Laparoscopic nephrectomy outside gerota fascia and en bloc ligation of the renal hilum for management of inflammatory renal diseases

Abstract

ObjectivesThis study aims to improve laparoscopic nephrectomy techniques for inflammatory renal diseases (IRD) and to reduce complications.Materials and MethodsThirty-three patients underwent laparoscopic nephrectomy for IRD, with a method of outside Gerota fascia dissection and en-bloc ligation and division of the renal pedicle. Operative time, blood loss, complications, analgesia requirement, post-operative recovery of intestinal function and hospital stay were recorded. The degrees of perinephric adhesion were classified based on the observation during operation and post-operative dissection of the specimen, and the association of different types of adhesion with the difficulty of the procedures was examined.ResultsAmong 33 cases, three were converted to hand-assisted laparoscopy, and one was converted to open surgery. Mean operative time was 99.6±29.2min, and blood loss was 75.2±83.5 mL. Postoperative recovery time of intestinal function was 1.6±0.7 days and average hospital stay was 4.8±1.4 days. By classification and comparison of the perinephric adhesions, whether inflammation extending beyond Gerota fascia or involving renal hilum was found to be not only an important factor influencing the operative time and blood loss, but also the main reason for conversion to hand-assisted laparoscopy or open surgery.ConclusionsIn laparoscopic nephrectomy, outside Gerota fascia dissection of the kidney and en-bloc ligation of the renal pedicle using EndoGIA could reduce the difficulty of procedure and operative time, with satisfactory safety and reliability. Inflammation and adhesion extending beyond Gerota fascia or involving renal hilum is an important predictor of the difficulty related to laparoscopic nephrectomy for IRD.

Minimally invasive nephrectomy for inflammatory renal disease

“…Liang et al. [2] analyzed the experience in LN with a method of outside Gerota's fascia dissection and en-block ligation and division of the renal pedicle similar to our reported cases. They reported 11% of conversions to hand-assisted laparoscopy and only one conversion to open nephrectomy.…”

“…Most surgeons prefer to perform open surgery for IRD due to the technical challenging dissection of these kidneys. Most recently, surgeons have accumulated a vast experience in laparoscopy, supporting the possibility of performing LN for IRD [1] , [2] . However, complications and conversion rates are not uncommon [4] , [6] , [7] , [18] .…”

“…This process can be promoted by obstruction of the urinary tract specially by stones [1] . These chronically non-functioning kidneys are removed in most cases when they are associated with pain, recurrent urinary tract infections, or renovascular hypertension [1] , [2] .…”

“…In the past decades, the open nephrectomy has been considered as the standard of care for this condition. However, this approach is related to wide, painful incisions with higher risk of surgical site infections, higher analgesic dose requirements, longer hospital stays and prolonged convalescence periods [1] , [2] . Due to the significant inflammatory process, the difficult dissection of the renal pedicle and adhesions to adjacent organs, makes this operation a technically demanding approach for minimally invasive surgery (MIS).…”

“…Due to the significant inflammatory process, the difficult dissection of the renal pedicle and adhesions to adjacent organs, makes this operation a technically demanding approach for minimally invasive surgery (MIS). In fact, some physicians consider IRD a relative contraindication for MIS [1] , [2] , [3] , [4] , [5] . MIS conversion rates in these type of cases is about 28% [1] .…”