What is this procedure? Nephrectomy means removal of a kidney using ‘keyhole’ (laparoscopic) surgery. The more modern laparoscopic method of kidney removal uses three or four one centimetre cuts (incisions). A thin tube with a light and camera on the end (a laparoscope), and surgical instruments can then be passed through these incisions. The camera sends pictures to a TV screen so that the surgeon can see the kidney and surrounding tissue. One of the incisions will be enlarged to enable the kidney to pass through once it has been disconnected from the surrounding tissues and blood vessels. A laparoscopic nephrectomy is performed under a general anaesthetic. You will meet the Anaesthetist on the day of your operation and he or she will discuss the anaesthetic with you. You should expect to stay in hospital for 2-4 nights. The laparoscopic method of kidney removal has been shown to cause less blood loss and fewer complications than the open method, and also has a shorter recovery time. The open surgical approach to kidney removal is now only used for complicated cases.
Why nephrectomy? A kidney may need to be removed for a number of reasons. These are outlined below:
- The kidney may be only partially working, or not working at all. If left in place it can be a source of repeated infections and pain.
- Infection may have damaged the kidney so that it requires removal.
- A cancer arising within the kidney may have been diagnosed. The usual treatment for this is to remove the affected kidney.
- If a cancer has been found in the kidney, it is occasionally necessary to remove the adrenal gland, which lies on top of the kidney, at the same time.
- For some kidney cancers, there is a high risk of cancer recurrence in the ureter (the tube which carries urine from the kidney to the bladder). If this type of cancer has been found, you will need a small incision low down on your abdominal wall, as well as the kidney operation described.
The reason for removing your kidney will be discussed with you. Before the operation is carried out it is usual to perform various scans and blood tests so that the surgeon has as much information about the diseased or cancerous kidney as possible. These tests also make sure that the remaining kidney is working normally. Providing that the remaining kidney is functioning normally you will not need to make any change to your lifestyle (eg diet) or activities after the operation.
Risks and side effects of laparoscopic nephrectomy? Any operation and anaesthetic carries risks. These risks are generally small and not doing the operation may carry a greater risk. Risks of the anaesthetic can be discussed with the anaesthetist who will be looking after you during the operation, and who will normally visit you beforehand. Possible risks and side effects from the procedure are outlined below. However, if you have any concerns please do discuss them with nursing and medical staff as it is important that you understand what is going to happen to you. You will be asked to sign a consent form before undergoing the operation but you may withdraw your consent at any time.
Common
- Some patients experience temporary shoulder tip pain and abdominal bloating for 24 hours after the operation. This may be due to inflation of the abdominal cavity with gas during the operation. Using the retro-peritoneal approach decreases this side effect. Mild painkillers are usually adequate to control the pain.
Sometimes
- Occasionally after this operation, infection, or a hernia, may occur in one or more of the incisions requiring further treatment. This happens very rarely when the surgeon uses the retro-peritoneal approach.
Rare
- Bleeding can occur during the surgery such that the surgeon has to abandon the keyhole approach and use the conventional open method of kidney removal. If this occurs a blood transfusion may be required.
- During the operation the lung cavity may be entered and this is repaired during the procedure without any extra incisions.
- Problems with the anaesthetic, or heart or blood vessel complications may occur requiring admission to the Intensive Care Unit. Such complications include a chest infection, clot/s on the lungs or in the legs, a stroke or a heart attack. These are not specific to laparoscopic procedures.
Preoperative period You will usually attend a pre-assessment clinic before your operation. The purpose of this appointment is to organise any more tests that may be needed, and check your fitness for the operation. A member of the nursing staff and one of the doctors from the surgeons team will see you. It is useful if you bring in a list of any medicines that you normally take at home, and let us know of any drug allergies you may have. It is important that the hospital know if you are on any drugs that thin the blood e.g. Aspirin, Warfarin, Clopidogrel, Dipyridamole.
If you are taking Warfarin it may be necessary to bring you into hospital a few days before your operation, or to change your Warfarin to an injection that can be given at home. You are normally admitted to hospital the day before your operation.
Day of your admission to hospital When you arrive on the ward you will be shown to your bed by a member of the nursing staff who will also explain the layout of the ward. Each bed has access to a personal telephone and a television. Prepaid cards for the telephone are available via a vending machine in the hospital. Televisions are hired on a daily basis. The telephone has an individual number which you can then give to friends and family.
Please leave a contact telephone number for a relative (ask the nurses to place it on the front of your folder) so that the surgeon can phone them after the procedure to inform them of your progress.
The day of your operation Before your operation you will need to starve (nil by mouth) to reduce the risk of problems during the anaesthetic. You may eat and drink normally up until 6 hours before your operation and then can have
clear fluids only until 2 hours before the surgery. Pease check with your anaesthetist what local regulations are before taking anything by mouth 6hrs before surgery.
Depending on what medicines you take, you may be asked to have your normal medicine regime, or some may be withheld and given to you after the operation.
You will be asked to bathe before the operation, to put on a theatre gown and to wear some special stockings during and after the operation. These stockings are used to reduce the risk of developing blood clots (DVT) in your lower legs.
Nursing staff will be able to give an approximate time for your operation, but this time is only intended as a guide.
You will be taken from the ward to the operating theatre on your bed.
After the operation you will ‘come round’ in the recovery area and then be collected and taken back to the ward by a member of nursing staff once you are
awake and comfortable.
How long will the operation take? The operation usually takes 2-3 hours but can vary depending on the specific operation.
After the operation You will have intravenous fluids (a drip) going into an arm vein. This will remain in place until you are drinking normally. You can start having some oral fluids immediately after the operation, and the drip can usually be removed the following day. Food can usually be started the day after the operation.
A drainage tube (catheter) to drain urine from the bladder will be inserted whilst you are under anaesthetic. This allows accurate measurements of your urine output. The urine may be blood-stained, but this is normal and will clear the following day. The catheter is usually removed the following day. Occasionally during the operation a wound drain is placed at the site of the kidney to drain away any blood. This will be removed when there is little or no drainage from it (usually the following day).
Following the operation it is usual to have mild shoulder or stomach pain for a couple of days. This pain is often described as a “wind-like” pain, and is due to the surgeon using gas to inflate your abdominal cavity so that he can visualise the kidney better. Most patients only need mild painkillers, but as in any surgery there may be more discomfort requiring stronger painkillers.
You may feel nauseated for 24 hours following the operation but medication can be administered to control this. You will be encouraged to sit out of bed for short periods the day following the operation and to walk a short distance. On the second day after the operation you should be able to be out of bed most of the day and walking longer distances.
The small wounds are closed with dissolvable stitches. Forty-eight hours after the operation the dressings are removed, and the wounds covered with a protective plastic film so that you can bath or shower as normal.
Once the catheter is removed and you are passing urine satisfactorily and mobilising well, you will be discharged home.
Discharge Before going home you will be informed about follow up arrangements. Follow up will be dictated by the reason for the kidney removal. You may need medicines to take home (TTAs), and will receive a 2 week supply of any medicines required. You will be referred to your local District Nurse so that he or she can visit you at home and check the wounds are healing satisfactorily.
It is sensible to avoid heavy lifting and driving for 2-3 weeks after the operation, since any sudden increase in abdominal pressure can cause pain in the wounds. Exercise should be increased gradually. Start with short walks and gentle exercise. Eat a healthy diet with plenty of fluids. Fresh fruit and vegetables are important to keep your bowels regular as your bowel can be ’lazy’ for several days after the operation.
You can return to work when you feel fit and depending on your job. Usually 2-3 weeks off work are needed. Sexual intercourse can be resumed 3-4 weeks after the operation. After any surgery you may feel tired and rather emotional for a number of weeks. This is quite normal, but if you feel depressed it is important to let your GP know.
Video Hand-Assisted Laparoscopic Radical Nephrectomy
