An overview of the process
The position causes most of the intraoperative trouble. The lateral decubitus position with the table broken, or the kidney bridge elevated, obstructs venous return and produces hypotension that resembles bleeding but is entirely mechanical.
Pre-op assessment
- Establish baseline creatinine and eGFR, and the state of the contralateral kidney. This determines postoperative reserve.
- Anaemia of chronic kidney disease is common.
- Check electrolytes, particularly potassium.
- Plan drug doses for reduced clearance and avoid nephrotoxins.
- Hypertension is near-universal. Assess end-organ effects; long-standing hypertension predicts intraoperative lability.
- For renal cell carcinoma, establish whether inferior vena caval tumour thrombus is present and at what level. This changes the operation entirely and a thrombus extending above the hepatic veins is a consultant-led, potentially bypass-level case. Consider paraneoplastic hypertension, polycythaemia and hypercalcaemia.
- In autosomal dominant polycystic kidney disease, anticipate massive kidneys, frequently hepatic cysts, hypertension and chronic kidney disease.
- Where BMI is high, the bariatric guideline applies to airway management and drug dosing.
- Uraemia impairs platelet function. A clotting screen does not detect this — the platelet count, prothrombin time and activated partial thromboplastin time are characteristically normal. Assess bleeding risk from the clinical history.
- Consent covers general anaesthesia, thoracic epidural, intrathecal morphine or regional block, arterial line, possible central venous access, blood loss and transfusion, and HDU where indicated.
Induction and intra-operative management
- Volatile or TIVA.
- Open resection: thoracic epidural, an arterial line, central venous access if indicated.
- Laparoscopic resection: standard monitoring is appropriate for a straightforward case. Consider an arterial line for significant hypertension, poor cardiac reserve, a large tumour or anticipated blood loss.
- Large-bore peripheral cannulae.
- Urinary catheter, core temperature monitoring, neuromuscular monitoring.
- Active warming.
- Single-dose antibiotic prophylaxis within 60 minutes of incision.
- Mechanical thromboprophylaxis should be used if not contraindicated.
- Renal vessels are short, wide and high-flow. Large tumours, polycystic kidneys and re-operations bleed. Follow blood loss on serial gases.
Positioning
- Lateral decubitus with the table broken or the kidney bridge raised.
- Over-breaking the table may kink the inferior vena cava and obstruct venous return. Consider unbreaking the table where hypotension occurs, before reaching for fluid or blood.
- Check the dependent eye and ear, the axillary roll, the dependent arm, the brachial plexus, the common peroneal nerve and the pressure areas. Confirm the mechanical thromboprophylaxis devices still function after positioning.
- The lateral position produces ventilation–perfusion mismatch and reduced compliance of the dependent lung, compounded by the flexed position and by pneumoperitoneum. Adjust ventilation for body habitus and intra-abdominal pressure.
- Returning from the broken lateral position to supine may unmask hypovolaemia. Reassess before moving.
Renal protection and fluid management
- Maintain perfusion to the remaining kidney.
- Goal-directed fluid therapy. Avoid overload.
- Monitor urine output, recognising that it is uninterpretable while one kidney is being clamped and removed.
- Avoid nephrotoxins where avoidable — aminoglycosides and contrast.
Perioperative analgesia
- Open resection: thoracic epidural. A flank incision crosses dermatomes and is painful.
- Laparoscopic resection: IT morphine, quadratus lumborum block is used also on this list. Technically more demanding in patients with a high BMI.
- Multimodal base with paracetamol, an opioid-sparing plan and port-site infiltration.
- PONV prophylaxis with at least two agents.
- For prophylactic low molecular weight heparin, allow 12 hours from the last dose before siting or removing an epidural catheter and 4 hours afterwards; for treatment dose, 24 hours and 4 hours. Extend the interval if insertion was traumatic.
Post-operative care
- HDU is anticipated after open high-risk nephrectomy. Straightforward laparoscopic cases return to the ward.
- Handover should include which kidney was removed and why, the function of the contralateral kidney, the blood loss, the epidural or block details, the dose of low molecular weight heparin and when the next is due, the fluid balance and urine output, and the last gas.
- Acute kidney injury in the remaining kidney is the complication this operation is set up to cause. Maintain perfusion and avoid nephrotoxins.
- Bleeding presents as tachycardia, a falling haemoglobin, flank swelling or hypotension.
- Pneumothorax may follow a flank incision or upper-pole dissection where the pleura is breached. Consider it in any postoperative desaturation.
- Pain and respiratory splinting produce atelectasis. Ileus follows transperitoneal approaches.
References
- Feast MJ. Adrenalectomy for phaeochromocytoma (The Sheffield Approach). Sheffield Teaching Hospitals, 2024. Cited here for the lateral positioning and table-break content, which describes the same set-up.
- Association of Anaesthetists of Great Britain & Ireland, Obstetric Anaesthetists' Association, Regional Anaesthesia UK. Regional anaesthesia and patients with abnormalities of coagulation.
- Kietaibl S, Ferrandis R, Godier A, et al. Regional anaesthesia in patients on antithrombotic drugs: Joint ESAIC/ESRA guidelines. European Journal of Anaesthesiology, 2022;39:100–132.
- Centre for Perioperative Care. Guideline for Perioperative Care for People with Diabetes Mellitus Undergoing Elective and Emergency Surgery, 2021, updated 2023.