One hand is better than two: conversion from pure laparoscopic to the hand-assisted approach during difficult nephrectomy

Abstract

INTRODUCTIONThe incidence of conversion from a laparoscopic to an open approach during nephrectomy is reported at 6-8%. 1 Conversion to an open procedure may be necessary to control haemorrhage or allow progress in dissection but the well established benefits of minimally invasive surgery (MIS) are obviously lost. Hand-assisted laparoscopy (HAL) also offers the benefits to the patient of MIS. We have used HAL to convert from the pure laparoscopic approach during difficult nephrectomies, rather than converting to traditional open surgery. MATERIALS AND METHODS A review of our prospective database was carried out to identify any conversions from the pure laparoscopic approach during nephrectomy or nephroureterectomy for benign or malignant disease. RESULTS A total of 87 laparoscopic nephrectomies (LNs) were identified over a 3-year period. There were five conversions to the HAL approach (5.7%) and no conversions to open surgery. The reason for conversion was failure to progress in all five cases. Operative times averaged 190 minutes with blood loss of 180ml. Histology revealed xanthogranulomatous pyelonephritis in four cases and renal cell carcinoma in one case. The median postoperative stay was 4 days. CONCLUSIONS Conversion to HAL during LN maintains the benefits of MIS in difficult nephrectomy and should be considered prior to converting to open surgery.

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

“…Hand port: Hand ports, as described by Mahesan et al, 8 can be used to salvage RV injuries by strategically placing the port incision over the bleeding vessel to allow rapid control. Surgical gloves can replace a hand-assisted laparoscopy device to prevent loss of pneumoperitoneum.…”

Xanthogranulomatous pyelonephritis

“…80% success rate of LN reported in two further series, could be due to improved technology and skills in laparoscopic surgery (25,26). Studies show that during difficult nephrectomies, hand assisted laparoscopy (HAL) reduces incidence of conversion to ON (25,28,29 (15). The uncommon association of XGPN and malignancy also contribute to the unpopularity of medical management (11,30,31).…”

Preventing conversion to open surgery during laparoscopic donor nephrectomy complicated by bleeding from the aorta

“…1,2 Conversion from laparoscopic to hand-assisted or open approach may be necessary in certain situations with reported rates between 1.3% and 5.5%. [1][2][3][4][5] Failure to progress is reported as the commonest reason for a surgeon to consider conversion to hand-assisted from pure laparoscopy, 4,5 while conversion to open via midline laparotomy is usually considered in cases requiring rapid hemostatic control. 1,5 Here, we report an effective and useful technique where conversion to open surgery was avoided during a living donor laparoscopic left nephrectomy, in a 27-year-old female with BMI of 33 Kg/m 2 complicated by bleeding from the aorta.The left kidney had a single artery, vein, and two ureters, and the procedure was straightforward.…”