A nephrectomy is a surgical procedure to remove a kidney. There are several types including simple, partial, and radical nephrectomies. A surgeon must have knowledge of renal anatomy and vasculature. Approaches can be open, laparoscopic, or robotic. Key steps include mobilizing the kidney, isolating and ligating the renal vessels, and closing fascial layers. Complications include bleeding, fistula, and loss of renal function.

1. Operative techniques: Nephrectomy
Presenter: Dr Sangamesh S K
Moderator: Col S Tripathy

2. Overview of presentation
• Surgical anatomy
• Indication of Nephrectomy
• Types of Nephrectomy
– Simple, Partial & Radical nephrectomy
– Donor Nephrectomy
• Different technique of Nephrectomy
• Complications

3. Surgical anatomy
• Bean shaped organ
• Location:
Retroperitoneal
• Extend :- T12-L3
• Two surface (anterior &
posterior)
• Two pole (superior &
inferior)
• Two border (medial &
lateral)

4. Position
• Lies psoas muscles :
Longitudinal axes
oblique
• Upper poles more
medial & posterior
• Medial aspect rotated
anteriorly : 30 degrees
• Right kidney : L1 top –
L3 bottom
• Left kidney : T12- L3

5. Anterior relation of kidney

6. Posterior relation of kidney

7. Axial section imaging

8. Renal vasculature

9. Segmental blood supply

10. Arterial supply

11. Indication of Nephrectomy
• Severe trauma
• Renal infection
– Xanthogranulomatous & Emphysematous Pyelonephritis
• Malignancy
• Non functioning kidney
– Stones & obstruction
• Renal fistula
• Renal vascular Hypertension
– All medical & surgical therapy have failed
• Transplantation

12. Types of Nephrectomy
• Simple Nephrectomy
– Removal of kidney within Gerota fascia
• Partial Nephrectomy
– Small-sized renal cancer
– Benign diseases- excised renal capsule (renorrhaphy)
• Radical Nephrectomy
– Complete removal of kidney outside Gerota fascia
– Ipsilateral adrenal gland
– Complete regional lymphadenectomy (crus of
diaphragm - aortic bifurcation)

13. Different surgical approach
1. Open approach of Nephrectomy
2. Laparoscopic
• Transperitoneal
• Retroperitoneal
• Hand assisted
3. Robotic assisted

14. Pre- op evaluation
• Global assessment of pt’s renal function is done:
– Urine analysis & culture
– Serum Creatinine
– GFR evaluation
– Cardiac & pulmonary status: Positioning & bleeding
– Cross sectional imaging (CT/MRI) :- Surgical planning
– Locally advanced metastatic lesion : Screen hepatic
status (stauffer syndrome)
– Renal Artery Embolisation (RAE) : Large tumor

15. Instruments
• General set
• Abdominal drainage tube
• Self-retaining retractors : omni tract, balfour
• Long genitourinary surgical instruments
• Bulldog &/or Satinsky vascular pedicle clamps
• Mixters right angle forceps
• Bulldog arterial clamp
• Retractor- doyen’s and deiver’s
• Kidney pedicle clamp

16. Positioning
• Induction & ET tube
placement
• Catheterization done
• Pt : Lateral decubitus
• Table flexed b/w iliac crest &
costal margin
• Head supported: Avoid
excessive flexion
• Pt back supported by blanket
• Dependent leg flexed & top
leg straight
• All pressure point : padded
surface
• Pt secured to table : tape

17. Surgical approach to kidney

18. Anterior approach of kidney
INCISION INDICATION BENEFIT LIMITATION
Midline
Transperitoneal
Trauma, IVC
Thrombus , B/L
Renal or Ureteral
disease , Horseshoe
Rapid ,Early
vascular control ,
Access both kidney
Limited exposure to
kidney & bowel
Subcostal Radical
nephrectomy ,
UPJO
Incision can extend
to chevron , early
vascular control
Bowel complication
Hilum access poor
Chevron B/L renal tumor ,
IVC thrombus
Excellent b/l
exposure ,
Injury to Liver ,
Spleen , Transection
of large muscle
Transverse
abdominal
Wilms tumor Easy access to
pedicle &
retroperitoneal
node
Modified
Thoracoabdominal
Radical
nephrectomy ,
lymphadenectomy
versatile Bowel
complication,
Transection of large
muscle

19. Flank incision
INCISION INDICATION BENEFIT LIMITATION
11th or 12th rib
supracostal
Partial
nephrectomy , &
Simple
nephrectomy
Good renal &
retroperitoneal
exposure
Pleural injury
11th rib Transcostal Partial and Simple
nephrectomy
Good renal &
retroperitoneal
exposure
Pleural injury &
Noticeable flank
defect
Thoracoabdominal Large renal mass ,
IVC thrombus ,
involvement of
surrounding
structure
Excellent exposure ,
Can approach
completely
extraperitoneally
Pleural injury ,
Transection of large
muscles,

20. Steps of flank approach

21. • After Gerota fascia incised & kidney is
dissected free from surrounding perinephric
fat.
• Renal artery identified & ligated before vein
• Renal vein ligated

22. Simple nephrectomy
Indications
• Poor functionaing kidney
– Obstruction, infection, trauma, stones,
nephrosclerosis, vesicoureteral reflux, polycystic
kidney, or congenital dysplasia
• Functional kidney
– Relieve intractable symptoms : bleeding, pain,
hypertension, or persistent infection

23. Simple nephrectomy
• Flank incision : retroperitoneal access
• Renal fascia incised , perirenal fat is separated
from kidney
• Aberrant vessels : near the poles
• Large hydronephrotic : puncture and aspirate
• Adrenal dissectd in upper pole
• Lower pole mobilised and ureter isolated
• Division of ureter : access to hilar structures

24. Right kidney approach

25. Left kidney approach

26. Radical nephrectomy : Right
• Additional mobilization of liver, avascular Rt triangular
ligament is incised
• White line of Toldt : pelvis to hepatic flexure
• 2nd part of duodenum : Kocher maneuver
• Dissection anterior to IVC : Identification of renal vein
& gonadal vein
• Ligature of ureter below : kidney lifted , artery more
exposed
• Difficult hilar dissections : Dissect in the interaortocaval
region
• Lumbar veins close approximation

27. Radical nephrectomy : left
• White line of Toldt : splenic flexure to descending
colon is reflected medially.
• Renocolic ligament is divided and extreme care is
taken to avoid injury to the tail of the pancreas
• Left renal vein is identified using the anterior
surface of the aorta as a guide
• Left renal artery is usually located cranial and
posterior to the left renal vein
• Further mobilization of the lower pole of the
kidney, the left ureter and the left gonadal vein

28. PARTIAL NEPHRECTOMY:- INDICATION
1) Absolute:- i) Single kidney
ii) Bilateral renal tumor
iii) Severe renal failure
2) Relative:- i) Abnormal contralateral
ii) Metabolic disease associated with
renal failure
iii) Genetic syndrome with tumor
multifocality (e.g VHL syndrome)
3) Elective:- i) Tumor < 4cm in young & healthy pt
ii) Peripheral tumor

29. Partial Nephrectomy : Relative
Contraindication
Technical issue
– Cold ischemia time >45min (consider extracorporeal
approach)
– Less than 20% of global nephron mass retained
Cancer related issue
– Diffuse encasement of renal pedicle by tumor
– Diffuse invasion of central collecting system
– Tumor thrombus involving major renal veins
– Adjacent organ invasion (stage cT4)
– Regional lymphadenopathy (stage cTxN1)

30. Partial nephrectomy
• Avascular plane : Segmental artery clamping
– 5ml Indigo carmine : clamped artey
– Cooled down to 20o
• Hyperfiltration injury :
– Over decades, FSGS : proteinuria and progressive
renal failure (nephron mass reduced by 80%)
• Vascular clamping: Ischemia & hypothermia

31. Partial Nephrectomy :- Wedge
Resection

32. Partial Nephrectomy: Segmental Polar
Resection

33. Complication of partial nephrectomy
• Urinary fistula
• Post operative bleeding
• Renal insufficiency

34. Wound closure
• Hemostasis and evaluate adjacent organs for any signs
of injury
• Pleural injury,
– retroperitoneum is filled to level of the flank incision with
saline.
– anesthesiologist then inflates lungs with high inspiratory
volumes
– Bubbling of saline irrigation in the retroperitoneum with
deep inspiration would suggest a pneumothorax
• Fascial layers approximated : two layers
– Transversus abdominis & internal oblique fasciae are
approximated together
– External oblique fascia is approximated as a separate layer

35. Donor Nephrectomy
• Kidney is mobilized, only remaining attachments are
the ureter, renal vein, and renal artery
• 12.5 g of mannitol and 20 mg of furosemide are rapidly
infused intravenously
• Immediately after dividing renal vessels, placed on
workbench : Pan of ice slush covered with a towel.
• Flushed intra-arterially by gravity flow with renal
preservation solution at 6°C
• Flushing should continue until it is cooled & renal
effluent is clear (~500 to 1000 mL)
• Kept in ice slush basin during procedure : Hypothermia

36. Donor nephrectomy
• Renal artery & vein are flushed independently
with preservation solution : Bleeding
• Retrograde flushing of ureter : Collecting system
leaks
• Transplanted into either lower quadrant,
transferred to iliac fossa
• Renal vein anastomosed : External iliac vein.
• Renal artery anastomosis
– End-to-end anastomosis to hypogastric artery
– End-to-side anastomosis with external iliac artery

37. Donor nephrectomy
• During anastomosis, vessels should be irrigated :
Heparin solution (10,000 U Heparin in 100 mL NS)
• Surgeon should consider injecting
– 10 mg Verapamil into renal artery following
anastomosis : Vasodilation.
• Ureter is implanted into dome of bladder with a
tension-free anastomosis
• Prior to completion ureteral anastomosis:
Ureteral stent is placed

38. Complication of Open Nephrectomy
• Hemorrhage
• Small bowel obstruction
• Pneumothorax
• Pneumonia
• DVT
• Superficial wound infection
• Bowel injury

39. LAPROSCOPIC NEPHRECTOMY
SURGICAL APPROACHES:-
1) Transperitoneal
2) Retroperitoneal
3) Hand-Assisted

40. TRANSPERITONEAL RETROPERITONEAL HAND-ASSISTED
Small incision & gives
advantage for trocar
placement
Limited working space
,result in difficulty in
orientation , trocar spacing
, & organ entrapment
Bridge b/w lap & open
surgery
Affords optimal working
space
Preferred in pt with h/o
multiple abdominal
procedure or pt with
peritonitis
Permits tactile feedback
Also preferred in pt with
abnormality of posterior
surface (exophytic cyst or
mass)
Allow the hand to assist
with dissection , retraction
, extraction & rapid control
of bleeding

41. PATIENT EVALUATION & PREPARATION
• Prior abdominal surgery
– Transperitoneal & retroperitoneal
– Pt positioning ,
– Placement of trocars
• Pre-op abdominal CT :- useful in surgical planning
• Rest of evaluation similar to open nephrectomy

42. Patient positioning & trocar sites

43. OPERATING ROOM

44. Procedure of transperitoneal approach
• Reflection of colon
• Dissection of ureter
• Identification of renal hilum
• Securing of renal blood vessel
• Isolation of upper pole
• Organ entrapment

46. Retroperitoneal Approach
• Retroperitoneal approach used for posterior or
lower pole lesion
• Pt in full flank position ,10mm trocar is placed in
posterior axillary line , halfway b/w iliac crest &
12th rib
• Pneumo-peritonium is established & anterior wall
is identified with gentle dissection of
retroperitoneal fat

47. Retroperitoneal approach

48. Retroperitoneal Approach
• Second 12mm port is placed under direct
vision in anterior axillary line
• A third port 5mm is placed superior to 2nd port
below rib cage
• Using the perinephric fat to elevate kidney ,
surgeon readily sees the lower pole &
posterior surface

49. Complication of laparoscopic renal
surgery
1. Access related problems:-
i. Solid organ injury
ii. Bowel injury
iii. Abdominal wall hematoma
iv. Epigastric vessel injury
2. Hemorrhage
3. Pneumonia
4. Pulmonary embolus
5. Unrecognized bowel injury
6. Incisional hernia :- after intact specimen removal

50. Nephrectomy: Robotic Port Placement

51. Robotic Nephrectomy : Operating room

52. Advantage of robotic over laparoscopic
• Minimal invasive approach
• 3D visual & depth perception

53. Thank you