Left laparoscopic radical nephrectomy

PREOPERATIVE DIAGNOSIS:  Left renal mass.

POSTOPERATIVE DIAGNOSIS:  Left renal mass.

OPERATION PERFORMED:  Left laparoscopic radical nephrectomy.

ANESTHESIA:  General.

ESTIMATED BLOOD LOSS:  300 mL.

DRAINS:  Foley catheter.

SPECIMENS:  Left kidney.

COMPLICATIONS:  None.

PROCEDURE IN DETAIL:  The patient was brought to the operating room and placed on the operating room table.  After general anesthesia and antibiotics were given, a Foley catheter was placed.  He then was placed in the lateral decubitus position with left side up.  Care was taken to pad all pressure points and joints.  Axillary roll was placed to protect his brachial plexus.  Additionally pillows had been placed between the legs.  Care was not taken not to have undue pressure on his shoulders, elbows, or his cephalus.  The abdomen was then prepped and draped in the standard surgical fashion.  Attention was turned to performing a horizontal 7 cm incision just above the umbilicus.  This was carried down to the skin and subcutaneous tissues.  The fascia was then identified and opened with Mayo scissors.  The fascia was then opened, the peritoneum was then entered, and the incision was further opened.  The Gelport hand-access device was placed into the incision.  Pneumoperitoneum was created through this port up to 15 mmHg.  Attention was then turned to _____ placing additional ports.  A 12-mm port was placed in the right lower quadrant.  Additionally, a 5-mm port was placed in the subxiphoid area for the camera, and an additional 12-mm assistant trocar was placed in between the camera port and the Gelport.  Using manual retraction and Harmonic scalpel the white line of Toldt was incised.  The left colon was then reflected all the way from the pelvic rim inferiorly all the way up to the spleen superiorly.  The splenorenal ligaments and splenocolic ligaments was divided.  Care was taken to not enter the spleen.  Further dissection was carried out medially until the ureter and gonadal vein was identified.  The ureter was dissected from surrounding structures.  The gonadal vein was then traced superiorly until its insertion into the renal vein was visualized.  The gonadal vein was doubly clipped and divided with Hem-o-lok clips.  The adrenal vein was then identified inserting into the left renal vein.  This was clipped and divided with Hem-o-lok clips.  The renal vein was completely isolated from the surrounding structures.  Posterior to the renal vein, the renal artery was identified.  A single Hem-o-lok clip was then placed to occlude the artery.  At this point, the renal vein was divided with endovascular GIA stapler device.  Following transection of the renal vein additional Hem-o-lok clips were placed on the renal artery.  Three clips were left on the patient’s side and one clip was left on the specimen side.  This was divided with EndoShears.  Attention was then turned to fraying the kidney further medially from the psoas muscle and hilar structures.  This was performed with Harmonic shears.  Similarly, the lateral attachments and posterior attachments were taken down.  The upper pole was also removed.  Care was taken down to enter the spleen over the stomach.  Additionally, care was taken to not enter the tail of the pancreas.  The adrenal gland was resected with the specimen as this was an upper pole to mid pole tumor.  The kidney was then freed from all the surrounding structures and it was removed from the hand port site, and it was passed off as a specimen labeled left kidney.  Hemostasis was then obtained.  The hilum and upper pole was inspected.  Surgicel material was placed in the adrenal bed remnant and upper pole.  Excellent hemostasis was obtained at the end of the case.  The lap counts were correct.  Obviously, prior to the kidney removal, the ureter was doubly clipped and divided.  Attention was then turned to closing the trocar site.  The right lower quadrant site was closed with a fascial closure device under laparoscopic vision.  Similarly, the 12-mm assistant port was then closed with the fascial closure device and a 0 Vicryl stitch under its laparoscopic vision.  The 5-mm trocar was removed under direct vision.  There was no bleeding.  Attention was then turned to closing the hand port at the midline, 0 PDS was used to close the fascia and peritoneum in a running suture, 2-0 chromic was used to re-approximate the subcutaneous fascial layer.  The skin incisions were closed with running 4-0 Monocryl.  Steri-Strips were applied and bandages were placed.  The patient was awake from anesthesia, transported to recovery room in stable condition.  There were no complications.