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Left Laparoscopic Partial Nephrectomy

Left Laparoscopic Partial Nephrectomy. Louis R. Kavoussi M.D. Professor of Urology & Ardeshir R. Rastinehad D.O. Resident in Urology The Institute of Urology at the North Shore LIJ Health System. Patient Selection. Indications Enhancing renal mass Relative Contraindications

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Left Laparoscopic Partial Nephrectomy

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  1. Left Laparoscopic Partial Nephrectomy Louis R. Kavoussi M.D. Professor of Urology & Ardeshir R. Rastinehad D.O. Resident in Urology The Institute of Urology at the North Shore LIJ Health System

  2. Patient Selection • Indications • Enhancing renal mass • Relative Contraindications • Vena caval thrombus • Multiple prior abdominal surgeries • Significant medical comorbidities • Contraindications • Peritonitis • Uncorrected coagulopathy

  3. Equipment • PATIENT POSITIONING • Gel bolster, Gel pads • 3" Adhesive Silk tape • Pillow, Heel pads • Sequential compression device • Foley catheter, orogastric tube • ENERGY/IMAGING : • Monopolar and Bipolar • Argon Beam Coagulator (ABC) • Ligasure Atlas (10mm) [Valley lab] • Laparoscopic ultrasound probe VIDEO/CAMERA EQUIPMENT: • Laparoscopes (10 and 5 mm 30) • Thompson laparoscope holder • Hot water thermos • Video tower • HD monitors (2) • Camera unit • Light source • Insufflator • DVR and printer

  4. SUTURES: Renorrhaphy stitches: O-Vicryl on CT needles (15 cm) Lapra-Ty Skin: 4-0 Caprosyn ADDITIONAL: Surgicel 10 mm Endoclip Lapra-Ty clips                            15 Fr Round Blake drain and 100 cc reservoir Equipment TROCARS/INSTRUMENTS: • Trocars: 12 mm (3), 5 mm (2) • Major tray • Veress needle • Standard Laparoscopy Instruments • 10 mm laparoscopic scissors • Laparoscopic Bull Dog Clamps • Irrigator/aspirator • [Strykeflow irrigation system, Stryker] 

  5. Patient Positioning • OR table lined with gel pad • 30º modified flank, supported by gel pads/bolster • Lower legs supported by pillow – (slight knee flexion) • Left arm draped over chest, supported by gel pads • Arms, hips, and lower leg secured by tape over eggcrate padding and towel • Table tested to ensure patient secure with full “airplane” tilt

  6. Patient Positioning Arm supported by gel pads; draped across abdomen and secured Pillow under knees with slight flexion; legs parallel

  7. Gel roll placed behind scapula and back Secured at level of arm and waist

  8. Orogastric tube and foley “Egg Crate” foam at all pressure points

  9. Pneumoperitoneum/Trocars • Veress needle placed at umbilicus • 15 mm Hg CO2 pneumoperitoneum • Primary 12 mm camera port at umbilicus • (Laterally shift trocars in obese patients) • Second 12 mm trocar • Directly lateral to the camera port at midclavicular line • Accessory 5 mm trocar • Approximately 8 cm superior to the camera port

  10. Trocar Placement Primary (12 mm) working ports 5 mm accessory port

  11. Procedure Outline • Establish pneumoperitioneum and place the trocars • Mobilization of the colon • Identification of ureter • Dissection of renal hilum and upward retraction of ureter/lower pole • Enter Gerota’s fascia, identify the mass using intra-operative ultrasound • Hilar occlusion with bulldog clamps • Excise mass and place in entrapment bag • Renorrhaphy • Remove the bulldog clamps and the specimen

  12. 1. History and Trocar Placement

  13. 2. Mobilization of the colon

  14. 3. Identification of ureter

  15. 4. Dissection of renal hilum and upward retraction of ureter/lower pole

  16. 5. Enter Gerota’s fascia and identify the mass using intra-op ultrasound

  17. 6. Placement of bull dog clamps

  18. 7. Excision of the mass

  19. 8. Renorrhaphy

  20. 9. Remove the bull dog clamps and the specimen (Clamp time = 26 minutes)

  21. Technical points • Tenting the ureter anteriorly and “marching” cephalad facilitates rapid identification and dissection of the renal hilum • Intraoperative ultrasound must be available to identify and delineate renal mass, especially with endophytic lesions

  22. Technical points • A mini-lap pad should be placed in the abdomen prior to releasing the bull dog clamps as it may be used to compress and tamponade unexpected bleeding from the renal bed • O-Vicryl on CT needles (15 cm), Lapra-Ty, and surgicel bolsters are used for hemostasis

  23. Credits Surgeon: Louis R. Kavoussi M.D. Chairman of Urology North Shore LIJ – Health System New Hyde Park, NY Video editors: Ardeshir R. Rastinehad, Michael C. Ost, Lee Richstone Evan R. Eisenberg Institute of Urology North Shore LIJ – Health System

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