Kidney surgeries were mostly performed in the form of open surgery in previous years. Thanks to the advances in the field of medical devices, most of the surgeries are performed by closed method. Renal surgeries performed with this closed method are generally called “laparoscopic surgery” or “minimally invasive surgery”. In the last 20 years, significant progress has been made in the field of laparoscopic surgery in the field of urology. In the last 20 years, we have been performing almost all of the kidney surgeries with laparoscopic, that is, closed methods. Robotic kidney surgeries can also be counted in the closed kidney surgery group. We will describe the use of robotic surgery in this area in another article. The advantages of laparoscopic surgery over robotic surgery are that it is cheaper and can be performed in many centers. Each method has its own advantages and disadvantages.
In this article, I will give a general information about closed kidney surgery (laparoscopic kidney surgery) using our own experience.
What is laparoscopic kidney surgery?
Closed kidney surgery is also known as laparoscopic or endoscopic kidney surgery. Although laparoscopic and endoscopic surgeries are known as “closed surgeries” among the public, these two are different from each other. In endoscopic surgeries, prostate, bladder, ureter and kidney surgeries are performed by entering through the urethra (external urinary canal) without any incision. In laparoscopic surgeries, the operation is performed by placing trocars (0.5-1 cm wide special plastic or metal surgical hand tools) through very small incisions in the abdomen.
Prostate TUR, HOLEP surgery, urethral stricture, bladder tumor, bladder stones, ureter stones, renal pelvis stones, ureter tumors, renal pelvis tumors and stones in the kidney are operated endoscopically.
In order to be able to perform laparoscopic and endoscopic surgeries, the necessary systemic must be complete. In addition to the medical equipment, trained assistants are also very important for a successful surgery.
Who can have laaparoscopic kidney surgery?
Most kidney diseases are performed laparoscopically. We also perform most of our surgeries laparoscopically.
- Atrophic kidney surgery
- Laparoscopic radical nephrectomy (kidney cancer surgery)
- Laparoscopic partial nephrectomy (removal of only the cancerous part of the cancerous kidney by closed method)
- Laparoscopic kidney cyst surgery (laparoscopic cyst excision)
- Laparoscopic kidney stone surgery
- Laparoscopic pelvic stone surgery 8laparoscopic pyelolithotomy)
- Laparoscopic pyeloplasty (canal stenosis at the kidney outlet, UPJ stenosis)
Preparation before closed kidney surgery
These surgeries are performed under general anesthesia. Since patients will receive general anesthesia, they need to undergo a detailed evaluation. Especially in cancer and elderly patients, examinations for lung and heart diseases are requested. For the purpose of pre-operative preparation;
- If patients are using blood thinners, these drugs should be discontinued at least one week before.
- Patients using chronic medication due to ailments such as heart, blood pressure and diabetes should definitely tell the anesthesiologist about them. These drugs are continued to be used as before.
- Detailed evaluation is made for the lungs and heart of elderly patients.
- Routine blood tests are taken for general anesthesia
- For cancer patients and patients with the possibility of bleeding, blood group determination and appropriate blood should be available beforehand.
- After all preparations are completed, patients should not eat or drink anything by mouth for at least 5-6 hours before surgery.
- After all the preparations are completed, the hospitalized patients read and sign the consent forms related to the surgery. In addition, the team that will perform the surgery informs the patient about the surgery and possible complications and risks.
How long is the operation time, type of anesthesia and hospital stay?
General anesthesia is applied in laparoscopic kidney surgeries, the duration of the operation varies according to the disease. While kidney cyst surgeries take a shorter time, cancer surgeries can take longer, such as 2-3 hours. The hospital stay of the patients after the operation varies according to the operation performed. Patients who have undergone laparoscopic surgery for kidney cysts or atrophic kidneys are discharged the next day, while patients who have undergone radical or partial nephrectomy due to kidney cancer can stay in the hospital for 2-4 days.
How is laparoscopic kidney surgery performed?
Closed or laparoscopic kidney surgery is the operation performed by entering 3-4 holes with a diameter of 0.5-1 cm in the area from the abdomen to the kidney area and viewing the kidney on the monitor. Tension is created by injecting gas into the abdomen with one of the trocars placed in the abdomen through the holes drilled, and the image is projected onto the screen (monitor) by placing an optic from another thorocar. Surgery is performed by placing aspirator, scissors or ligature (laser cutter and cauterizer) from other trocars. Laparoscopic kidney surgeries are as follows;
- Laparoscopic kidney cyst surgery: The cyst is exposed by laparoscopic access, freeing the periphery of the kidney. This surgery is also called “laparoscopic cyst excision” or “laparoscopic cyst decortication” surgery. The cyst is separated from the kidney and removed by cutting with ligature or scissors. Then the cyst fluid is aspirated and a drain is placed and the operation is terminated.
- Laparoscopic atrophic kidney surgery: The periphery of the kidney is freed from neighboring organs by laparoscopic method. The kidney’s arteries and veins are found, tied and cut with special clips, and the kidney is taken out by placing it in a bag. At the end of the operation, a drain is placed in the operation area and the operation is terminated.
- Laparoscopic radical nephrectomy: Similar to atrophic kidney surgery. Here, the kidney and the membrane surrounding the kidney (Gerota’s fascia) and adipose tissue are also removed. If the cancer is in the upper part of the kidney, the adrenal gland is also removed.
- Laparoscopic stone surgery: Stone surgeries are usually performed endoscopically. In some cases, laparoscopic stone surgery can also be performed. If there is a large stone in the renal pelvis or ureter, the stone can be removed laparoscopically (laparoscopic pyelolithotomy) in the appropriate patient.
- Laparoscopic partial nephrectomy: Here, not the entire kidney, only 0.5 cm of normal tissue is removed from the surrounding of the cancer. This is also called nephron-sparing surgery.
What should be considered after closed kidney surgery?
After the operation, patients are taken to their rooms if it is a short operation and there is no problem. Antibiotics and painkillers are given intravenously. Since they receive general anesthesia, patients do not eat or drink orally for 4-5 hours after surgery. Patients’ temperature, pulse and blood pressure are measured at regular intervals. After 4-5 hours, if there is no nausea and vomiting, after the effect of the anesthesia wears off, they take liquid food and start walking slowly. Depending on the size of the surgery and the general condition of the patient, the patients are discharged the next day or stay for another day or two. Patients are discharged by giving pain relief and preventive antibiotic treatment and making necessary recommendations. It is recommended that patients do not work too hard for the first 3-4 weeks, and do not lift heavy.
How is the post-operative follow-up done?
Discharged patients are included in the follow-up program according to the surgery performed and the underlying disease. If an operation was performed due to cancer, the chemotherapy and radiotherapy programs to be applied according to the stage of the disease are explained to the patient in detail. Follow-up programs are given to the patients and they are called for regular controls.
What are the advantages of laparoscopic kidney surgery?
Closed kidney surgery has many advantages over open surgery. For these reasons, laparoscopic surgeries are more preferred. The advantages of laparoscopic surgery over open surgery are;
- The surgical incision is very small
- Wound healing is fast
- Postoperative hospital stay is shorter
- Less pain than open surgery
- Patients return to their daily work earlier
- Bleeding is less
- Since the incision is small, it is more advantageous aesthetically
- Less risk of wound infection
In which cases is laparoscopic kidney surgery not performed?
Laparoscopic (closed) kidney surgeries are not suitable for every patient. In some cases, laparoscopic surgery is not performed and open surgery should be performed. In the following cases, open kidney surgery should be preferred instead of laparoscopic surgery;
- Patients with previous abdominal or kidney surgery
- If there is severe adhesion to the surrounding organs due to previous infection
- If the size of the cancer is very large in patients with kidney cancer
- If there is a risk for laparoscopic surgery
- If there is serious progression (invasion) to surrounding organs and great vessels in kidney cancer patients
What are the complications of laparoscopic kidney surgery?
Complications, albeit rare, may occur in closed kidney surgeries. These common complications are;
- Bleeding: Less than open surgery
- Conversion to open surgery: Sometimes there is a low probability of conversion to open surgery due to bleeding or other reasons.
- Neighboring organ injury: Lliver in right side kidney surgery, spleen injury during left kidney surgery, bowel injury, vena cava and aorta (large veins and arteries in the posterior abdominal wall) injury.
- Postoperative coagulation in large vessels and pulmonary embolism (also seen in open surgeries, but the risk is lower in closed kidney surgeries).
- Anesthesia-related complications: These complications are very rare and not serious.
In summary; Today, laparoscopic (closed) surgeries are widely used in urological surgeries. The most commonly used area of laparoscopy is kidney surgery in urology. Closed kidney surgery has many advantages over open surgery, such as shorter hospital stays, less pain, and earlier start of daily work. For these reasons, closed kidney surgeries are preferred to open surgeries.
Prof. Dr. Emin ÖZBEK
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