Laparoscopic and robot-assisted nephrectomy

In this chapter the main technical steps of laparoscopic and robot-assisted nephrectomy are discussed. Laparoscopic nephrectomy: examine carefully the position of the donor preoperatively, to avoid discomfort for the patient and for the surgeons. Communicate with all the members of the surgical team, including anaesthesiologists and nurses, to clarify the main phases of the operation. Get ready for a rapid open conversion, drawing on the body of the donor the midline incision. Remind that hand-assisted technique can become useful to manage unexpected difficulties. Avoid the use of non-tissue affixing ligation technique for renal vessels. Plan a strategy to maximize the length of renal vessels, using Endoscopic GIA or TA stapling device, keeping away from early bifurcations. Note the advantages of using a LigasureTM vessel sealing for dissection, to shorten operative time and to avoid clips interfering with the stapling suture line. Pay a lot of attention to haemostasis of the Pfannenstiel incision, since the heparin bolus effect may result in subcutaneous hematoma. Robot assited nephrectomy: do not put metallic clips where you will need to use staplers. Place the patient in order to avoid collisions among robotic arms and between robotic arms and the patient itself. For donor safety concerning renal artery: It’s better to use TA instead of GIA stapler to avoid the risk of stapler malfunctioning. The section should be done with robotic scissors after placement of an hem-o-lock on the arterial stump. Always administer one bolus of curare together with heparin to facilitate the kidney extraction. Left Nephrectomy: extend the dissection of the splenopancreatic block up to the left diaphragmatic crura. Renal vein should be encircled with an elastic tape after the section of gonadic and adrenal veins in order to: Easily recognize it during posterior isolation of the kidney. Modulate robotic arm’s strength with adequate traction during dissection manoeuvres and staplering.