NEPHRECTOMY​

 

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A nephrectomy is a surgical procedure to remove all or part of a kidney:

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1. Types of Nephrectomy:

   • Radical Nephrectomy: Removal of the entire kidney, along with a portion of the tube leading to the bladder (ureter), the adrenal gland, and some surrounding fatty tissue.

   • Simple Nephrectomy: Removal of just the kidney.

   • Partial Nephrectomy: Removal of only the diseased or injured portion of the kidney. It's also called kidney-sparing or nephron-sparing surgery.

2. Reasons for Nephrectomy:

   • Kidney cancer or tumor

   • A non-functioning or damaged kidney due to infection, scarring, or other disease.

   • Severe injury to the kidney.

   • Donor nephrectomy, where a kidney is removed for transplantation.

3. Surgical Approaches:

   • Open Nephrectomy: A large incision is made in the abdomen or side to access the kidney. This approach is less common these days but may be used for particularly large tumors or in complex cases.

   • Laparoscopic Nephrectomy: Small incisions are made, and long instruments are used to remove the kidney. A small camera (laparoscope) guides the surgeon. This approach usually results in shorter recovery time and less pain than open surgery.

   • Robotic-Assisted Laparoscopic Nephrectomy: Similar to laparoscopic but performed using a robotic system. The surgeon controls robotic arms from a console.

                                                                                                 

Benefits of laparoscopic approach include less pain, earlier PO intake, and shorter hospitalization.

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Renal cell carcinoma is most prevalent in males over 50 years old.

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                                                             Anesthetic Implications for Nephrectomy

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Anesthesia type: General

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Airway: ETT

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Preoperative:

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• For renal cell carcinoma, patients undergo preop staging to determine if the tumor involves the IVC or right atrium

• Tumor can obstruct IVC and reduce venous return (causes hypotension)

• Patients with cavo-atrial involvement will need anticoagulation with heparin therapy 

• Preoperative arterial embolization of the kidney can facilitate surgery

• IVC may need to be clamped during resection

• Patient may be anemic

• An arterial line is standard, and a central line may be needed

• Two large-bore peripheral IVs

• Potential for significant blood loss

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Intraoperative:

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• Supine position for transabdominal approach

• Flexed lateral decubitus position for retroperitoneal approach

• Duration based on surgeon experience

• Expected EBL 200-500 (significantly higher for tumors involving renal vessels or IVC)

• Mannitol and/or furosemide may be administered for maintenance of urinary output

• Preserve renal blood flow with adequate hydration

• Pneumoperitoneum decreases renal blood flow

• Avoid nephrotoxic drugs, hypotension, and hypovolemia

• During flank incision, the pleura space may be accidentally entered through a diaphragm tear (requires chest tube)

• Thoracoabdominal incision usually requires chest tube at the end of surgery

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Postoperative:

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• If significant extension into IVC, patient may require cardiopulmonary bypass

• Those with cavo-atrial disease should be cared in a critical care unit

• Pain management

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Complications:

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• Pneumothorax

• Diaphragmatic injury

• Pulmonary embolus

• Arrhythmias

• Renal failure and need for dialysis

• Bleeding

• Respiratory complications

• Damage to surrounding structures (hollow viscus injuries and splenic lacerations)

• Urinary leak

• Hemodynamic instability

• Bowel obstruction

• Peritonitis

• Wound infection

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Sources:

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Longnecker, D. E., Brown, D. L., Newman, M. F., & Zapol, W. M. (2012). Anesthesiology, 2nd ed.

 

Macksey, L. F. (2011). Surgical procedures and anesthetic implications: A handbook for nurse anesthesia practice. 

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Jaffe, R. A. (2020). Anesthesiologist's Manual of Surgical Procedures (6th ed.). 

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Singh-Radcliff, N. (2013). 5-Minute Anesthesia Consult.

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