PERITONEUM-PRESERVING LAPAROSCOPIC NEPHRECTOMY

PATIENT SUMMARY

In this video, we demonstrate our surgical technique of simultaneous bilateral laparoscopic nephrectomy via retro-peritoneal prone approach in a 11-year old girl with Frasier syndrome.

This condition is associated with gonadal dysgenesis and Wilms tumor 1 (WT1) gene. The child was on long-term continuous ambulatory peritoneal dialysis (CAPD) and our pediatric nephrology colleagues referred the patient to us for removal of both kidneys without jeopardizing the patient's ongoing peritoneal dialysis.

SURGICAL TECHNIQUE

Our video shows the important steps in safe patient positioning, a brief description of port access and placement, and important retroperitoneal structures visualised in the prone position. The surgery is summarized into key steps,

1. Incision of curtain of perinephric fascia

2. Safe technique of kidney mobilisation

3. Releasing the kidneys from the peritoneal membrane without injury

4. Securing hilar renal vessel for both left and right nephrectomies.

The procedures were completed safely, with mean operative time of 85 minutes per kidney. Postoperative pain relief was intravenous acetaminophen at 15 mg per kg at 6 hourly intervals. Patient did not require postoperative blood transfusion.

She was started on low pressure peritoneal dialysis the day after surgery, back to her regular CAPD protocol on the second postoperative day, and then discharged home.

The advantage of the laparoscopic retroperitoneal techniques is that it avoids mobilization of bowel and reduces the risk of post-operative ileus. Its other benefits include reduced postoperative pain and improved cosmesis. There is less risk of transperitoneal spillage of infected urine in chronically obstructed kidneys, thereby reducing risk of future bowel adhesions. Compared to the lateral retroperitoneal approach, the prone approach allows early and safe access to the renal hilum.

In the case of this young girl, this approach was selected because it was crucial that the peritoneal membrane was left intact without any breach that could interfere with CAPD.