2.3 Hand-Assisted Laparoscopic Nephrectomy

Contents

Introduction 39 Indications 40 Contraindications 40 Techniques 41

Hand-Assisted Laparoscopy Devices 41 Compressive Base 41

Adhesive Base 41

Technique: Placement of Ports and Hand-Assisted Device (Hand-Port System) 41

Results: Comparison with Other Techniques 42 Simple Nephrectomy 42

Radical Nephrectomy 42 Nephroureterectomy 43 Live-Donor Nephrectomy 43 Partial Nephrectomy 44 Complications 44

Future Horizons 45 Conclusion 45 References 45

Introduction

Since the first procedure by Clayman and associates in 1990, laparoscopic nephrectomy is becoming the gold standard for kidney removal [1]. The technical difficulty of laparoscopic nephrectomy is a major fac- tor preventing its widespread dissemination.

Tschada et al. in 1995 [2] and Winfield et al. in 1996 [3] described the insertion ofthe gloved finger into the laparoscopic operative field to assist an other- wise purely laparoscopic procedure; Cuschieri and Shapiro, in 1995, reported a pneumoperitoneum access bubble to allow the hand into the abdomen for dissec- tion and organ removal [4], and in 1994 Tierney et al.

reported hand assistance for splenectomy and colec- tomy and nephrectomy [5].

Leakage ofCO

and spraying ofblood limited the usefulness of (hand-assisted laparoscopy (HAL), but in 1996 the first hand-assisted laparoscopic port was

approved by the Food and Drug Administration for use in the United States and since has been used ex- tensively [6].

Hand-assisted laparoscopic surgery bridges the gap between open and laparoscopic surgery. As has been said by Dr. R.V. Clayman, ªone hand is worth a thou- sand trocarsª (Ramon Guiteras Lecture, American Urologic Association Annual Convention 2000). It in- volves inserting the surgeon's hand into the insufflated abdomen. Hand-assisted laparoscopy is clearly advan- tageous for those laparoscopic procedures that require removal ofa relatively large amount oftissue intact, which would otherwise necessitate an extended trocar incision.

Hand-assisted laparoscopic surgery has many theo- retical advantages. These may benefit the surgeon, but may also have a positive clinical impact for patients.

In addition, through improved control ofcomplica- tions, reduced operative time and technical simplifica- tion in comparison with standard laparoscopy, the hand-assisted procedure has economic advantages.

Ifan incision is needed to remove a specimen at the end ofa laparoscopic procedure, then it is advan- tageous to make the incision at the start ofthe proce- dure, through which the hand may be inserted in or- der to facilitate surgery [7, 8]. Also, hand-assisted lap- aroscopic surgery returns the tactile sensations lost to the surgeon in laparoscopic surgery. The use ofpalpa- tion allows the surgeon to locate pathology that is not immediately visible and to identify structures such as blood vessels and ureters [9]. A further advantage is that, whereas three-dimensional perception is lost using standard laparoscopy, having a hand inside the body assists the surgeon in locating structures and di- recting instruments in three-dimensional space.

The ability to dissect tissues bluntly is restored using hand-assisted laparoscopic surgery. This allows natural tissue planes to be separated and adherent tis- sues to be safely divided. In addition, hand-assisted

2.3 Hand-Assisted

Laparoscopic Nephrectomy

Franœois Rozet, Declan Cahill,

Franœois Desgrandchamps

laparoscopic surgery permits safe retraction of large organs such as the spleen, esophagus, liver and intes- tines. These organs are difficult to handle using stan- dard laparoscopic instruments, and are easily dam- aged. Furthermore, in the hand-assisted procedure, the surgeon's hand works in conjunction with laparo- scopic instruments during suturing, clip application and stapler positioning. Clip security is easily verified and presentation oftissue to staplers is greatly en- hanced. With regard to perioperative infection, hand- assisted laparoscopic devices cover the wound, and protect it from contamination during specimen re- moval [10].

Hand-assisted laparoscopic surgery gives surgeons the added confidence they need while learning ad- vanced laparoscopic procedures. Urologists with mini- mal laparoscopic experience can perform difficult pro- cedures, such as laparoscopic radical nephrectomy, safely and efficiently [10, 11]. In addition, hand-as- sisted laparoscopy allows the surgeon to control situa- tions that might otherwise require conversion to open surgery (e.g., excessive bleeding). Hand-assisted access can also be used as an intermediate step, rather than converting from laparoscopy-assisted to open surgery.

Hand-assisted laparoscopic surgery procedures typi- cally require fewer ports and instruments than do cor- responding laparoscopic-assisted procedures. Further advantages ofhaving the surgeon's hand in the abdo- men include tactile feedback, the ability to palpate, blunt dissection, organ retraction, control ofbleeding and rapid organ removal. These advantages render the laparoscopy technically simpler, with resultant shorter operative time [6, 12, 13].

The improved efficiency of hand-assisted laparo- scopic surgery over standard laparoscopy results in decreased operative times. Most major laparoscopic procedures can be reduced by up to 1 h or more, de- pending on their complexity.

Clinical trials indicate that hand-assisted laparo- scopic surgery outcomes (e.g., patient pain, return to normal activity, time ofsurgery and duration ofileus) are equal to or better than those with laparoscopic surgery. The postoperative advantages oflaparoscopy in reducing morbidity and hastening convalescence are not sacrificed. Studies comparing patient postop- erative discomfort after laparoscopic and hand-as- sisted laparoscopic procedures have not identified a significant difference [13, 14], although long-term convalescence has been shown to be 1±3 weeks longer [15].

With regard to cosmetic appearance following the procedure, hand-assisted laparoscopic surgery inci- sions are much smaller than those used with standard open surgery, and are closer to those employed in standard laparoscopy than one might imagine. For ex- ample, because the PneumoSleeve (Dexterity Inc., Atlanta, GA, USA) the incision is made on the insuf- flated abdomen (see ªTechnique: Placement of Ports and Hand-Assisted Device (Hand-Port System)º), the average 7-cm incision measures only 5.5 cm postoper- atively [12]. Furthermore, hand-assisted surgery typi- cally requires fewer ports than do laparoscopy-assisted procedures. Finally, the use offewer ports and a mus- cle-splitting incision may result in reduced pain for the patient [16].

Indications

n Simple nephrectomy n Live-donor nephrectomy n Radical nephrectomy n Nephroureterectomy n Adrenalectomy (large)

HAL is indicated for simple and radical nephrectomy, and nephroureterectomy where the surgical specimens are large and so the use ofa hand port incision does not disadvantage the benefits of reduced wound mor- bidity in laparoscopy. Regardless ofspecimen size, where the use ofHAL discourages open nephrectomy in favor of the laparoscopic approach it is to be en- couraged.

Theoretically HAL is counterintuitive for partial ne- phrectomy as the specimen is small, not requiring an extended incision for retrieval. However, a significant advantage is that HAL may avoid the need to clamp the renal hilar vessels by allowing simple manual po- lar compression for hemostasis [17].

Contraindications

n Lack oftraining n Small workspace

n Small or benign specimen

HAL is an adjunct to laparoscopy or may facilitate its

uptake. It is not a means to bypass laparoscopic train-

ing.

We do not recommend HAL in young children and during retroperitoneoscopy, as the hand takes up too much space, complicating exposure. Small atrophic kidneys or nonfunctioning kidneys of other etiologies are suitable for morcellation and therefore better per- formed by pure laparoscopy, although in the presence ofchronic inflammation or prior surgical procedures, such as xanthogranulomatous pyelonephritis or auto- somal dominant polycystic kidney disease, may com- plicate a pure laparoscopic procedure.

Techniques

Hand-Assisted Laparoscopy Devices

Hand-assisted laparoscopy devices [13] facilitate intra- abdominal placement ofthe hand during laparoscopy.

To date, various devices are available for hand-assisted access during laparoscopy. Each ofthem has advan- tages and disadvantages. There are currently four de- vices available: the PneumoSleeve, the Hand-port (Smith and Nephew, Andover, MA, USA), the Intromit (Applied Medical, Rancho, Santa Margarita, CA, USA) and the Lap Disk (Hakko Shoji, Tokyo, Japan). The base adapted to the abdominal wall can be either adhesive (PneumoSleeve, Intromit) or compressive (Hand-port, LapDisk).

All the devices are effective and selection depends on surgeon preference, location of hand incision, body habitus and the past surgical history ofthe patient.

Compressive Base

The Hand-port system is composed ofa base that is adapted to the abdominal wall and a sleeve that covers the surgeon's arm. The Hand-port can be installed at the beginning ofthe procedure, and before or after in- sufflation, as described by Wolf et al. [13]. The pri- mary advantage ofinserting the system before insuf- flation is that all trocars may be introduced under di- rect vision, which may help to reduce potential vascu- lar or visceral injuries [14, 18]. The default of such a system is that the base may be ejected during the pro- cedure [16]. In our experience, the base is easy to re- insert.

The LapDisc [18] system has no plastic sleeve that attaches the surgeon's wrist to the device. A three- layer silicone valve connected by a rubber membrane, which covers the peritoneum and abdominal wall, forms the mechanical occlusion.

Adhesive Base

The PneumoSleeve and the Intromit devices require clean and dry skin before positioning. When the ab- domen is fully insufflated, the adhesive base is placed in its final position.

Devices that require adherence to the abdominal wall may loosen during the procedure, and may in- duce leakage ofthe pneumoperitoneal gas and loss of intra-abdominal pressure. Some authors [19, 20] have described the use ofMastisol (surgical adhesive; Fern- dale Laboratories Inc., Ferndale, MI, USA) or benzoin to produce a stickier abdominal surface, thus permit- ting more secure placement ofthe hand-assisted de- vice [19]. It is also possible to seal the interior ofthe abdominal wall template with a patch ofTegaderm (Johnson & Johnson Inc., Arlington, TX, USA) in or- der to reduce escape ofintra-abdominal fluid and gas between the adhesive ring and the skin. An alternative solution to reduce the incidence ofair leak is applica- tion ofa large Steri-Drape (3-M Health Care, St Paul, MN, USA) to the abdominal wall at the start ofthe surgical procedure [21].

Technique: Placement of Ports and Hand-Assisted Device (Hand-Port System)

Under general anesthesia, the patient is placed on a flexed table in a full flank position as per open and stan- dard laparoscopic nephrectomy, prepared and draped in the normal way. A mid-line incision above the umbili- cus is made, in length equal to the surgeon's glove size (6.5±8.5 cm). The peritoneum is then entered, the hand- port device is inserted (Fig. 1) and the surgeon's nondo- minant wrist is inserted into the abdominal cavity. Port sites are placed 2±3 cm around the area ofthe base. A 10-mm trocar is introduced under finger control. This first trocar is placed at the level of the mid-axillary line where the laparoscope will be placed, and the pneumo- peritoneum is created. Two additional trocars (5±

12 mm in diameter) are inserted under direct vision, one above the iliac crest and the other under just below the costal margin at the level ofthe mid-axillary line.

Those two trocars are used as operative trocars for

the placement ofscissors, stapler and clip applier. A

fourth trocar may be placed during the procedure to in-

sert a laparoscopic liver retractor. The kidney is then

approached as previously described for simple or radi-

cal nephrectomy (Fig. 2) [9, 20, 22].

Results: Comparison with Other Techniques Hand-assisted laparoscopic nephrectomy must be compared with other surgical approaches, including open surgery and pure laparoscopy.

Simple nephrectomy is usually done using standard transabdominal or retroperitoneal laparoscopy. Chronic inflammation or prior surgical procedures may lead to hilar and perinephric fibrosis, resulting in technical dif- ficulties. In these cases, hand-assisted laparoscopic sur- gery may be useful in performing simple nephrectomy.

Hand-assisted laparoscopic surgery has also simplified the management oflarger renal tumors while maintain- ing the benefits of a minimally invasive procedure. La- paroscopic radical nephrectomy specimens can be re- moved intact and without morcellation [7, 13, 20, 23].

Simple Nephrectomy

Various surgical approaches have been reported for simple nephrectomy. Laparoscopic procedures may be performed by either retroperitoneal or transperitoneal approach. Compared with open surgery, patients un- dergoing standard laparoscopic nephrectomy have less pain, shorter duration ofhospital stay and faster re- sumption ofnormal activities [20].

Wolfet al. [13] compared hand-assisted with stan- dard laparoscopic nephrectomy; morcellation was used for kidney removal. These investigators reported a shorter operative time and fewer complications for the hand-assisted group, and no significant differences in analgesic use, time to oral intake, duration ofhospital stay and time to full recovery, as compared with the laparoscopic group.

However, pure laparoscopy is preferred for simple nephrectomy as the specimen is suitable for morcella- tion, i.e., extraction without port-site extension, and often the extraperitoneal route is preferred, which is less suited to HAL.

Radical Nephrectomy

When compared to the hand-assisted laparoscopic approach, open radical nephrectomy has been shown to give an advantage in terms ofoperative time [22]

(Table 1). However, Stifelman et al. [17] noted an op- erative time of3.3 h among 74 patients undergoing a hand-assisted laparoscopic nephrectomy, versus 3.3 h for 20 patients undergoing an open nephrectomy.

There was reduced blood loss, analgesic requirement and length ofstay in the HAL group. Cleveland clinic Fig. 1. Right nephrectomy. The base of the hand-assisted

device (Hand-Port) is placed and the surgeon inserts his handinto the abdominal cavity

Fig. 2. Exposing the right kidney

data [24], (n=100), show a modest advantage for pure laparoscopy.

Nakada et al. [23], comparing hand-assisted and open laparoscopic radical nephrectomy, demonstrated that the hand-assisted laparoscopic technique is a safe, effective and minimally invasive option for treating re- nal cell carcinoma. Operative times with hand-assisted laparoscopic nephrectomy were significantly longer than those with open nephrectomy, but the hand-as- sisted laparoscopic nephrectomy patients had a short- er duration ofhospital stay, an earlier return to work and to a complete recovery [22].

Batler et al. [10] retrospectively compared their ex- periences with 24 initial hand-assisted and retroperi- toneal laparoscopic nephrectomies. All but one of those procedures were radical laparoscopic nephrec- tomies. Their data revealed no significant differences in operative time, estimated blood loss, narcotic usage, hours to oral intake, duration ofhospital stay, or activity level at 2 weeks after the procedures. The same team previously reported on ªthe experience of the inexperiencedº [25]. In that study, novice laparo- scopic surgeons performed the first six hand-assisted laparoscopic nephrectomies. Because halfofthe hand- assisted procedures were performed by young and in- experienced surgeons, it is difficult to draw meaning- ful comparisons of operative times [22]. A random- ized prospective study comparing these techniques performed by the same surgeons would provide us with more accurate answers.

Nephroureterectomy

Stifelman et al. [17] have shown superior results for HAL versus open and pure laparoscopic nephroureter- ectomy. Most notable in their series is the time saving ofmore than 3 h in the HAL nephroureterectomy se- ries compared with the pure laparoscopic series. The Cleveland clinic data [26] demonstrate a superior pure laparoscopic experience in terms ofoperative time and length ofstay, although a particularly long conva- lescence time of8 weeks (Table 2).

Live-Donor Nephrectomy

In terms oflive-donor nephrectomy, the results are again similar between the pure laparoscopic and HAL, with recovery advantages for both over open surgery [17, 37, 38, 42]. However, allograft function is another factor of utmost importance that needs to be consider- ed. Stifelman et al. [27] showed similar allograft func- tion between open and HAL live-donor nephrectomy.

Comparing pure laparoscopic and open live donor ne- phrectomies. Noguiera et al. [38] reports higher nadir creatinine in laparoscopic cases. This phenomenon has not been seen with the HAL technique (Table 3).

Others have confirmed shorter operating times and warm ischemia time in HAL donor nephrectomy [43]

but no functional difference in the transplanted graft at 1 year [43, 44].

Fabrizio et al. [41] have stated that since introduc- ing HAL live donor nephrectomy to John Hopkins In- Table 1. Comparison of HAL, pure laparoscopy andopen

surgery in radical nephrectomy Procedure Operative

time (hours)

Blood loss (cc)

Duration of stay (days)

Convales- cence (weeks) Stifelman [17]

HAL (n= 74) 3.3 131 3.7 <4

Open (n=11) 3.3 372 5.2 ±

Wolf [36]

HAL (n= 18) 205 194 ± ±

Pure laparos-

copy (n= 15) 280 304 ± ±

Gill [26]

Pure laparos-

copy (n= 100) 2.8 212 1.6 4

Table 2. Comparison of HAL, pure laparoscopy andopen surgery in nephroureterectomy

Procedure Operative time (hours)

Blood loss (cc)

Duration of stay (days)

Convales- cence (weeks) Stifelman [17]

HAL (n= 22) 4.5 180 4.1 2.7

Laparoscopy

(n=25) 7.7 199 6.1 2.8

Open (n=11) 3.9 311 6.3 >6

Gill [26]

Pure laparos-

copy 3.9 242 2.3 8

(n=42) Landman [15]

HAL (n= 16) 4.9 201 4.5 8

Pure laparos-

copy (n= 11) 6.1 190 3.3 5.2

stitution in Baltimore, Maryland, the number oflive- donor renal transplantations has increased by 100%.

Partial Nephrectomy

Hand-assisted laparoscopic partial nephrectomy is fea- sible and reproducible [28, 37]. The surgeon's hand in the operative field facilitates dissection, vascular con- trol, hemostasis and suturing [28]. It is less ideal an indication than whole-specimen nephrectomy, as small specimen size negates the need for a large incision.

The surgeon's hand may be used for manual compres- sion ofpolar tumors, negating the need for hilar ves- sel clamping and whole kidney ischemia. In experi- enced hands, the Cleveland Clinic data [29] shows that similar results may be achieved without hand assis- tance and the resultant wound, as large specimen re- trieval is unnecessary (Table 4).

Complications

There is a learning curve to hand-assisted laparo- scopy. In a 1999, the Southern Surgeon's Club study [30], in which 27 highly skilled laparoscopic surgeons from 16 states across the United States evaluated hand-assisted laparoscopy, recommended its use ªonly for experts in laparoscopic surgery and for procedures that are either too complex or take too long to be managed by pure laparoscopic surgery.ª

Hand-assisted laparoscopic surgery has some inher- ent disadvantages: PneumoSleeve device malfunction 53% (including device replacement in 14%) [30]. The de- vices can be unwieldy and they leak gas frequently. On small abdomens, the space that they occupy may inter- fere with port placement. The cosmesis of the incisions for the HAL device is less favorable than it is for laparo- scopic ports. For the true minimalist, undertaking pure laparoscopy, the specimen may be retrieved via a Pfan- nenstiel incision in the male or transvaginally in the fe- male [31]. Convalescence may be prolonged by the long- er incision. Although both Wolfet al. [32] and Slakey et al. [33] found that hand-assistance did not alter conva- lescence significantly compared with that after standard laparoscopy, there is likely a small degree ofincreased postoperative pain and duration ofconvalescence for hand-assisted vs standard laparoscopic procedures.

Open conversion (22%) [30], device air leak (25%), and postoperative complication rate (26%) [22] are also factors to consider. Importantly, intra-abdominal hand fatigue, ranging from mild fatigue to severe cramping, was noted in an additional 21% ofcases [34, 35].

Okeke et al. 2002 [35] reported complications re- lated to hand ports in three of13 cases. There were two severe hand port wound infections and one inci- sional hernia. One patient required conversion to open surgery due to irresolvable air leakage around the port. In one patient, the tumor ruptured during ex- traction. Although no local recurrence has been iden- tified 21 months postoperatively, this calls into ques- tion whether or not it is safe to remove tumors with- out some form of sack. This group has abandoned hand-assisted techniques for upper tract malignancy.

The additional cost ofthe hand-assistance device is often cited as a disadvantage of the technique. Its sup- porters cite that the cost is recouped by the reduction in operating room time and other supply cost savings when HAL is used, such as the requirement for fewer ports and in the case oflive-donor nephrectomy, no entrapment sack [36].

Table 3. Comparison of HAL, pure laparoscopy andopen surgery in live-donor nephrectomy

Procedure Operative time (hours)

Blood loss (cc)

Duration of stay (days)

Convales- cence (weeks) Stifelman [17, 42]

HAL (n=60) 4 83 3.7 4

Open (n=30) 4.4 364 4.5 9.2

Laparoscopy

(n=100) 3.9 266 3 4

Wolf [37]

HAL (n=10) 3.6 103 1.8 ±

Ratner [38]

Pure laparos-

copy (n=175) 3.9 260 3 4

Table 4. Comparison of HAL, pure laparoscopy andopen surgery in partial nephrectomy

Procedure Operative time (hours)

Blood loss (cc)

Duration of stay (days)

Convales- cence (weeks) Wolf [37]

HAL (n=10) 3.3 460 2 ±

Stifelman [28]

HAL (n=11) 4.6 319 3.3 ±

Gill [29]

Pure laparos-

copy (n= 50) 3 270 2.2 ±

Future Horizons

HAL nephrectomy clearly has a future for those over- whelmed by the skill level ofpure laparoscopy when starting a service. By acting as a bridge between open surgery and laparoscopy, it may bring laparoscopy into the armamentarium ofsurgeons who would otherwise continue to perform open surgery in situa- tions where it is essentially becoming contraindicated.

It is likely to hold a position for transperitoneal to- tal nephrectomy where a similarly sized incision would otherwise be made at the end ofa pure laparo- scopic procedure, and for the same reason it is unlike- ly to become the procedure ofchoice for partial ne- phrectomy that does not require significant incision extension for specimen retrieval. Simple nephrectomy is probably best performed retroperitoneally, which is less suited to HAL, unless the specimen is very in- flamed or large when transperitoneal nephrectomy may be preferred.

Conclusion

Hand-assisted laparoscopic surgery is a promising technique, has clear advantages to open surgery, is comparable to pure laparoscopy and may further the indications for laparoscopy. It is well tolerated and ef- fective in nephrectomy. Logical indications for its ap- plication include those laparoscopic cases that require removal ofa large amount oftissue intact and as a bridge between open and laparoscopic alternatives.

Moreover, with regard to efficacy and safety, hand-as- sisted laparoscopic surgery may also find application in technically difficult situations [25].

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3 Renal Cell Carcinoma II