For a left radical nephrectomy, the patient is placed in the right lateral decubitus position with the left flank up (Fig. 53-1, B). The patient is centered over the break in the bed. The lower leg is bent and the top leg straight, and the dependent hip, knee, and ankle padded appropriately. Pillows can be placed between the legs. An axillary roll should be placed under the axilla, to protect from nerve damage. The patient’s lower arm is placed straight out on an arm board, and the upper arm should be secured to an upper arm board. The upper arm must be safely positioned away from the working field to ensure full access to laparoscopic instrumentation.

It is important to secure the patient to the table with heavy tape wrapped around the patient (preferably directly to skin) and table several times, to prevent the patient from moving or sliding during surgery. For the transperitoneal approach, the patient can be rotated posteriorly just before being secured to the table. It is also helpful to plan for the extraction site, marking it before positioning and including it in the prepped and draped area.

Port sites have been described in several ways, depending on surgeon preference. The author’s group typically uses the Verres needle for access, although the Hasson cutdown technique is also appropriate. Correct placement of the right-handed port is typically marked half the distance between the anterior superior iliac spine and the umbilicus, then moved superiorly up to the level of the umbilicus. This would typically be a 10-mm port. The middle camera port is typically placed just lateral to the rectus abdominis muscle, approximately in line with the tip of the 12th rib. The left-handed, typically 5-mm port is approximately at the junction of the lateral aspect of the rectus muscle and the subcostal border.

Mobilization of Left Colon

Once the abdomen is entered, a brief survey completed, and any adhesions dissected free, the first step is to reflect the left colon. Although the standard description of mobilizing the colon describes incising along the white line of Toldt, it is not necessary to incise that laterally; in fact, it could be more challenging to incise that laterally because the peritoneum needs to be dissected off Gerota’s fascia posteriorly and reflected medially to expose the retroperitoneum and kidney (Fig. 53-2).

FIGURE 53–2 Reflected colon and mesentery medially; kidney and Gerota’s fascia laterally.

It is important to incise the peritoneum lateral to the colon. If the white line of Toldt is incised, the surgeon must be certain not to continue to follow that plane posteriorly, to prevent dissecting the kidney’s lateral attachments, complicating the dissection. It is useful to leave the kidney’s lateral attachments until after the hilum is controlled; the lateral attachments help “retract” the kidney up without using one of the instruments to retract the kidney. This peritoneal layer is very thin; the surgeon must stay outside Gerota’s fascia, but avoid entering the posterior mesentery. There is a clear difference in the appearance of the fat layers of Gerota’s fascia (paler yellow) and posterior mesentery (brighter yellow).

It is often helpful to free up the upper-pole attachments between the spleen and kidney to avoid an inadvertent capsular tear of the spleen from a retraction injury. It is important to reflect the colon far enough superiorly to ensure sufficient access to the upper pole of the kidney, and low enough to ensure access to the ureter below the lower pole.

Dissection

Ureter

Once the colon is reflected, it is helpful to dissect the ureter free. Starting below the lower pole of the kidney, the surgeon should dissect lateral to the aorta, identifying the ureter and gonadal vein (Fig. 53-3). Once identified, the ureter should be retracted laterally, exposing the psoas muscle posteriorly. At that point, the ureter can be clipped and divided with the lateral attachments to the ureter all the way to the abdominal side wall. The proximal end of the divided ureter can then be used for gentle retraction to help follow the psoas muscle, ureter, and gonadal vein (on the left) as landmarks up to the renal hilum.

FIGURE 53–3 Anatomic relations of kidney and psoas exposure.

Renal Hilum

Typically the renal vein will be anterior to the renal artery. Once the attachments overlying the hilum are divided, the renal artery should be identified posterior to the renal vein. Some variation may be seen, because the renal artery can be directly posterior, inferior, or slightly superior to the renal vein, but typically is directly posterior (Fig. 53-4, A).

FIGURE 53–4 Relationships of renal vessels and adrenal gland.

The renal artery should be controlled and divided before dividing the renal vein. The surgeon should be cautious because accessory arteries or veins and lumbar vessels may require control. Preoperative imaging is typically helpful, but these accessory vessels are not always identified, and intraoperative caution should be taken while dissecting the renal hilum.

Adrenal Gland

The original description of the radical nephrectomy involved removal of the adrenal gland, but more recent evidence shows that removal of the adrenal gland may not be necessary for all radical nephrectomies. The adrenal gland is often preserved in many contemporary series of radical nephrectomies.

If the surgeon desires to preserve the adrenal gland, the dissection should start immediately superior to the renal vein (Fig. 53-4, B). On the left, the renal vein should be divided distal to the adrenal vein insertion into the renal vein. The adrenal gland should be dissected from the upper pole of the kidney. On the right side, special caution is taken because the right adrenal vein is short, with its insertion directly into the vena cava.