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Open Kidney Surgery (the problem)
Laparoscopic techniques are ideally suited to the surgery of kidney cancer. The kidneys are well protected within the body. They are located deep inside, shielded from behind by the protection of the ribs, and in the front by the overlying other organs and body wall. The sheer depth of the kidneys within the body not only protects them, but also makes it so that traditional open kidney surgery requires a large incision (with muscle-splitting and rib-removing that promises a painful, prolonged recovery, with possible respiratory complications and incisional hernias).
Every possible approach for open kidney surgery seems to have its own landmines and booby traps. An anterior open approach, across the front of the belly, risks prolonged recovery due to ileus (“sleeping" of the bowel , preventing oral intake), and adhesions ( scarring that could later cause obstruction of the bowel). The posterior approach is restricted by the immovable fortress of the spine and ribs.
The most favored open approach, therefore, has always been a lateral approach- which itself requires a big incision, usually between the eleventh and twelfth ribs (often removing one of both ribs in the process). This incision must be large to allow one to maneuver around the blood vessels to gain control of them (a vital step in any cancerous kidney's removal). A small incision risks poor control, whichis usually discovered too late.The lateral incision must also spare the nerves to the muscles or they'll thin and whither, and the patient can then develop a large hernia. The difficulty preventing this is, the nerves run parallel to the direction of the incision and don't particularly run straight as arrows, so sparing of the nerves is sometimes impossible. Even when nerves have been visibly spared, there is still a slight risk of herniation (presumably from cutting small unseen branches off the main nerve).This approach also often requires a partial detachment of part of the diaphragm to reach and control the upper portion of the kidney. Such a weakened diaphragm makes it difficult for patients to fight off pneumonias in the post -op period. Thus, even this best open approach can have a painful slow recovery, possibly complicated by pneumonias, hernias, and future bowel obstructions. Seeing any of these complications in just one patient is enough to make any conscientious surgeon become dedicated to perfecting his laparoscopic skills. The laparoscopic approach and techniques neatly minimize or eliminate each of these problems.
The Laparoscopic Approach (the solution)
Laparoscopy for kidney surgery is usually performed through two or three tiny puncture sites and a 2.5 inch incision (through which the final specimen is removed). These are either centered around the upper left or right side of the belly, depending on which kidney is being operated on. The recovery from this approach is much quicker than with the old twelve inch long muscle splitting incision. Laparoscopic kidney removal minimizes ileus. The proceedure doesnt require detachment of the diaphragm, so pneumonias are rare. The smaller incision shortens post operative stay (usually two days), minimizes post-op discomfort, has less risk of hernia and scar formation, is more cosmetic and speeds up the patient's complete return to normal activity (2 wks compared to 6 for open surgery).The cancer-curative rates of laproscopic kidney surgery equal the those of open surgery, yet with considerably less risk, discomfort and disability.
Laparoscopic Nephrectomy (LN) vs Hand Assisted Laparoscopic Nephrectomy(HALN)
Since a kidney is too big to be removed through any of the 1/4" inch diameter laparoscopic port sites, ultimately even the laparoscopic approach requires a mini incision (2.5" long) for the removal of the final specimen. Today, kidney surgery can be "hand assisted" in which that mini incision is made at the beginning of the case. The surgeon's one hand is introduced right from the start through this small incision to assist in the procedure, which is performed with instruments passed through two additional laparoscopic ports. This small incision also later serves as the exit route for the final specimen. It doesn’t seem to matter whether the removal of the kidney is a purely "laparoscopic nephrectomy" (with a later final mini- incision to remove the specimen" , or a "hand assisted laparoscopic nephrectomy"- with a hand in the abdomen from the beginning to provide the surgeon with better control and tactile feedback. Both approaches are excellent and both avoid the complications seen with the open surgery.
Preserving Kidney Function (avoiding dialysis) "Nephron-sparing" laparoscopic surgery
In certain instances, notably for smaller cancers or those growing from either the upper or lower ends of the kidney, "nephron- sparing" surgery (which removes the whole cancer yet leaves the cancer-less but still functioning kidney behind) can be performed by either the laparoscopic or hand-assisted laparoscopic techniques. "Nephron sparing" surgery should only be considered when its felt 1) the procedure will completely ( and safely) remove the cancer and 2) the remaining cancer-less kidney has function that is necessary to the patient and is viable enough to survive on its own. CT scans and consultations with nephrologists are usually undertaken to evaluate patients pre-operatively in consideration of such "nephron-sparing" procedures.
Who should have open kidney surgery?
Not everyone is a candidate for laparoscopic kidney surgery. Patients with multiple previous abdominal/kidney surgeries, obese patients, those with advanced tumors which are bulky or threaten vascular invasion, some nephron-sparing procedures where the mass to be removed is particularly big or centered near the blood vessels are all instances where the procedure should best be approached through an open incision.
Patient's Comments After Laparoscopic Kidney Removal
The patients have all been very favorably impressed with their lack of discomfort, short hospital stay, and quick recovery. If you are considering laparoscopic kidney surgery, all of our previous patients can identify with the situation you're in, and have gladly offered to share their experiences with you to help you either make your treatment decision or simply provide you with emotional support.
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