Nephrectomy is performed in children for benign poorly functioning renal units causing recurrent urinary tract infections (UTIs), abdominal pain, hypertension etc. The laparoscopic route has gained popularity for their removal since its introduction, irrespective of age and appears to generate less stress response.[1,2] The additional benefit of small scars is appreciated by parents during decision making. Common indications for Nephrectomy in children are Dysplatic kidney due to VUR, Multicystic dysplastic kidney and prolonged non treated PUJ obstruction.

Laparoscopic nephrectomy has become the standard of care for removal of benign Non functioning kidney’s (NFKs).[3] Many studies have demonstrated its safety in children, even in those weighing less than 10 kg.[4,5] Laparoscopy is associated with less stress response, minimal morbidity, better cosmetic results, less post-operative pain and shorter hospital stay as compared to the open technique and has been considered superior to open surgery by some authors.[2,6,7]] Blood loss and complication rates are comparable to open techniques. Studies have shown that mean operative times decrease significantly after about ten Laparoscopic Nephrectomy (LNs).[8,9]] Our operative time and conversion rates also fell significantly after the first ten cases. With experience, other procedures can be performed simultaneously without much increase in operative time.

Surgical technique

The child is placed in a semi-lateral position with the side to be operated raised at an angle of about 30-40° with a bolster underneath and the patient strapped to the operating table after padding pressure points. A 10 mm umbilical port was inserted through an umbilical or peri umbilical curvilinear incision by open technique. Pneumoperitoneum is created using carbon dioxide (CO_-2) at a pressure of 8-10 mm Hg and flow rate of 0.8-1.5 lit/min. Two 5 mm working ports were then inserted under vision, in the epigastrium (midway between the xiphisternum and umbilicus) and in the mid-clavicular line just below the level of the umbilicus on the side to be operated. Occasionally an additional 5 mm port maybe placed. The ipsilateral colon along the white line of Toldt as well as the hepatic/splenic flexure is completely mobilized. The Gerota’s fascia is opened, the vascular pedicle isolated and artery and vein separately ligated. The ureter is traced as close to the bladder as possible safeguarding the vas deferens/gonadal vessels. The patient is then placed back in supine position and the entire operated area irrigated with normal saline till clear. The specimen is removed through the umbilical port site. The sheath was closed with interrupted 3-0 Vicryl and skin with Vicryl Rapide. Port wounds are usually infiltrated with 2% bupivacaine. Orals maybe resumed on the first postoperative day in the absence of ileus. Antibiotics maybe given for the first 48 hours after surgery. Usually they will be discharged by 48 hours.

 

One of the largest series from India concludes the feasibility and safety of Laparoscopic Nephrectomy in children with benign NFK. They conclude that the procedure should be preferred over the open technique wherever basic expertise and technical facilities are available. The learning curve for the procedure is not as steep as it was previously thought to be and longer operative times and higher conversion rates in the initial period must not act as a deterrent[10].

REFERENCES:

1. Koyle MA, Woo HH, Kavoussi LR. Laparoscopic nephrectomy in the first year of life. J Pediatr Surg. 1993;28:693–5.
2. Sekhon V, Menon P, Arora S, Rao KL. Nephrectomy in children: Comparison of stress response to laparoscopic and open methods. J Indian Assoc Pediatr Surg. 2013;18:53–7.
3. Hamilton BD, Gatti JM, Cartwright PC, Snow BW. Comparison of laparoscopic versus open nephrectomy in the pediatric population. J Urol. 2000;163:937–9.
4. Mulholland TL, Kropp BP, Wong C. Laparoscopic renal surgery in infants 10 kg or less. J Endourol. 2005;19:397–400.
5. Castillo OA, Foneron-Villarroel A, López-Fontana G, Bolufer E, Rodríguez-Carlin A. Laparoscopic nephrectomy in children. Actas Urol Esp. 2011;35:195–9.
6. Scafuri AG, Miranda EP, Dénes FT, Castilho LN, Mitre AI, Arap S. Comparison of videolaparoscopic versus open surgery for benign renal diseases in children. Actas Urol Esp. 2009;33:1115–21.
7. Ku JH, Yeo WG, Choi H, Kim HH. Comparison of retroperitoneal laparoscopic and open nephrectomy for benign renal diseases in children. Urology. 2004;63:566–70.
8. Higashihara E, Baba S, Nakagawa K, Murai M, Go H, Takeda M, et al. Learning curve and conversion to open surgery in cases of laparoscopic adrenalectomy and nephrectomy. J Urol. 1998;159:650–3.
9. Ku JH, Yeo WG, Kim HH, Choi H. Laparoscopic nephrectomy for renal diseases in children: is there a learning curve? J Pediatr Surg. 2005;40:1173–6.
10. Prema Menon, Abhilasha T Handu, KLN Rao, Suman Arora. Laparoscopic nephrectomy in children for benign conditions: indications and outcome. J Indian Assoc Pediatr Surg. 2014 Jan-Mar; 19(1): 22–27.