14.1. Operating Room Setup and Patient Positioning for
Laparoscopic Adrenalectomy and Donor Nephrectomy
Michael Edye, M.D., F.R.A.C.S., F.A.C.S.
A. Introductory Concepts
A. Both the adrenal gland and kidney can be approached transperitoneally or retroperitoneally. Retroperitoneal access is often used by surgeons with a background in urology or past experience with the lumbar approach to the adrenal gland. The prone position is used for the laparoscopic posterior approach to the adrenal. Positioning for the more common transperitoneal access is described in this chapter, with reference to the special needs of laparoscopy.
B. Patient positioning and OR setup are essential components for tech- nical success because they ensure a stable and reproducible operative environment, which eliminates surprises.
C. For each procedure, accurate identification and dissection of one key structure facilitates rapid exposure of the target to be removed and suc- cessful completion of the procedure:
1. Right adrenal: the lateral aspect of the vena cava 2. Right kidney: the right renal vein
3. Left adrenal: the left renal vein
4. Left kidney: the left renal artery (or arteries)
D. As a rule, the laparoscope port should be sited so as to best visualize the key structure. From the list above, it is apparent that the patient position for transabdominal nephrectomy and adrenalectomy should be the same; however, some port positions and the location of the extraction site will vary depending on the target organ.
B. Operating Room Setup for Transabdominal Approach
A. The patient is placed in the lateral decubitus position (see positioning section below).
B. One surgeon and one assistant perform these procedures. In the transperitoneal approach, both surgeon and assistant stand facing the patient’s abdomen, watching a monitor placed on the far side of the patient behind the patient’s back (Figure 14.1.1).
C. The second monitor is placed on the surgeon’s side of the table, behind the operative team. If the scrub nurse stands opposite the surgeons, on the far side of the table, she will be able to view the operation via this monitor (see Figure 14.1.1).
D. During procedures such as nephrectomy that require exposure, liga- tion, and division of large vessels, a scalpel with a large blade for rapid
Figure 14.1.1. Operating room set up for left adrenalectomy or nephrectomy with patient in left lateral decubitus position.
laparotomy should be on the table and available at all times. Vascular instruments, self-retaining retractors, and other equipment necessary for a laparotomy should also be available in the room.
E. The kidney rest should be lowered or table flexion reduced, or both, before closing any muscle incisions, especially if it has been neces- sary to convert to an open procedure.
C. Transabdominal Approach: Patient Positioning
A. Lateral decubitus position: This is the recommended patient position.
The full lateral decubitus position allows the mobile viscera (trans- verse colon, small intestine) to fall toward the midline, thus exposing the retroperitoneum. Other fixed organs such as spleen and colon will follow suit as they are freed from their attachments.
B. Extraction site: The extraction site should be planned in advance. Mark the proposed incision with an indelible pen after induction of anes- thesia, while the patient is still supine. Once the patient is rolled into the decubitus position it is impossible to judge the midline and skin creases with accuracy; if the incision is chosen in this position, asym- metric and unsightly scars will often result. There are several possible incision locations through which a bulky structure such as the kidney can be removed.
i. A Pfannenstiel transverse suprapubic incision is one option; the incision length is determined by the narrowest dimension of the kidney. The aponeurosis is incised transversely, after which a vertical incision is made between the rectus muscles, which are retracted laterally. This approach minimizes the trauma to the musculature such that, in many cases, little or no analgesic is required in the postoperative period.
ii. A short (2-cm) muscle-splitting flank incision over the lateral border of the rectus is also well tolerated and gives ample room for removal of a small adrenal mass.
iii. When hand-assisted methods are used, the kidney is usually extracted through the hand incision.
C. Conversion incision (contingency): Anticipate the need for a prompt conversion and plan accordingly before starting the case. The routine use of a kidney rest together with table flexion facilitates exposure should it be necessary to open the patient. A subcostal incision 3 cm from the costal margin can be made rapidly if the patient is properly positioned and provides good access to the vascular pedicle and the upper abdomen. It is wise to choose and mark the location of the con- version incision while the patient is supine.
D. Necessary operating table and positioning equipment: The following items should be available when performing these cases.
1. Operating table that will flex in the middle, centered on a kidney rest
2. Cushion to separate the legs
3. Broad cloth tape (4 inches/10 cm wide, nonelastic)
4. Arm board and arm support
5. Axillary roll (I.V. fluid bag, molded silicone gel, or equivalent) 6. A bean bag for holding the patient
7. Pads to cover and protect bony prominences E. Positioning the patient: sequence of events.
1. Before turning the patient:
a. Antithromboembolic leggings are fitted and activated.
b. The patient is anesthetized and a urinary catheter inserted.
c. The endotracheal tube is securely fastened to the patient’s face. At all times great care is taken to ensure that the endotra- cheal tube remains intact, especially during position changes.
d. The extraction site incision and the conversion incisions are clearly marked before repositioning.
e. An assistant is delegated to hold the upper arm during the repositioning of the patient.
2. Turning and positioning the patient
a. A bean bag is placed on the table directly under the patient’s trunk.
b. The patient is next placed in the lateral decubitus position such that the side to be operated on is uppermost (see Figure 14.1.1). The patient’s flank should be centered over the kidney rest. Once in position, the kidney rest is elevated. If a kidney rest is not available, a large bag of fluid should be placed under the flank.
c. The bean bag, after being molded to the patient’s body contour, is next suctioned, thus helping to secure the body position.
d. The dependent limb is flexed at the knee and thigh while the upper leg is kept straight. The legs are separated by a cushion.
e. The patient’s abdomen should be close to the edge of the operating table (the reverse of the position used for conven- tional nephrectomy).
f. An axillary roll is placed under the dependent axilla, which elevates the axillary contents. This should prevent compres- sion of the brachial plexus.
g. The table is placed in slight Trendelenburg position and then flexed at its center. A table flexion angle of 30° should be adequate (Figure 14.1.2).
h. The head must be supported from below to keep the cervi- cal and thoracic spines roughly axial without lateral flexion.
F. Securing the patient in position.
1. Lower body:
i. While the patient’s back is maintained at right angles to the mattress, the lower trunk is securely but NOT tightly taped to the table. Broad adhesive cloth tape is recommended. The tape is attached to the table below the level of the hips (toward the feet) and is then run obliquely over the greater trochanter of the hip (yet below the pubis) before being attached to the opposite side of the table below hip level.
ii. When taped in this manner, access for a Pfannenstiel inci- sion is preserved.
iii. This fixation prevents side-to-side displacement of the trunk.
Care should be taken to ensure that the urinary catheter tubing is free of kinks and that it runs via gravity drainage to a reservoir at the anesthetist’s end of the table.
2. Upper body:
i. Bean bag as described above.
ii. The lower arm lies on an arm board and is flexed at the shoul- der and elbow so the hand is roughly level with the face.
iii. The upper arm is supported on a stack of padding with about 90° of shoulder flexion. This will prevent the patient’s arm from limiting the surgeon’s access to the uppermost abdom- inal port.
iv. The upper trunk is fixed in position with cloth tape that extends from the far end of armboard, over the upper shoul- der, to the table on the opposite side.
v. Note that although the patient should not be tightly taped, it is important that the adhesive should be in contact with the arm, shoulder, and trunk, unless the skin is in poor condi- tion (as in renal failure, Cushing’s syndrome, or the elderly) to prevent movement of the patient under the strapping.
Removal of the tape at the case’s end should be done gently.
A solvent should be used to soften the adhesive in patients whose skin is in poor condition.
Figure 14.1.2. Lateral view of patient in lateral decubitus position with table flexed.
