Pediatric Urology

International Braz J Urol Vol. 28 (4): 346-348, July - August, 2002

Official Journal of the Brazilian Society of Urology

TRANSPERITONEAL LAPAROSCOPIC NEPHRECTOMY IN CHILDREN:

SURGICAL TECHNIQUE WITH 3 TROCARS
ROBERTO K. B. MIURA, CARLOS E. R. JUNQUEIRA, LEOLINDO TAVARES, ROBERTO R.
MAROCLO, ROGÉRIO DE M. MATTOS, RONALDO DAMIÃO
Section of Urology, State University of Rio de Janeiro (UERJ), and Cardoso Fontes
Municipal Hospital, Rio de Janeiro, RJ, Brazil

ABSTRACT

Introduction: The first videolaparoscopic nephrectomy in children was performed in 1992,

and since then, little experience, and small series of pediatric patients have been reported. The tech-
nique, described by Clayman and accepted worldwide, requires the insertion of 4 or 5 trocars. Introduc-
tion of trocars is an important cause of complication in videolaparoscopic surgery. The authors report
laparoscopic transperitoneal nephrectomy in children using only 3 trocars, to minimize risk of vascular
injury or visceral perforation.
Surgical Technique: The patient is placed in supine position with flank rotated at approxi-
mately 45°. After pneumoperitoneum is established, the first trocar is introduced in umbilicus for the
laparoscope. Under direct vision, the second trocar is placed at ipsilateral midclavicular line, and the
third and last trocar in the epigastric region. Laparoscopic transperitoneal nephrectomy was performed
in 3 children aged 7, 8, and 14 years old. Right nephrectomy was performed in 2 cases, and left nephre-
ctomy in one. Mean operative time was 163 min (100 to 230 min), and no transfusion was necessary.
Patients were discharged from hospital on day 2 to 4 after the procedure. There were no conversions to
open surgery, and no intra or postoperative complications.
Comments: Every trocar and instrument introduction into the abdominal cavity presents an
important risk of vascular injury or visceral perforation. The risk per patient is naturally increased with
the number of trocars utilized. Injuries during laparoscopic procedures can theoretically damage every
intra- or retroperitoneal organ. The majority of these lesions will need immediate or delayed open
surgery, due to hematoma formation, postoperative bleeding, abscess, or peritonitis. Transperitoneal
videolaparoscopic nephrectomy in children can be performed using only 3 trocars. The technique al-
lows a better cosmetic result, and reduces the risk of trocar introduction injuries, like vascular and
visceral lesions.

Key words: kidney; nephrectomy; laparoscopy; children

Int Braz J Urol. 2002; 28: 346-8

INTRODUCTION nosis of cryptorchidism, intersexual disorders, and

gonadectomy (1).
The introduction of videolaparoscopic sur- Even though the first laparoscopic nephrec-
gery brought a new dimension to surgical practice. In tomy in children has been performed in 1992 (1), at
urologic scope, laparoscopic procedures are per- present little experience and small series have been
formed only in few centers, especially in children, published (2,3), and the most diffused technique needs
for which this technique was described to the diag- the introduction of 4 or 5 trocars (2,3).

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 LAPAROSCOPIC NEPHRECTOMY WITH 3 TROCARS

Injuries due to trocar insertion are major and mobilization of the descendent colon for left nephre-
potential complications of the laparoscopic technique, ctomy; anterior renal fascia opening and identifica-
comprehending from visceral injuries to serious vas- tion of the renal parenchyma and ureter during lower
cular trauma (4,5). The authors describe the pole dissection. Ureter was clipped, divided, and fixed
transperitoneal laparoscopic nephrectomy technique to facilitate approaching renal hilus, without being
in children performed with only 3 trocars. necessary introducing a fourth trocar for kidney trac-
tion and major vascular exposure.
SURGICAL TECHNIQUE Renal pedicle was approached with dissec-
tion, clipping and division of renal artery and vein
Patients were admitted on the day before sur- individually. Both arterial and vein duplications may
gery and were not submitted to a specific bowel prepa- exist, and if a large vein is found, endoscopic vascu-
ration, only an 8 hour fasting. Antimicrobial prophy- lar staplers, as Endo-GIA, can be used for a safe liga-
laxis with 1st generation cephalosporin was adminis- ture. Then proceed to kidney upper pole dissection
tered before the procedure. After general anesthesia, and removal of surgical specimen. The cavity was
nasogastric and bladder tubes were inserted. Patients revised with special care to renal bed hemostasis.
were placed in supine position, with the flank in 45º Surgical specimens were removed through 12-mm.
elevation in the side to be operated. incision, after been placed in an endo-bag.
A small circular incision in the inferior um- Three children aged 7, 8 and 14 years old
bilicus edge was made, the rectus abdominalis apo- underwent a transperitoneal videolaparoscopic ne-
neurosis was fixed, and the Veress needle was intro- phrectomy using this technique. Two of them were
duced. The pneumoperitoneum was established with male and one was female. All had urinary tract infec-
12-mm. Hg and the first 10-mm. trocar was introduced tion and the radiologic exams (ultrasonography, urog-
for the 30º optical insertion. The second 12-mm. tro- raphy, and cintigraphy) showed lost of renal unity.
car was placed under direct vision at the midclavicular None was submitted to previous renal or ure-
line in the ipsilateral flank, and the third and last 5- teral surgery, and in all cases, adrenal glands were care-
mm. trocar in the epigastric region (Figure-1). fully preserved. Right nephrectomy was performed in
Nephrectomy itself was performed by inci- 2 cases, and left nephrectomy in one, and no surgical
sion of the paracolic gutter, with medial mobilization field draining was performed in any of them.
of the ascendant colon for right nephrectomy, and Operating time ranged from 100 to 230 min-
utes (mean 163 minutes). Patients were discharged
between postoperative days 2 and 4. There were no
intra- or postoperative complications, and no patient
required a blood transfusion. Patients are in medical
follow up and returned to their normal activity on
day 10 after the surgery.

COMMENTS

Trocar and other instruments insertion in ab-

dominal cavity present an important risk of vascular
injury or visceral perforation. The risk per patient is
naturally increased with number of trocars utilized.
Figure 1 - Patient in supine position, with the flank in 45º eleva-
Based on videolaparoscopic splenectomy with 3
tion in the side to be operated. Trocars are placed in umbilicus trocars experience, this technique has been recently
(10-mm.), hemiclavicular line (12-mm.) and epigastric region performed for nephrectomy aiming to achieve a lower
(5-mm.). risk (4).

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 LAPAROSCOPIC NEPHRECTOMY WITH 3 TROCARS

Desgrandchamps et al. (4) reported sults, lesser surgical trauma and reduces the risk of
videolaparoscopic nephrectomy results in 20 patients injuries related to trocar insertion, as vascular and
using only 3 trocars. In this study, operative time was visceral lesions.
similar for 3 and 5 trocars use, indicating that reducing
the number of instruments did not make performing
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Received: October 2, 2001

Accepted after revision: May 5, 2002

Correspondence address:
Dr. Roberto Kazumi Baldas Miura
Av. das Américas, 5001 / 226
Rio de Janeiro, RJ, 22631-004, Brazil
Tel.: + 55 21 2432-7828

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