doç. Dr. Lütfi TUNÇ

1. Transperitoneal Laparoscopic Nephrectomy : a
new technique
"You can't solve a problem on the same level that it
was created. You have to rise above it to the next
level."
—Albert Einstein (1879-1955)

2. Standard technique (transperitoneal
laparoscopic nephrectomy)
1. port placement,
2. mobilization of colon,
3. dissection of the ureter,
4. dissection of lower renal pole,
5. dissection of renal hilum,
6. occlusion and division of the renal
artery and vein,
7. completion of nephrectomy.

3. Mobilization of the Colon ( right
laparoscopic nephrectomy)
Standard New
• Colon is mobilized by incising the • The part of the peritoneum
ipsilateral line of Toldt. immeditially under the liver is
• Peritoneal incision extends from incised from triangular ligament
the right common iliac artery, to the vena cava
coursing lateral to the cecum and • At the vena cava, the insicion of
ascending colon and around the the peritoneum is extended
hepatic flexure. inferiorly to the lower pole of
• At its cephalad end, the incision is the kidney,
carried medially in a horizontal • Ascending colon and hepatic
manner between the liver and flexure are rolled medially.
transverse colon • During this procedure you can
• Ascending colon and hepatic see the second part of the
flexure are rolled medially. duodenum and it is easily
• Duodenum is dissected medially retracted medially.
until the anterior surface of the
inferior vena cava is clearly seen
(endpoint of dissection).

4. • In the standard technique the peritoneal
incision starts inferior and goes superior .
• Our technique the incision starts superior and
goes inferior.

5. Finding the Ureter
(Standard technique )
• The ureter is identified in the retroperitoneal fat just medial
to the psoas muscle.
• In general, the ureter is located more medially than
expected.
• If the ureter is hard to find:
1. Identify the gonadal vessels that course anterior and
parallel to the midureter
2. Gently stroke the retroperitoneal fat in a horizontal
manner (at right angles to the longitudinal axis of the
ureter) with an atraumatic grasper, and look for ureteral
peristalsis;
3. Look for the ureter where it crosses the common iliac
vessels.

6. Dissection and retraction of the Ureter
(Standard technique)
• The ureter is mobilized and retracted laterally.
Atraumatic forceps
Percutaneously placed suture to loop the ureter.
Alternatively, the ureter can be clipped and divided
at this point.
• Lateral traction of the ureter, whether the ureter is
intact or divided, helps to expose the renal hilum for
disection.
Glenns urologic surgery,

7. • In laparoscopic surgery :
Disecting and retracting the ureter take time
Require another port
Retracting the ureter actually makes the
disection of the renal hilum more difficult.

8. Renal Polar Dissection and
Retraction(Standard technique)
• Gerotas fascia is entered and the lower renal
pole is identified and mobilized
circumferentially.
• The upper renal pole is detached from the
adrenal gland and mobilized.
• Upper and lower renal poles are retracted
laterally by an atraumatic grasper.

11. Modification of the standard transperitoneal laparoscopic nephrectomy
technique seems to significantly facilitate the procedure
• February 2004 –April 2010
• Patients underwent laparoscopic surgery at Gazi
University Department of Urology and other University and
training hospitals.
• Indications for surgery
RCC 96 patients
TCC 10 patients
Nonfunctional kidney 77 patients
• Conventional technique 85 patients
• New Technique 98 patients
• Mean operation time(after port placement until the specimen is
placed in the endobag)

12. RESULTS
n age Op. Time Blood loss Hospital stay
(Minute) (ml) (days)
Convansionel 85 51 85.9±3.9 150 3
New tecnique 98 53 30.1±7.5 30 2
• Operation time was significantly shorter in new technique
group (p<0.001)
• Mean intraoperative blood loss was lower in new
technique group (p<0.05).

13. Conclusions:
• We recommend initially exposing the upper
kidney pole followed by dissection of the renal
hilum rather than dissection of the ureter and
dissection of the lower renal pole during L-RN,
L-NU and L-SN
• This change makes these procedures easier
and quicker.

14. In laparoscopic nephrectomy which
procedure is safe for renal pedicle
control?
• Vascular stapler
• Polymer clip
• Titanium clip
• Suture
• Ligasure

15. Renal pedicle control

16. En Bloc Ligation
A- V Fistula?
• The first case of fistula formation after en bloc
ligation of the renal pedicle was reported by
Hollingsworth (1934) in a patient with
tuberculosis renal disease.
• Approximately 60 cases of fistula formation have
been reported.
• In all these cases en bloc ligation was performed

17. White WM, Klein FA, Gash J, Waters WB. Prospective radiographic
followup after en bloc ligation of the renal hilum. J Urol. 2007; 178:
1888-91
• Prospective study
• All patients underwent en bloc ligation of the
renal hilum during nephrectomy for malignant
diseases
• AVF signs: Hypertension, abdominal bruit, new
onset congestive heart failure.
• Follow up time: 12 months
• CT- arteriography: to assess arteriovenous fistula

18. White WM, Klein FA, Gash J, Waters WB. Prospective radiographic followup after en
bloc ligation of the renal hilum. J Urol. 2007; 178: 1888-91
• In the 40 patients who underwent computerized
tomographic arteriography no fistulas were noted.
• Conclusions: after en bloc ligation of the renal hilum
with a titanium endovascular stapler, risk of
arteriovenous fistula formation is very low.

20. In laparoscopic nephrectomy, which is safe for
use on the renal pedicle?
• Two clinical studies, total patients = 248
En bloc vascular stapler n = 158
Single titanium stapler n = 90
• Postoperatively, no arteriovenous fistulas or other
complications were seen in either group
• Conclusion: vascular stapler is safe for controlling the
renal pedicle, and en bloc control does not increase
the risk of arteriovenous fistula

21. Conclusions
• Based on clinical followup and prospective
radiographic evaluation there appears to no
risk of arteriovenous fistula formation after en
bloc ligation of the renal hilum using a
titanium endovascular stapler.

25. Conclusion
• What is now proved was once only imagined.
– William Blake
• Whatever technique you are considering,
if your “gut” says yes, then you probably
should use it.
-- Lutfi Tunc