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Open Simple nephrectomy via a Flank Incision
Simple nephrectomy is the surgical removal of a kidney, in contrast to radical nephrectomy without adipose capsule, adrenal glands, ureters, or lymph nodes.
For more techniques of kidney surgery see open radical nephrectomy, open partial nephrectomy, laparoscopic (radical) nephrectomy and retroperitoneoscopic nephrectomy.
Indications for Simple Nephrectomy
Non-functioning kidney due to benign diseases with symptoms such as hematuria, recurrent urinary tract infections, nephrolithiasis, hydronephrosis or flank pain. See also renal trauma for indications of nephrectomy after trauma.
The contraindications are dependent on the surgical risk, coagulation disorders, the renal function of the contralateral kidney and the impact of the surgical procedure on the quality of life or life expectancy of the patient.
Surgical Technique of Simple Nephrectomy
Preoperative Patient Preparation:
- Perioperative antibiotic prophylaxis, if risk factors for wound infection are present.
- Perioperative indwelling catheter
- Consider epidural anesthesia
- Lateral decubitus position of the patient, the operation room table is flexed
The simple nephrectomy is usually done via a flank incision. The dissection is done between the 11th and 12th rib to spare the subcostal nerve. Blunt dissection of the layer between renal fascia and the psoas muscle is done. The peritoneum is dissected of the ventral portion of the renal fascia until the renal vein is identified. On the right side, the duodenum has to be dissected of the vena cava (Kocher maneuver).
Preparation of the Renal Hilum:
The ureter is mobilized, dissected and ligated. The dissection is carried on in cranial direction following the ureter, until the renal hilum is reached. The renal vessels are separated and dissected using overholt clamps and double ligation with e.g. Vicryl 0.
Preparation of the Upper Pole:
The kidney must be mobilized of the psoas muscle, lateral abdominal wall, adrenal gland and liver (right side). Especially in benign cases, adhesions between the renal fat and organ capsule are intense and sometimes extend into neighboring organs (e.g. xanthogranulomatous nephritis, tuberculosis or after multiple kidney surgery). Nephrectomy may be easier in the layer of radical nephrectomy. Alternatively, intracapsular nephrectomy may be performed as a last option: the organ parenchyma is dissected from the organ capsule which remains in the body. This surgical technique is indicated when there is a high risk of adjacent organ injury due to adhesions, such as removal of a non-functioning kidney transplant.
Drainage of the retroperitoneum is often performed, but it is probably not necessary after uncomplicated nephrectomy.
Follow-up after nephrectomy
- Early mobilization
- Intensive respiratory therapy
- Thrombosis prophylaxis
- Laboratory tests (hemoglobin, creatinine)
- Wound checks.
Analgesics according to the WHO ladder are prescribed, e.g. a combination of metamizol and tramadol. A peridural anesthesia facilitates postoperative pain management.
Complications of nephrectomy
- Bleeding and hemorrhage
- Wound infection
- Injury to adjacent organs: liver, splen (splenectomy), bowel injury, peritonitis, pancreatic tail injury with pancreatic fistula, pneumothorax
- Incisional hernia (due to subcostal nerve injury)
- Chylous fistula due to injury of intestinal lymphatic vessels
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Deutsche Version: Einfache lumbale Nephrektomie