INCISIONAL HERNIA AFTER LAPAROSCOPIC NEPHRECTOMY WITH INTACT SPECIMENREMOVAL - CAVEAT-EMPTOR

Purpose: We report 5 cases of postoperative incisional hernia after la paroscopic nephrectomy with intact removal of the specimen. Materials and Methods: During the last 5 years 29 patients underwent laparoscopi c nephrectomy with intact removal of the resected specimen due to a la rge kidney and/or malignancy. Of these 29 patients 5 had a postoperati ve incisional hernia at the site of intact removal, including 3 with r enal tumors and 2 with large polycystic kidneys due to adult onset aut osomal dominant polycystic kidney disease. The records of these patien ts were reviewed to determine any specific factors that might relate t o the development of this complication. Results: An incisional hernia developed at the wound site in 5 patients (17%) 41 to 73 years old (me an age 53.4). Average body mass index for the patients was 34.2 (range 26 to 47). Average weight and size were 542 gm. and 20.3 x 10.3 cm., respectively, for the 3 resected malignant specimens and 1,975 gm. and 23.8 x 16.5 cm., respectively, for the 2 benign kidneys. A transverse lower flank muscle cutting incision (average 10.4 cm.) was performed to remove the resected kidney. Incisional hernias appeared after an av erage of 6.6 weeks postoperatively. Risk factors for a postoperative h ernia included obesity in 80% of the patients, chronic renal insuffici ency due to autosomal dominant polycystic kidney disease in 40%, posto perative pulmonary complication in 40% and metastatic cancer in 20%. C onclusions: Our experience has led us to avoid a lower flank port conn ecting incision for specimen removal. Instead we changed to a midline or subcostal incision in these patients. In addition, we believe that with the availability of the impermeable organ entrapment sacks there is less need for intact specimen removal even for renal tumors. Curren tly large benign kidneys (autosomal dominant polycystic kidney disease ) are morcellated in situ to a suitable size for entrapment, while ren al tumors are entrapped and morcellated directly. Presently our only i ndication for intact removal is in the case of a renal pelvic or calic eal transitional cell cancer.