title: Outcomes of hand-assisted laparoscopic nephrectomy in technically challenging cases.
abstract: OBJECTIVE
  To evaluate the outcomes of hand-assisted laparoscopic nephrectomy in patients with significant complicating clinical factors.
  
  
  METHODS
  We performed a retrospective review of 322 hand-assisted laparoscopic nephrectomy cases that were completed at a single institution from 1998 to 2004. Patients with a history of extensive abdominal surgery or prior procedures on the affected kidney, evidence of perirenal inflammation, renal lesions 10 cm or more in diameter, or level I renal vein thrombus were included.
  
  
  RESULTS
  A total of 42 patients were included in this series. Of these, 16 patients had a lesion 10 cm or larger, 10 had a renal vein thrombus, and 10 had undergone prior major abdominal surgery. Many patients had more than one complicating factor. Another 6 patients had a history of prior renal procedures or chronic inflammatory processes involving the affected kidney. One Stage T4 renal tumor with paraspinous muscle invasion was successfully managed without conversion. The overall mean operative time and estimated blood loss was 235 minutes and 439 mL, respectively, with a mean hospital stay of 4 days. Four patients (9.5%) required open conversion (one renal hilar injury, two failure to progress, and one persistent bleeding from the renal fossa). Postoperative complications included pulmonary embolism in 1, ileus in 1, and chronic obstructive pulmonary disease exacerbation in 1 patient. One patient developed an incarcerated port site hernia requiring reoperation.
  
  
  CONCLUSIONS
  Hand-assisted laparoscopic nephrectomy is an attractive minimally invasive option in the setting of significant complicating factors. This technique may facilitate the successful laparoscopic completion of these challenging cases with reasonable operative times, blood loss, and complication rates.
authors.affiliation: Department of Urology, Thomas Jefferson University, Jefferson Medical College, Philadelphia, Pennsylvania 19107, USA. pkalra1@gmail.com
authors.forename: Pankaj
authors.initials: P
authors.lastname: Kalra
authors.forename: Deborah T
authors.initials: DT
authors.lastname: Glassman
authors.forename: Leonard G
authors.initials: LG
authors.lastname: Gomella
authors.forename: Stephen E
authors.initials: SE
authors.lastname: Strup
authors.forename: David E
authors.initials: DE
authors.lastname: McGinnis
authors.forename: Daniel R
authors.initials: DR
authors.lastname: Simon
authors.forename: Mark F
authors.initials: MF
authors.lastname: Chang
authors.forename: Dolores S
authors.initials: DS
authors.lastname: Byrne
authors.forename: Ramsay L
authors.initials: RL
authors.lastname: Kuo
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D006801:Humans; D010535:Laparoscopy; D008875:Middle Aged; D009392:Nephrectomy / Q000009:adverse effects* / Q000379:methods*; D011183:Postoperative Complications / Q000453:epidemiology / Q000209:etiology; D012189:Retrospective Studies; D016896:Treatment Outcome