During the last decade, the laparoscopic extraperitoneal approach has been used successfully for various urological procedures [1–3]. When performing a simple nephrectomy, the retroperitoneal space is more than adequate, but its limited dimensions seem to be a drawback for routine radical nephrectomy. Furthermore, if tissue is not morcellated it is also necessary to make an incision of at least 5 cm to retrieve the specimen at the end of the procedure . Therefore, we made the extraperitoneal incision at the beginning of the procedure rather than at the end, and tried to make maximum use of it with the HandPort™ device (Smith & Nephew, Andover, MA, USA). By inserting the surgeon's hand, tissue retraction is improved and controlled blunt dissection of the perirenal fat is facilitated [5,6]. These advantages made the operation easier and less time-consuming, without compromising the integrity of the peritoneal cavity. This procedure is indicated in all patients with renal parenchymal tumours up to 8 cm, who have had no major previous extraperitoneal surgery.
While under general anaesthesia, the patient is placed in a lumbotomy position. A 7 cm incision is made in the continuation of the 12th rib, starting at the tip. The fibres of the three muscle layers are split instead of cut, in an attempt to reduce the surgical trauma and postoperative pain. When the extraperitoneal space is reached, the working space is developed by manually reflecting the peritoneum. It is important at this stage to make sure that the peritoneum is also bluntly dissected alongside the incision, to allow adequate placement of the inner ring of the HandPort device. At this time, after insertion of a surgical towel in the extraperitoneal space, the three trocars can be safely placed, avoiding trauma to the peritoneal sac. One 5-mm port and one 10 mm port are placed in the anterior and posterior axillary line, at the level of the iliac crest. A third port (10 mm) is placed subcostally, in the posterior axillary line (Fig. 1). It is important to have at least 4 cm between the first incision and the trocars, to prevent conflict with the inflated cuff of the HandPort. The ports should also be at least 1 cm cranial of the iliac crest to allow tilting of the trocars during the procedure. The HandPort device is mounted and the pneumoretroperitoneum established with a maximum pressure of 13 mmHg. Both surgeons stand at the rear of the patient, facing the monitor, which is positioned at the ventral side of the patient, at the level of the patient's shoulders. For a left-sided nephrectomy the surgeon standing more caudally holds the camera in the right hand and has the left hand in the HandPort, and vice versa for a right-sided nephrectomy.
The other surgeon holds two laparoscopic instruments and starts dissecting the hilar vessels, approaching them posteriorly. At this stage, the hand can be helpful as a retractor and in helping to identify the vessels and ureter (Fig. 2). Once vascular control is achieved, the hand can be used for blunt dissection of the perirenal fat very rapidly, and adherent structures or vessels can be laparoscopically divided. The kidney is then extracted through the HandPort device (Fig. 3). Finally, the whole extraperitoneal cavity is carefully inspected for bleeding after the blunt dissection.
During a 5-month period (January 2002 to May 2002) we used this technique in five patients (four men and one woman, mean age 66 years, range 56–79). All tumours were preoperatively staged as T1–2N0M0, with a mean (range) diameter of 4.9 (2.8–7.8) cm; the mean operating time (skin incision to closure) was 103 (70–130) min, the postoperative stay 4 (3–5) days, and no narcotic analgesics were needed after the first day. All patients resumed oral intake of food within 1–2 days after surgery. In one patient the operation had to be converted to open surgery because of a tear in a lumbar vein during hand-assisted exposure of the renal pedicle; this was in the only patient with a right-sided tumour. When converting the procedure the hand was helpful in compressing the vein and minimizing blood loss. The pathological report showed negative surgical margins in all patients.
Making this incision (which is needed at the end of a laparoscopic radical nephrectomy) at the start of the procedure allows a faster development of the working space, and provides an excellent retractor for identifying and exposing the renal pedicle [5,6]. Finally, there is an important decrease in the operating time needed to dissect the perirenal fat. Although we initially considered that the retroperitoneal space might be too small for insertion and movement of a hand, experience has shown otherwise. Thus, it is possible to make full use of the HandPort device with no need for an extra incision and still keeping the advantages of a completely extraperitoneal procedure. By making a muscle-splitting incision instead of cutting through the muscle fibres, the postoperative bother from this incision is minimised and comparable with a four-trocar procedure.
The price of the device (E425 in Belgium) is a considerable drawback, especially as there is no reimbursement for it in our country, although using the HandPort reduces expensive operating time. The working space, even though sufficient, remains limited and the static position of the hand can cause some discomfort to the surgeon when holding the same position for several minutes ; it is possible to injure the inserted hand when cutting, coagulating or when placing a trocar without removing the hand.
In conclusion, the completely extraperitoneal use of a hand-assistance device for radical nephrectomy is feasible and fast, and offers significant advantages both for the patient and the surgeon.