Chap60N Open surgery for kidney

• To preserve stability and prevent forward roll, the dependent leg is flexed at the hip and knee and the top leg is kept straight.
• An axillary roll is deployed just caudal to the axilla to prevent compression or injury of the axillary neurovascular bundle.
• The bed is flexed until the flank muscles are under stretch.
• The bed is placed in Trendelenburg position so that the flank is rendered parallel to the floor.
• After opening the muscles, fused lumbodorsal fascia is exposed , which gives rise to the internal oblique and transversus abdominis muscles.The lumbodorsal fascia and internal oblique muscle are divided. The subcostal nerve should be identified between the internaloblique and transversus abdominis muscles and spared.
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• An anatomic approach to the kidney, with incision of fascial planes rather than muscle. 
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Removal of the kidney within the Gerota fascia—is used to manage nonmalignant diseases of the kidney.

Complete removal of the kidney outside the Gerota fascia together with the ipsilateral adrenal gland and complete regional lymphadenectomy from the crus of the diaphragm to the aortic bifurcation as described by Robson and colleagues in 1969 for management of renal malignancy. 

Today, the adrenal gland is typically spared when technically possible, since removal of the adrenal gland, when not involved by tumor, has not been shown to improve survival of patients with renal cancer. Extensive lymphadenectomy is only done in select cases when

Radical nephrectomy is reserved for renal tumors that are not amenable to partial nephrectomy.

• Indications for radical nephrectomy include
• - tumors in nonfunctional kidneys
• - large tumors replacing the majority of renal parenchyma
• - tumors associated with detectable regional lymphadenopathy,
• - tumors associated with renal vein thrombus.

• When technically feasible, partial nephrectomy is the preferred method of choice for managing most renal masses in order to preserve maximum renal function. 
• While in the past partial nephrectomy was reserved for specific conditions (bilateral tumors, tumor in a solitary kidney, patient at high risk of future renal failure) and small tumors less than 4 cm in diameter, indications for partial nephrectomy have considerably widened to include most renal masses that can be safely and completely removed independent of their size

• Diffuse involvement by tumor
• Large tumor size (>10 cm)
• Extrarenal tumor extension
• Tumor thrombus
• Lymphadenopathy and regional metastasis
• Adrenal mass on imaging

• Enlarged lymph nodes on imaging
• Cytoreductive surgery for metastatic disease
• Tumor size greater than 10 cm
• Nuclear grade 3 or greater
• Sarcomatoid histology
• Presence of tumor necrosis on imaging
• Extrarenal tumor extension
• Tumor thrombus and direct tumoral invasion of adjacent organs

Colon - plan for partial colectomy. 

• Spleen - plan for splenectomy 
• Liver - because of presence of its bilaminar capsule, the liver is not usually directly invaded by renal tumors despite preoperative imaging studies that may suggest extension of right-sided renal tumors to the liver. However, in rare circumstances when a right-sided renal tumor does directly invade into the liver, appropriate preoperative surgical planning is essential.

Paracaval, precaval, retrocaval, and interaortocaval nodes from the right crus of the diaphragm to the bifurcation of the IVC.

• Anteromedial surface of the aorta,  is
• clipped and divided and rolled laterally.
• The split is continued cranially along the aorta to the level of the SMA and caudally past the IMA to the bifurcation of the aorta.
• While the IMA and the celiac trunk have to be preserved, the IMA can be tied and divided in case of involved lymphadenopathy.
• Once the lymphatics are dissected off the anterior and lateral surface of the aorta, the assistant gently elevates the aorta on either side to expose, secure, and divide the lumbar arteries.
• Once the lumbar arteries are properly secured, the aorta is rolled medially and the tissue between the anterior longitudinal vertebral ligament and the aorta (retroaortic lymph nodes) is resected.
• The interaortocaval nodes are resected only if they are palpable or visualized on preoperative imaging, or if there is extensive nodal involvement around the aorta.
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• When a significant portion of renal parenchyma is removed, the renal blood flow is delivered to a smaller number of nephrons, which can lead to increased glomerular capillary perfusion pressure that results in an increased single-nephron glomerular filtration rate called hyperfiltration.
• Over decades, the hyperfiltration can injure the remaining nephrons, resulting in focal segmental glomerulosclerosis and the clinical manifestations of proteinuria and progressive renal failure.