Left Nephrectomy Davidoff-Mansfield

Hello. This video will show a left radical nephrectomy and lymph node sampling in a five year old girl who presented with a large abdominal mass that on imaging appeared to be a localized left renal tumor, likely a Wilms tumor, as up front resection was indicated in an effort to minimize adjuvant therapy, after completion of a radiographic workup, the patient was taken to the operating room. After placement of subcutaneous infusport, the patient was repositioned with a small bump under the ipsilateral flank. My preferred incision is a bilateral subcostal incision, although others may use a midline incision or for very large tumors, a thoraco abdominal incision. The abdomen has now been opened, and the large tumor can be seen through the colon mesentery. The colon and mesentery are being separated from the surface of the kidney tumor, with care being taken not to violate the surface of the tumor and also not to make a hole in the colon mesentery, although a small mesenteric defect can easily be closed. Most of the initial dissection and tumor mobilization is performed laterally with the tumor separated from the inside of the lateral abdominal wall. I prefer this order of approach rather than starting medially to control the vessels early on, since occasionally the wrong vessels may be divided. Particularly with larger tumors, this dissection continues from the lateral aspect of the mass to the posterior surface. These planes are generally avascular, with only small vessels being present which can be controlled easily. Now the superior margin of the tumor is being defined. You can see the pancreas being separated from the upper aspect of the kidney tumor. This is a good illustration of how even large Wilms tumors typically only push away adjacent organs but rarely invade them. Occasionally, control of larger vessels requires ties. Clips Or as shown here. The ligature. Now attention is turned to the medial dissection. You can see the large left renal vein coming into view, as well as the flattened adrenal gland on the superromial surface of the kidney. The adrenal gland does not always need to be taken with the nephrectomy specimen if it appears to be uninvolved with tumor, but in this case, the decision was made to remove the ipsilateral adrenal in continuity with the tumor and kidney. Now dissection around the large left renal vein is being performed medial to the takeoff of the left adrenal vein prior to dividing the. Left renal vein. And despite preoperative imaging that doesn't identify an intravascular tumor thrombus, the vein should be palpated to be sure that no tumor exists within the vein. Once absence of thrombus can be confirmed, an endoscopic GIA stapler is used to control and divide the vein. Of course, it can be taken with sutures or clips as per the operating surgeon's preference. Although some surgeons prefer to take the artery first to avoid congestion of the kidney and tumor, I have not found this to be a concern since the two vessels can be taken in rapid succession. Additionally, the artery which generally courses behind the vein is easier to access once the vein has been divided. By saving vessel ligation until the end of the dissection and mobilization of the kidney tumor, there is greater reassurance that they are the correct vessels to take. The ureter is tied off distally with silk sutures. Clips can also be used. The timing of the division of the ureter during the conduct of the operation is not critical. Finally, the remaining medial attachments. Of the kidney are divided. Small vessels are controlled with cautery in the ligature. And a very large renal tumor is separated and removed intact. This particular tumor weighed almost 2000 g. Lastly, periaortic lymph nodes are sampled to ensure appropriate staging of the patient regardless of whether they appear to be pathologically involved or not. Clips are used to prevent postoperative lymph leaks. The bed is inspected for hemostasis and the abdomen is closed in layers.