maintained, the catheter was drained, placed in a laparoscope, and filled with CO2 gas. (4) Or a transverse cross-section of 1 cm in the middle of the iliac crest, cut the skin and use the vascular clamp to bluntly separate the lumbar fascia, and puncture the puncture through the lumbar fascia, ie reach the peritoneum. After the gap, the CO2 gas is charged, the air pressure reaches 2 kPa, and the aeration amount is about 2 liters. Pull out the pneumoperitoneum, insert a 10mm puncture cone into the muscle space, indwell the cannula, and place the laparoscope. A balloon catheter was placed after the retroperitoneal space. After 5 minutes of compression and hemostasis were maintained, the catheter was drained and placed in a laparoscope. (5) Free upper renal pole, lower kidney pole, ureter, renal artery, renal vein, etc., the operation is the same as the abdominal cavity. (6) The anatomical features of the retroperitoneal cavity seen under laparoscopy are summarized as: "one muscle, two lines and three belts". One muscle: The lower part of the TV screen is all or one part of the psoas muscle, which is the most obvious marker for the longitudinal or lateral positioning of the retroperitoneal cavity. Second line: the peritoneal junction of the anterior abdominal wall and the peritoneal junction of the posterior abdominal wall. Three belts: the anterior abdominal wall muscle in the upper part of the visual screen. This area is the anterior abdomen puncture cone puncture area and should not exceed the peritoneal junction of the anterior abdominal wall. Below the eccentric screen, the extra-abdominal muscle is the posterior abdomen puncture area, the peritoneal area between the two lines, the foot end 1/2 is the peritoneal exposed area, the fat is less, the middle part has the colon; the head end 1/2 is the fat sac There is a kidney inside, and there is a liver or spleen separated by a peritoneum at the top. (7) The difference between the retroperitoneal route and the transabdominal approach: the abdominal cavity is broad, the visceral surface is smooth, the marking is clear, and the stereoscopic effect is strong, which can reduce some difficulties of laparoscopic surgery. After the retroperitoneal expansion and tear, the surface of the structure is rough, lacking in marking, and the stereoscopic effect is poor. Advantages: Free from abdominal organs, easy to expose, less restricted, can reduce the interference of operating channels and instruments on abdominal organs, without the risk of abdominal cavity contamination, can reduce the gastrointestinal reaction and the chance of postoperative abdominal infection and adhesion . The lateral position is convenient for exposing the kidney, and the doctor can learn from the experience of open surgery. complication 1. Subcutaneous emphysema: CO2 gas leaks to the skin, and disappears within 1~2d, no special treatment is needed. 2. Major bleeding: due to hemostatic clips falling off or incomplete clipping. If it occurs during surgery, it should be timely to find the end of the blood vessel, re-clamping to stop bleeding, and those who cannot stop bleeding should immediately open the surgical treatment. If bleeding occurs after surgery, it should be immediately surgically explored and stopped. 3. Peripheral organ damage: right kidney resection is easy to damage the liver, duodenum, vena cava, intestinal tube, etc.; left kidney resection is easy to damage the spleen, pancreatic tail, intestinal tube and so on. Clear and careful operation during surgery can be avoided. Open surgery should be repaired in case of serious injury.