高度肥満症例(Body mass index : 62.6)に対するハンドアシスト併用腹腔鏡下根治的腎摘除術の1例

: A 41-year-old Japanese man (177 cm, 196 kg, body mass index 62.6) was referred for treatment of a right renal mass 7 cm in diameter. Preoperative examination showed slight liver dysfunction and elevated hemoglobin A1c level (7. 2%). Cardiac and respiratory functions were within normal limits. Hand assisted laparoscopic radical nephrectomy with a transperitoneal approach was performed. The patient was laid on two parallel-shifted beds and intubation was performed in the lateral position. Insufflation time was 6.5 h, and estimated blood loss was 550 ml. Although the amount of bleeding was greater than usual, surgery was uneventful and no blood transfusion was required. On postoperative day 1, the patient resumed oral fluid intake and ambulation. An antithrombotic drug was administered subcutaneously as prophylaxis for deep vein thrombosis. The patient was discharged 9 days after surgery without any complications. Pathological diagnosis was renal cell carcinoma (clear cell carcinoma, pT3a). The surgical margin was negative. Despite the increasing prevalence of obesity, laparoscopic surgery in severely obese patients is uncommon in Japan and standard procedures have not been established. The transperitoneal approach is appropriate for such patients because it provides good orientation and surgical space. Hand-assisted laparoscopic surgery in obese patient has the advantage that the first incision for the hand port is long enough for safe laparotomy. Moreover, counter-traction by the hand is useful and the pulse of the renal artery can be perceived. However, extraction of the specimen from the hand port was more difficult than expected and an extra incision was required in this case.