Nephrectomy  ( Surgery)
Description:  Left laparoscopic hand-assisted nephrectomy.

PREOPERATIVE DIAGNOSIS: , Left renal mass, left renal bleed.,POSTOPERATIVE DIAGNOSIS:  ,Left renal mass, left renal bleed.,PROCEDURE PERFORMED: , Left laparoscopic hand-assisted nephrectomy.,ANESTHESIA:,  General endotracheal.,EBL: , 100 mL.,The patient had a triple-lumen catheter A-line placed.,BRIEF HISTORY:,  The patient is a 54-year-old female with history of diabetic nephropathy, diabetes, hypertension, left BKA, who presented with abdominal pain with left renal bleed.  The patient was found to have a complex mass in the upper pole and the lower pole of the kidney.  MRI and CAT scan showed questionable renal mass, which could be malignant.  Initial plan was to let the patient stabilize for 2 weeks and perform the nephrectomy.  At this point, the patient was unable to go home.  The patient continually complained of pain.  The patient required about 3 to 4 units of blood transfusions prior.  The patient initially came in with hemoglobin less than 5.  The hemoglobin prior to surgery was 10.,Risks of anesthesia, bleeding, infection, pain, MI, DVT, PE, respiratory failure, morbidity and mortality of the procedure due to her low ejection fraction were discussed.  Cardiac clearance was obtained.  The patient was high risk, family and the patient knew about the risk.  The recommendation from the pulmonologist, cardiologist, and medical team was to get the kidney out at this point because the patient and the family stated that they would not do well at home without any intervention.  The patient and family understood all the risks and benefits in order to proceed with the surgery.,DETAILS OF THE PROCEDURE:,  The patient was brought to the OR.  Anesthesia was applied.  The patient had A-line triple-lumen catheter.  The patient was placed in left side up, right side down oblique position.  All the pressure points were well padded.  The right fistula was carefully padded completely around it.  Axilla was protected.  The fistula was checked throughout the procedure to ensure that it was stable.  The arms, ankles, knees, and joints were all padded with foam.  The patient was taped to the table using 2-inch wide tape.  OG and a Foley catheter were in place.  A supraumbilical incision was made about 6 cm in size and incision was carried through the subcutaneous tissue and through the fascia and peritoneum was entered sharply.  There were some adhesions where the omentum was into the umbilical hernia, which was completely stuck.  The omentum was released out of that just so we could obtain pneumoperitoneum.  Pneumoperitoneum was obtained after using GelPort.  Two 12-mm ports were placed in the left anterior axillary line, and mid clavicular line.  The colon was reflected medially.  Kidney was dissected laterally behind and inferiorly.  There was large hematoma visualized with significant amount of old blood, which was irrigated out.  Dissection was carried superiorly and the spleen was reflected medially.  The spleen and colon were all intact at the end of the procedure.  They were stable all throughout.  Using endovascular GIA stapler, all the medial and lateral dissection was carried through the stapler to ensure that the patient had minimal bleeding due to low cardiac reserve.  Hemostasis was obtained.  The renal vein and the renal artery were stapled and there was excellent hemostasis.,The dissection was carried lateral to the adrenal and medial to the right kidney.  The adrenal was preserved.  The entire kidney was removed through the hand port.  Irrigation was performed.  There was excellent hemostasis at the end of the nephrectomy.  Fibrin glue and Surgicel were applied just in case the patient had delayed DIC.  The colon was placed back and 12-mm ports were closed under direct palpation using 0 Vicryl.  The fascia was closed using loop #1 PDS in a running fashion and was tied in the middle.  Please note that prior to the fascial closure, the peritoneum was closed using 0 Vicryl in running fashion.  The subcuticular tissue was brought together using 4-0 Vicryl.  The skin was closed using 4-0 Monocryl.  Dermabond was applied.  The patient was brought to the recovery in a stable condition.