Ian Smith, Anurag Golash & Clare Hammond

(This article was originally published in the Journal of One-Day Surgery Vol. 23 No. 1, 2013. It was Number 1 in the 'How i Do It' series, updated in 2020)

Patient Selection

• Non-functioning kidney or renal cell carcinoma
• T1 tumour <7 cm
• Typical day surgery criteria, of which a well motivated patient is by far the most important

Anaesthetic Techniques

• We use a standardised protocol which is similar to that used for laparoscopic cholecystectomy
• Induction with fentanyl and propofol. Tracheal intubation and controlled ventilation breathing sevoflurane in air-oxygen
• Long acting intraoperative opioids are avoided
• Multimodal antiemesis with dexamethasone and ondansetron
• Intravenous hydration with 1 or (maximum) of 2 litres Hartmann’s solution

Surgical Technique

• Standardised transperitoneal laparoscopic approach with patient in lateral recumbent position
• Staples or locking clips to renal pedicle
• Infiltration of trocar ports and extraction site with 30 ml of 0.5% levo-bupivacaine
• No urinary catheter or routine drains

Peri-operative Analgesia

• Preoperative oral slow-release ibuprofen, 1600 mg
• Intraoperative iv paracetamol near end of case
• Fentanyl 2mcg/kg towards the end of the case
• Postoperative regular paracetamol and codeine, if needed
• Rescue intravenous fentanyl, if required 

Take Home Medication

• Slow release ibuprofen, paracetamol  and codeine for 5 days
• Buccal antiemetics if PONV problematic while in hospital

Organisational issues

• Surgeon must be experienced in laparoscopic perirenal procedures with a low rate of complications
• District nurse follow-up after discharge (at least during early phase of learning curve)
• Written information listing warning signs of serious postoperative complications and patients encouraged to self-refer to the surgical assessment unit if these signs are present
• As with cholecystectomy, immediate postoperative outcome is difficult to predict, so increasingly a default to day case booking strategy is adopted

Common Pitfalls

• Wound drains are not a substitute for careful haemostasis
• We do not routinely measure urine output or renal function as small, asymptomatic changes do not alter management
• Anticipated Day Case Rates
• 15–20% (for both benign and malignant)