V5-07: DIRECT APPROACH FOR LEFT NEPHRECTOMY WITH THROMBUS IN RENAL VEIN : Keeping in Mind a Classic Laparoscopic Acces

Video

Introductions and Objectives
We describe and demonstrate the feasibility of early ligature of the renal artery and vein using a direct access to the renal pedicle at the level of the Treitz ligament during left transperitoneal radical laparoscopic nephrectomy in a patient with thrombus in left renal vein very near of the renal Cava vein

Methods
To reproduce the principles of open radical nephrectomy and in order to achieve early ligature for the treatment of left RCC with transperitoneal approach, we used the direct access to the renal artery at the level of the Treitz ligament . The advantage of this access signifies a total lack of manipulation of the renal mass and the thrombus .

Results
the patient and trocars are placed in convencional position . The procedure begins with the identification of the fourth part of the duodenum and the inferior mesenteric vein. An incision of Treitz ligament and posterior peritoneum is performed along the route of the inferior mesenteric vein. The anterior-lateral surface of the aorta is identified. The aorta is carefully dissected from paraaortic nodal tissue and its wall clearly exposed . The dissection continues upwards from the mesenteric inferior artery, in this phase lumbar arteries and the gonadal artery are identified and clipped. The renal vein which crosses over the aorta is retracted, the renal artery identified and carefully dissected up to its origin. The renal artery is secured with a laparoscopic Hem-o-Lok.The renal vein identified, isolated, secured with Hem-o-lock and sectioned. The nephrectomy is completed by dissection of the Gerota’s fascia from the muscle fibres of the diaphragm. The Gerota’s fascia and entire contents are removed using a endobag

Conclusions
This technique permits the surgeon to follow the classic steps and principles of radical nephrectomy, which have driven open surgery techniques for several years. It also ensures ligature of the renal artery and vein for anatomic variations, in the presence of large renal masses and thrombus.

Funding: self-funded