Task Analysis for a Laparoscopic Transperitoneal Radical Nephrectomy
TASK ANALYSIS FOR A LAPAROSCOPIC TRANSPERITONEAL RADICAL NEPHRECTOMY
DR. NATHALY GOMEZ CASTANEDA
1. Initially position the patient in supine for the anesthesia steps.
2. Placement of orogastric tube and 18 Fr Foley catheter
3. Position the patient in a modified lateral decubitus position with the umbilicus placed over the break in the operating table.
4. Flexed the table as needed or put a ballon under the patient at the level of the umbilicus
5. Support the buttocks and the dorsum with padding and all the potential pressure points
6. The surgeon is positioned on the abdominal side of the patient, and the first assistant is placed caudally to the surgeon.
7. The laparoscopic cart is positioned at the back of the patient’s chest with the operative team facing the video monitor.
8. The instruments table is positioned behind the operative team.
9. A cutaneous incision is made two finger breadths below the costal margin arch, at the level of the lateral border of the rectus muscle.
10. The Veress needle is introduced through the incision
11. Establish the pneumoperitoneum
12. Remove the Veress needle
13. Introduce an 11-mm trocar through the same incision, perpendicularly to the abdominal wall.
14. Introduce the optics through the trocar
15. Inspect the abdomen for any injury due to insertion of the Veress needle or the trocar, and to identify adhesions in areas where the secondary ports will be placed.
16. Second Port colocation (5 mm) according to the baseball diamond concept
17. Third Port (11 mm)
18. Fourth Port (5 mm) If liver retraction is necessary during a right-side nephrectomy.
19. Colon Mobilization: For a left-side nephrectomy, the plane between the descending colon and the underlying Gerota’s fascia is developed to allow the colon to fall medially This plane of dissection is carried out cranially. The splenorenal and lienocolic ligaments are incised, allowing the spleen and the tail of the pancreas to be separated from the upper pole of the kidney.
20. For a right-side nephrectomy, the liver is cranially retracted using a grasper that is fixed to the abdominal wall. The ascending colon is mobilized and dissected from the underlying Gerota’s fascia. Mobilization of the colon continues caudally to the common iliac vessels.
21. Following the medial mobilization of the colon and mesocolon
22. Visualize the gonadal vessels
23. Inside the Gerota’s fatty tissue at the level of the lower pole of the kidney to locate the psoas muscle The psoas is followed to expose the ureter just lateral and deep to the gonadal vessels.
24. Dissect the ureter and freed it until the crossing of the iliac vessels. Both structures are lifted and, by visualization of the psoas muscle, followed cranially to the lower pole and hilum of the kidney
25. Release the attachments between the psoas muscle and Gerota’s fascia by sharp and blunt dissection,
26. Coagulate the small vessels to the ureter and branches of the gonadal vein with the bipolar grasper.
27. On the left, tracking the course of the left gonadal vein into the renal vein and firm elevation of the lower pole of the kidney on both sides assists in the identification and blunt dissection of the renal hilum.
28. The renal vessels should be individually dissected
29. The renal vein is dissected, taking care of the lumbar veins that drain posterior to the vessel.
30. The left adrenal vein is preserved if the ipsilateral adrenal gland is not removed.
31. The renal artery is exposed posterior to the renal vein and dissected
32. Hem-o-lok. polymer clips are applied to the artery
33. Use three clips on the renal vein
34. Transect the vessels
35. The dissection continues posteriorly and superiorly to the upper pole. The attachments of the kidney to the posterior and lateral abdominal wall are released by blunt and sharp dissection.
36. The ureter is double-clipped with Hem-olock clips and transected to allow the kidney to be fully mobilized.
37. Performe a lower ilioinguinal muscle-splitting incision
38. Introduce a large laparoscopic bag through the small opening of the ilioinguinal incision. The kidney is placed intact inside the bag and the specimen is removed.
39. The abdominal wall is closed using running Vicryl 2-0 for the peritoneum and muscle
40. When the abdominal wall is closed, pneumoperitoneum is re-established and the optic introduced for revision of the hemostasis.
41. Insert a silicone Penrose drain
42. Close the skin incisions with subcuticular Monocryl 3-0.
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