Background and Purpose: Hand-assisted laparoscopic nephrectomy (HALN) has become widely used for the management of localized renal masses and for simple nephrectomy. Centers of excellence have slowly disseminated this surgical approach throughout academic institutions and private practices. The transfer of this technique to inexperienced surgeons and centers has not been well studied. We examined our outcomes for HALN with an experienced surgeon (DMA) at a new academic center. We also examined the effectiveness of the transfer of these techniques as trainees go out into practice.
Patients and Methods: A total of 85 hand-assisted laparoscopy procedures were performed between September 2001 and August 2003 of which 61 were HALN. Four fellows and eight chief residents, under the guidance of one attending surgeon (DMA), performed all HALN procedures. Parameters measured included patient age, ASA score, body mass index, operative time, estimated blood loss, number of trocars used, time to oral intake, analgesics required, length of stay, complications, and tumor size. The average patient age was 57.4 years (range 26–87 years) and the mean ASA score 2.5 (1–4). The mean BMI was 28.3 (range 20–46). There was a slight predominance of right-sided lesions. In addition to evaluating our early results with HALN, a questionnaire was sent to all graduates of our program starting 2 years prior to the arrival of DMA to assess the application of laparoscopy to their practices.
Results: All cases were completed without open conversion. The total operative time averaged 184 minutes(range 67–257 minutes), with 80% of patients requiring two trocars. The average blood loss was 136 ml (range 25–700 mL), but only one patient required transfusion postoperatively. The mean time to oral intake was 17.1 hours (range 1.5–240 hours), the average length of stay was 4.3 days (range 1–28 days), and total narcotic requirements averaged 111 mg of morphine sulfate equivalents (range 6.7–519 mg). Sixty-six percent of the procedures were performed for malignancy. The average tumor size in these cases was 3.9 cm (range 1–12 cm). There was one death, in an 80-year-old patient who had a bowel injury necessitating re-exploration and bowel resection. This patient had a postoperative myocardial infarction and died. Two patients developed postoperative hernias at their hand-port site. Other significant complications included diaphragmatic injury (repaired laparoscopically), one pulmonary embolus, two cases of pancreatitis, and one case of pneumonia. Three patients experienced postoperative ileus. Of the 20 graduates of this program since 2000, 4 were laparoscopic/ endourology fellows, and 2 of the residents pursued fellowship training after graduating. Graduates of the year 2000 to 2001 represent surgeons who graduated prior to the arrival of DMA. Of those resident graduates who did not pursue fellowship, two of the seven surgeons who graduated prior to the arrival of DMA are performing laparoscopy. Both of these surgeons pursued formal postgraduate laparoscopic training. Six of the seven non-fellowship-trained residents who graduated since DMA's arrival are performing laparoscopy; the other is early in practice and intends to do so. None of these surgeons has pursued postgraduate training prior to performing laparoscopy in their practices.
Conclusions: The HALN techniques can be transferred quickly and efficiently between one center and another under the guidance of an experienced surgeon. Operative times are acceptable, with complication rates comparable to previously reported series. Our data show that exposure during residency markedly increases the likelihood that surgeons will carry the techniques into their practices.
