Nephrectomy
Indications
- Malignancy [renal cell carcinoma]
- TCC of ureter requiring nephro-ureterectomy
- Non-functioning kidney
- Chronic pyelonephritis
Possible approaches
- Open
- Anterior/Transperitoneal
- Posterio-lateral/Retroperitoneal
- Laparoscopic
- Transperitoneal
- Retroperitoneal
Procedure (Right nephrectomy - Anterior/peritoneal approach)
- CT scan + confirm presence of opposite kidney (otherwise you're in big shit) + mark side + consent
- GA + supine
- Kocher's subcostal incision
- identify hepatic flexure, duodenum, gonadal vessels
- Mobilise colon medially: display perinephric fat
- Identify kidney (surrounded by paranephric fat), ligate vascular pedicle (prevents dislodging of tumour cells into circulation)
- Identify vascular pedicle
- Clamp renal artery
- Palpate renal vein; ligate and divide
- Divide renal artery
- Mobilise kidney within fascia (Gerota's, surrounds perinephric fat)
- Divide ureter at accessible point
- Remove kidney with perinephric fascia intact
- Place suction drain
- Close wound in layers
Procedure - Posterio-lateral approach
- Lateral decubitus position + renal bridge on operating table under contralateral loin.
- Subcostal incision along line of 12th rib: Midline -> posterior axillary line (ie, quite large)
- Divide layers: skin / lat dorsi / ext obl / int obl / quad lumb / > kidney
Laproscopic nephrectomy
- Dissect out
- Bring to surface
- Make skin incision to deliver
Complications
- Early
- Wound infection
- Bleeding
- Haemorrhage
- General - DVT, Chest infection, PE
- Late
- Tumour reccurrence
