From Basics to Advanced Laparoscopic Urology

A few days back, we performed Laparoscopic Radical Nephrectomy with Renal Vein Thrombectomy for a patient with a large left renal mass (9x8 cm) with renal vein thrombus in a retro-aortic renal vein. The surgery was successful, with minimal blood loss. The patient got discharged on post-operative day two.

This made me reflect on my journey as a laparoscopic urological surgeon throughout my residency.

My tryst with laparoscopy started with my General Surgery residency. Our unit used to do laparoscopic donor nephrectomy almost twice a week. I used to be the second assistant to my boss, with the senior resident or junior consultant showing the camera. My job used to be to lift the kidney while dissecting the renal hilum or at times to retract the pancreas, spleen and colon. The first and foremost thing to learn in laparoscopy is the anatomy. And what better than to learn the normal anatomy at first. That is where the donor nephrectomy came to my aid. Donors being healthy people had a normal renal anatomy with pristine surgical planes. The only problem was that being a junior resident in a high volume center, we didn’t use to get a post-night duty off. And more often than not, we used to be scrubbed in the donor, first thing in the morning, after a night of monitoring post-transplant patients, operating GI perforations or intestinal obstructions. But there was no scope for laxity. Our boss used to keep us on our toes by taking pop quizzes about the structures seen on the screen. The constant apprehension of an incoming question used to work like an energy drink. Now that I think about it, that was the biggest contributor to my learning and inclination towards laparoscopic urology.

When I got into my super-specialization residency in Urology, a lot of laparoscopic work got replaced by robotics. In these three years, I assisted almost a hundred robot assisted radical prostatectomies, partial nephrectomies or pyeloplasties. Our boss again was a no-nonsense guy in the operation theatre. I used to be at the bedside during these surgeries and mostly used to have the suction cannula in my control. Suctioning the right place and the right time, retracting properly and clip application for minor vascular pedicles was the next step in my learning. At the same time, for laparoscopy, I had gotten promoted to holding the camera. We used to do radical nephrectomies, ureterolithotomies, ureteric reimplants … you name it. To be honest, I do confess to not having a lot of hands-on laparoscopy during this time. But in retrospect I find my Faculty’s words ringing true – ‘You need to learn about the peri-operative care of patients, read about the theory in detail and assist as much as you can during your residency. Anyone can perform surgery – that is just being trained; you need to be educated first!’

When I got out of the residency and into my fellowship, I used to think if these words of wisdom were actually true. In my first case of donor nephrectomy, I couldn’t reflect the colon properly because even though I knew the planes and I knew the instruments, I didn’t have a hands-on experience with how to move them. But with the help of my mentors and surgical assistants, I was able to learn the proper operating techniques within a short time. That is when it hit me; what my Faculty used to say was indeed true. Because my basics were strong, because I had seen and assisted so much, I was able to be trained to perform surgery in a flash. But I still used to get stuck at some steps of the surgery during my initial months of the fellowship.

As I finished my fellowship and joined as a consultant, I had successfully and completely performed advanced laparoscopic procedures multiple times. This time-interval made a huge revelation for me and I found the secret sauce to success. Theory about the normal and abnormal anatomy, seeing, assisting and doing laparoscopic surgery just makes the cup half full. What makes the winning difference is a characteristic that is common to all surgeries – Confidence! Confidence in your ability to operate, to know what to cut and most importantly what not to cut and believing that slow and steady will win the race makes all the difference in the world.

So in conclusion, I am left with a few learning points for my juniors and colleagues –

1. Know your theory; there is no substitute for it!

2. Get to know the normal anatomy first; if your center doesn’t do laparoscopic donors, then see some videos or contact your colleagues … youtube’s right there!

3. Assist, assist, assist; as much as you can – that will be the stepping stone to performing the surgery yourself!

4. Have confidence in your abilities; believe that you can progress when needed (considering you have followed the previous steps)

5. Know the peri-operative care; ultimately you want the patient to have a successful outcome from your surgery – that is the aim!

6. Train your surgical assistants like you were trained yourself; a good assistant can be the difference between a successful surgery and a complication!