One hand is better than two: conversion from pure laparoscopic to the hand-assisted approach during difficult nephrectomy.

INTRODUCTION: The incidence of conversion from a laparoscopic to an open approach during nephrectomy is reported at 6-8%. Conversion to an open procedure may be necessary to control haemorrhage or allow progress in dissection but the well established benefits of minimally invasive surgery (MIS) are obviously lost. Hand-assisted laparoscopy (HAL) also offers the benefits to the patient of MIS. We have used HAL to convert from the pure laparoscopic approach during difficult nephrectomies, rather than converting to traditional open surgery.

MATERIALS AND METHODS: A review of our prospective database was carried out to identify any conversions from the pure laparoscopic approach during nephrectomy or nephroureterectomy for benign or malignant disease.

RESULTS: A total of 87 laparoscopic nephrectomies (LNs) were identified over a 3-year period. There were five conversions to the HAL approach (5.7%) and no conversions to open surgery. The reason for conversion was failure to progress in all five cases. Operative times averaged 190 minutes with blood loss of 180 ml. Histology revealed xanthogranulomatous pyelonephritis in four cases and renal cell carcinoma in one case. The median postoperative stay was 4 days.

CONCLUSIONS: Conversion to HAL during LN maintains the benefits of MIS in difficult nephrectomy and should be considered prior to converting to open surgery.