Laparoscopic nephrectomy simplified – A “two-window technique” for safer approach to hilum for a novice

Abstract

Though the overall safety of laparoscopic nephrectomy (simple or radical) is well established, for a novice it remains a challenge. The classical description of laparoscopic nephrectomy entails dissection either from caudal to cephalad side or vice versa. Herein we describe our “two window technique” for managing renal hilum during laparoscopic (simple/radical) nephrectomy. Our main intention in description of this technique is to reduce the level of apprehension for a novice urologist for performing laparoscopic nephrectomy. After colon mobilization, sequential lower and upper windows are created around the hilum following which hilar vessels are dissected circumferentially when the hilum is at a stretch by traction from either of the window. There are multiple potential advantages of this method which includes easier and safer dissection especially for novice in this field by giving a safety window of application of vascular clamp in cases of vascular bleeds. Intrahilar dissection in stretched condition becomes safer with vision from all around 360° for safe application of Hem-o-lok® clips. Due to the widely exposed field, injuries to adrenal vein and lumbar veins would be minimized and the chances of missed accessory vessel would be minimized. En mass hilar control with vascular clamp in cases of partial nephrectomy is possible with same approach as well as the en block stapling is feasible in cases of nephrectomy. This needs a validation across multiple centers with comparative studies before considering it as a standard of practice. We sincerely believe that this is safe and easily reproducible by a novice.

Laparoscopic Radical Nephrectomy in the Current Era: Technical Difficulties, Troubleshoots, a Guide to the Apprentice, and the Current Learning Curve

“…Hilar dissection is the most critical step of LRN, and we routinely develop both superior and inferior windows to delineate the vascular anatomy, as described by Chiruvella et al 6 The para-renal fat is light yellow colored and fine-textured in contrast to the deep yellow and granular Gerota fat. In case of difficult dissection with adhesions, the suction cannula can greatly assist blunt hilar dissection.…”

Simplifying Laparoscopic Nephrectomy for Beginners: Double Window Technique With En Bloc Hilar Stapling

“…This technique also avoids the catastrophic possibility of injury to the superior mesenteric artery as the kidney is lifted off entirely from the aorta before a stapler is deployed. It has also been shown to be easily reproducible by surgeons who are still in the early part of their experience [ 5 ]. An additional advantage of this technique is that at the time of application of the stapler, both the blades of the stapler can be well visualized as compared to the inferior approach in which the visualization of the upper blade may not be optimum.…”

“…The conventional method is the inferior approach in which the lower pole is mobilized first followed by the dissection of the hilum, isolation followed by ligation of artery and vein, and then the upper and lateral mobilization [1][2][3]. The most critical part of laparoscopic nephrectomy is the management of the renal hilum [2,4,5]. It entails the identification and meticulous dissection of the renal artery and vein and their ligation [1][2][3].…”

“…It entails the identification and meticulous dissection of the renal artery and vein and their ligation [1][2][3]. This requires a significant amount of experience and may be the most difficult step for surgeons who are in the initial phase of their learning curve [4,5]. Injury to these vessels during dissection can lead to catastrophic life-threatening consequences.…”

Use of posterior radial nephrotomy in laparoscopic enucleation of renal hilar tumors

“…This technique helps to keep the hilar vessels under stretch, which facilitates their skeletanization and also helps in the subsequent clamping. [ 6 ] We follow the “Polar Flip” technique, i.e., the kidney is rotated by around 45°–60° after freeing from its lateral attachments, so that the lower pole faces anteriorly and the upper pole faces posteriorly, thereby exposing the posterior surface for maneuverability. The polar flip is primarily performed to gain access to the posterior surface of the kidney.…”