NEPHRECTOMY

IT IS DEFINE AS REMOVAL OF KIDNEY
A nephrectomy is the surgical removal of a kidney, the organ that filters waste from the blood and produces urine. There are two

kidneys, right and left. Each is about 4 inches to 5 inches long.
They are located at the back of the abdomen, just below the diaphragm, behind the liver on the right, and the spleen on the left.
A portion of each kidney is protected by the lowest one or two ribs and by the muscles that cover the back and side of the body




Depending on the reason for a nephrectomy, all or part of one kidney or both kidneys will be removed:

1. SIMPLE NEPHRECTOMY
2. SUB CAPSULAR
3. RADICAL NEPHRECTOMY

1. SIMPLE NEPHRECTOMY:
It involves removal of the kidney and the upper ureter without removing the perinephric fat or gerota’s fascia.

2. SUB CAPSULAR:
It is not a preoperatively planned approach to nephrectomy, but rather an expedient way to complete a nephrectomy when one encounters marked

fibrosis involving the perinephric fat and the renal capsule.

3. RADICAL NEPHRECTOMY:
By definition is the removal of the kidney, the perinephric fat overlying gerota’s fascia the lymph nodes around the area also removed. The

prime condition of this type of nephrectomy is Adenocarcinoma.

A nephrectomy may be used to remove a kidney for the following reasons:
• The kidney has a cancerous (malignant) tumor. This usually requires a radical nephrectomy.
• The kidney has been damaged by infection, kidney stones, anruction of urine outflow or cysts.
• The patient has severe high blood pressure (hypertension) caused by renal artery stenosis. In this condition, a diseased artery results in damage to

one kidney. Nephrectomy usually does not cure the high blood pressure in this illness, but it can make control of blood pressure more manageable.
• Severe trauma, such as an automobile accident, has damaged the kidney beyond repair
• A living donor has agreed to donate one kidney for transplantation
• A transplanted kidney has been rejected by the recipient's body and is not functioning. This is called an allograft nephrectomy and is different

surgically from removing the patient's own kidney.

PREPARATION:
About one week before surgery, you will need to stop taking aspirin and other blood-thinning medications. Beginning at midnight on the

night before surgery, you must not eat or drink anything. This reduces the risk of vomiting during surgery. As part of the general preparations for surgery,

your doctor will review your allergies and medical and surgical histories. If you are a woman, and there is any chance that you might be pregnant, you must

tell your doctor before surgery.
SIMPLE NEPHRECTOMY
Principles and Justification:
INDICATION:
Nephrectomy is indicated in the followed cases:
1. Non functioning kidney secondary to pyelonephritis, vascular lesion (eg: post traumatic), glomerulonephritis or acquired cystic disease.
2. Non functioning dysplastic kidney (congenital)
3. Sclerotic kidney in renal hypertension
4. Non functioning kidney in calculous disease
5. Hydronephrosis (congenital or acquired) with loss of function and parenchymal atrophy.
6. Pyonephrosis
7. Xanthogranulomatus pyelonephritis
8. Non functioning kidney in renal tuberculosis.

CONTRAINDICATION: Contraindication for this procedure include

poor general condition, coagulation disorders or severe cardiorespiratory disease.





PRE OPERATIVE PREPARATION:
1. Overall and differentiated renal function must be assessed by creatinine clearance estimation and isotope renography.
2. Any urinary tract infection must be treated .
3. If tuberculosis is suspected or verified, anti tuberculos treatment is essential for both before and during the procedure.
4. Generally the patient have stable cardio circulatory function, perioperative and postoperative elastic support of the legs should be provided,

and all blood clot ting parameters should be normal (caution is advised in patients on anticoagulant theraphy).
5. Cross matched blood must be available during the operation, and low dose heparin prophylaxis is advisable.

ANAESTHESIA:
GENERAL ANAESTHESIA+EPIDURAL ANAESTHESIA

POSITION:
1. The lateral position is usually the position of choice when the approach is lumbar or transthorasic, the affected side is up (in case of

unilateral nephrectomy)
2. The patient’s waist his over the middle break in the table, and the rest of the body is flexed.
3. The arm on the unaffected side is extended on an arm board; a mayo stand padded with a pillow may support the arm on the affected side
4. The leg unaffected side is extended, and the uppermost leg is flexed with a pillow between the legs, adequate padded is needed around the feet

and ankles
5. The position is secured by wide adhesive tape at the shoulder, thighs and legs, fastened to the undersurface of the table.

SKIN PREPARATION:
Begin at the level of the 12th rib extending from the axilla to 2-3 inches below the iliac crest, and down to the table anteriorly and

posteriorly.

DRAPING:
Folded towels
Transverse sheet

INSTRUMENT TROLLEY:
Mosquito straight artery forceps : 6


Mosquito curved artery forceps : 6
Straight artery forceps (medium) 6” : 6


Straight artery forceps (large) 8” : 6
Curved artery forceps (medium) 6” : 6
Curved artery forceps (large) 8” : 6
Right angled artery forceps (small) : 1
Right angled artery forceps (large) : 1
Needle holder : 2
Allis tissue forceps : 6
Babcock : 6
Kochear : 6
Straight scissors : 1
Curved scissors : 1
B.P handle : 1
Scalpel : 1
Blades 10, 11,15 : 1
Self retaining retractor : 2
Langenbeck retractor : 2
Morris retractor : 2
Kelly’s retractor : 2
Deavers retractor : 2
Non toothed forceps (small) : 1
Non toothed forceps (medium) : 1
Toothed forceps (small) : 1
Toothed forceps (medium) : 1
Pull sucker : 1



MISCELLANEOUS ITEMS
Steridrape : 1
Towel clips : 3
Peanuts : 5
Vessel loops : 4
SUTURE MATERIAL
1-Vicryl
2-0 Chromic
2-0 Ethilon (for skin)
1-0, 2-0, 1, 3-0 Sutpack (for artery and vein)

OPERATION
SURGICAL ACCESS:
The choice of approach is determined not only the type of disease (benign or malignant), but also by the patient’s anatomy (obesity, age),

surgical history, the type of renal disease, general condition, cardiocirculatory function and the surgeons own preference.
A transperitoneal chevron incision may be chosen for patients on dialysis when bilateral nephrectomy is necessary before renal transplantation:

alternatively, both kidneys can be removed without changing the patient’s position by using a bilateral dorsal lumbotomy with the patient prone. In renal

trauma the kidney should always approached from an anterior transperitoneal incision for early control of the renal capsule.


INCISION:
The incision extends from the angle of the 12th rib posteriorly
to 8-15cms beyond the tip of the 12th rib anteriorly
The three muscle layers (external and internal oblique and transverses muscles) are divided, carefully avoiding the intercostals and sub-costal

nerves.
The gerota’s fascia is then incised with scissors, followed by blunt dissection.
The ureter is exposed and snared, the perirenal fat displaced and the posterior aspect of the kidney exposed.
The peritoneum, which adheres to the kidney is separated and the kidney mobilized the peritoneum is closed with vicryl sutures.
Dissection of the upper pole of kidney from fatty tissue and supra renal gland is achieved by blunt dissection. One should also look for accessory

vessels and ligate them or coagulate them is required.
Delivery of the lower pole is also achieved in the same way.
After both the poles of the kidney have been mobilized and renal artery, renal vein and the ureter are dissected.
Care should to avoid injury to the ovary or testicular vein on the left side and the suprarenal veins on both sides.
The renal vein is snared and the kidney turned medially to expose the renal artery, which is located behind and above the vein.
After double ligation with vicryl division of the renal artery is done.
The renal vein is treated in the same way.
The kidney is removed after division of the ureter between clamps.
A 20Fr silastic tube drain is placed with its tip within the gerota’s fascia, it is brought out through the gerota’s fascia, through a separate stab

incision.
The wound is closed in layers.

POST OPERATIVE CARE:
1. The patient should be mobilized on the first day after surgery.
2. Low dose anticoagulant treatment is given until the patient is discharge.
3. Intravenous fluid replacement is required until bowel activity returns to normal (usually on the second postoperative day).
4. Serum electrolytes, blood urea nitrogen, creatinine and blood count should be monitored on the first day after surgery, and as necessary thereafter.

COMPLICATION:
1. Haemorrhage may rise from small vessels in the adrenal region (fatty tissue,etc) or from the renal pedicle.
2. If significant haematoma is revealed in ultrasonagraphy in the renal fossa, surgical exploration `is necessary.
3. Post operative chest infections are a cause of morbidity.
4. Iileus may be prolonged because of perioperative handling of the bowel, retroperitoneal haematoma or premature resumption of oral fluids.