«They said, "Exalted are You; we have no knowledge except what
You have taught us. Indeed, it is You who is the Knowing, the
Wise."»
-The Holy Quran 2.32.
«Say: "Nothing will happen to us except what Allah has decreed for
us: He is our protector": and on Allah let the Believers put their
trust. »
« Success is to be measured not so much by the position that one has
reached in life as by the obstacles which he has overcome while trying
to succeed. »
-Booker T. Washington
«The birth of excellence begins with our awareness that our beliefs
are a choice. We usually don’t think of it that way, but belief can be
a conscious choice. You can choose beliefs that limit you, or you can
choose beliefs that support you. The trick is to choose the beliefs that
are conducive to success and the results you want and to discard the
ones that hold you back. »
MOHAMMED V DE RABAT
FACULTE DE MEDECINE ET DE PHARMACIE - RABAT
DOYENS HONORAIRES :
1962 – 1969 : Professeur Abdelmalek FARAJ 1969 – 1974 : Professeur Abdellatif BERBICH 1974 – 1981 : Professeur Bachir LAZRAK 1981 – 1989 : Professeur Taieb CHKILI
1989 – 1997 : Professeur Mohamed Tahar ALAOUI 1997 – 2003 : Professeur Abdelmajid BELMAHI 2003 - 2013 : Professeur Najia HAJJAJ – HASSOUNI
ADMINISTRATION :
Doyen
Professeur Mohamed ADNAOUI
Vice-Doyen chargé des Affaires Académiques et estudiantines
Professeur Brahim LEKEHAL
Vice-Doyen chargé de la Recherche et de la Coopération
Professeur Toufiq DAKKA
Vice-Doyen chargé des Affaires Spécifiques à la Pharmacie
1 - ENSEIGNANTS-CHERCHEURS MEDECINS ET PHARMACIENS
PROFESSEURS :
DECEMBRE 1984
Pr. MAAOUNI Abdelaziz Médecine Interne – Clinique Royale
Pr. MAAZOUZI Ahmed Wajdi Anesthésie -Réanimation
Pr. SETTAF Abdellatif Pathologie Chirurgicale
NOVEMBRE ET DECEMBRE 1985
Pr. BENSAID Younes Pathologie Chirurgicale
JANVIER, FEVRIER ET DECEMBRE 1987
Pr. LACHKAR Hassan Médecine Interne
Pr. YAHYAOUI Mohamed Neurologie
DECEMBRE 1989
Pr. ADNAOUI Mohamed Médecine Interne –Doyen de la FMPR
Pr. OUAZZANI Taïbi Mohamed Réda Neurologie
JANVIER ET NOVEMBRE 1990
Pr. HACHIM Mohammed* Médecine-Interne
Pr. KHARBACH Aîcha Gynécologie -Obstétrique
Pr. TAZI Saoud Anas Anesthésie Réanimation
FEVRIER AVRIL JUILLET ET DECEMBRE 1991
Pr. AZZOUZI Abderrahim Anesthésie Réanimation- Doyen de FMPO
Pr. BAYAHIA Rabéa Néphrologie
Pr. BELKOUCHI Abdelkader Chirurgie Générale
Pr. BENCHEKROUN Belabbes Abdellatif Chirurgie Générale
Pr. BENSOUDA Yahia Pharmacie galénique
Pr. BERRAHO Amina Ophtalmologie
Pr. BEZAD Rachid Gynécologie Obstétrique Méd. Chef Maternité des
Orangers
DECEMBRE 1992
Pr. AHALLAT Mohamed Chirurgie Générale Doyen de FMPT
Pr. BENSOUDA Adil Anesthésie Réanimation
Pr. CHAHED OUAZZANI Laaziza Gastro-Entérologie
Pr. CHRAIBI Chafiq Gynécologie Obstétrique
Pr. EL OUAHABI Abdessamad Neurochirurgie
Pr. FELLAT Rokaya Cardiologie
Pr. GHAFIR Driss* Médecine Interne
Pr. JIDDANE Mohamed Anatomie
Pr. TAGHY Ahmed Chirurgie Générale
Pr. ZOUHDI Mimoun Microbiologie
MARS 1994
Pr. BENJAAFAR Noureddine Radiothérapie
Pr. BEN RAIS Nozha Biophysique
Pr. CAOUI Malika Biophysique
Pr. CHRAIBI Abdelmjid
Endocrinologie et Maladies Métaboliques Doyen de la
FMPA
Pr. EL AMRANI Sabah Gynécologie Obstétrique Pr. EL BARDOUNI Ahmed Traumato-Orthopédie Pr. EL HASSANI My Rachid Radiologie
Pr. ERROUGANI Abdelkader Chirurgie Générale – Directeur du CHIS-Rabat
Pr. ESSAKALI Malika Immunologie
Pr. ETTAYEBI Fouad Chirurgie Pédiatrique
Pr. HASSAM Badredine Dermatologie
Pr. IFRINE Lahssan Chirurgie Générale
Pr. MAHFOUD Mustapha Traumatologie – Orthopédie
Pr. RHRAB Brahim Gynécologie –Obstétrique
Pr. SENOUCI Karima Dermatologie
MARS 1994
Pr. ABBAR Mohamed* Urologie Directeur Hôpital My Ismail Meknès Pr. ABDELHAK M’barek Chirurgie – Pédiatrique
Pr. BENTAHILA Abdelali Pédiatrie
Pr. BENYAHIA Mohammed Ali Gynécologie – Obstétrique Pr. BERRADA Mohamed Saleh Traumatologie – Orthopédie Pr. CHERKAOUI Lalla Ouafae Ophtalmologie
Pr. LAKHDAR Amina Gynécologie Obstétrique
Pr. MOUANE Nezha Pédiatrie
MARS 1995
Pr. BARGACH Samir Gynécologie Obstétrique Pr. DRISSI KAMILI Med Nordine* Anesthésie Réanimation Pr. EL MESNAOUI Abbes Chirurgie Générale Pr. ESSAKALI HOUSSYNI Leila Oto-Rhino-Laryngologie
Pr. HDA Abdelhamid* Cardiologie Inspecteur du Service de Santé des FAR Pr. IBEN ATTYA ANDALOUSSI Ahmed Urologie
Pr. OUAZZANI CHAHDI Bahia Ophtalmologie
Pr. SEFIANI Abdelaziz Génétique
Pr. ZEGGWAGH Amine Ali Réanimation Médicale DECEMBRE 1996
Pr. AMIL Touriya* Radiologie
Pr. BELKACEM Rachid Chirurgie Pédiatrie
Pr. BOULANOUAR Abdelkrim Ophtalmologie Pr. EL ALAMI EL FARICHA EL Hassan Chirurgie Générale
Pr. GAOUZI Ahmed Pédiatrie
Pr. MAHFOUDI M’barek* Radiologie
Pr. OUZEDDOUN Naima Néphrologie
Pr. ZBIR EL Mehdi* Cardiologie DirecteurHôp.Mil. d’Instruction Med V Rabat NOVEMBRE 1997
Pr. ALAMI Mohamed Hassan Gynécologie-Obstétrique
Pr. BEN SLIMANE Lounis Urologie
Pr. BIROUK Nazha Neurologie
Pr. ERREIMI Naima Pédiatrie
Pr. FELLAT Nadia Cardiologie
Pr. KADDOURI Noureddine Chirurgie Pédiatrique
Pr. KOUTANI Abdellatif Urologie
Pr. LAHLOU Mohamed Khalid Chirurgie Générale
Pr. MAHRAOUI CHAFIQ Pédiatrie
Pr. TOUFIQ Jallal Psychiatrie Directeur Hôp.Ar-razi Salé
Pr. YOUSFI MALKI Mounia Gynécologie Obstétrique NOVEMBRE 1998
Pr. BENOMAR ALI Neurologie Doyen de la FMP Abulcassis Pr. BOUGTAB Abdesslam Chirurgie Générale
Pr. ER RIHANI Hassan Oncologie Médicale
Pr. BENKIRANE Majid* Hématologie
JANVIER 2000
Pr. ECHARRAB El Mahjoub Chirurgie Générale Pr. EL FTOUH Mustapha Pneumo-phtisiologie
Pr. EL MOSTARCHID Brahim* Neurochirurgie
Pr. MAHMOUDI Abdelkrim* Anesthésie-Réanimation Pr. TACHINANTE Rajae Anesthésie-Réanimation Pr. TAZI MEZALEK Zoubida Médecine Interne NOVEMBRE 2000
Pr. AIDI Saadia Neurologie
Pr. AJANA Fatima Zohra Gastro-Entérologie
Pr. BENAMR Said Chirurgie Générale
Pr. CHERTI Mohammed Cardiologie
Pr. ECH-CHERIF EL KETTANI Selma Anesthésie-Réanimation
Pr. EL HASSANI Amine Pédiatrie - Directeur Hôp.Cheikh Zaid
Pr. EL KHADER Khalid Urologie
Pr. EL MAGHRAOUI Abdellah* Rhumatologie
Pr. GHARBI Mohamed El Hassan Endocrinologie et Maladies Métaboliques
Pr. MDAGHRI ALAOUI Asmae Pédiatrie
Pr. ROUIMI Abdelhadi* Neurologie
DECEMBRE 2000
Pr.ZOHAIR ABDELLAH * ORL
Pr. BALKHI Hicham* Anesthésie-Réanimation
Pr. BENABDELJLIL Maria Neurologie
Pr. BENAMAR Loubna Néphrologie
Pr. BENAMOR Jouda Pneumo-phtisiologie
Pr. BENELBARHDADI Imane Gastro-Entérologie
Pr. BENNANI Rajae Cardiologie
Pr. BENOUACHANE Thami Pédiatrie
Pr. BEZZA Ahmed* Rhumatologie
Pr. BOUCHIKHI IDRISSI Med Larbi Anatomie
Pr. BOUMDIN El Hassane* Radiologie
Pr. CHAT Latifa Radiologie
Pr. DAALI Mustapha* Chirurgie Générale
Pr. DRISSI Sidi Mourad* Radiologie
Pr. EL HIJRI Ahmed Anesthésie-Réanimation
Pr. EL MAAQILI Moulay Rachid Neuro-Chirurgie
Pr. EL MADHI Tarik Chirurgie-Pédiatrique
Pr. EL OUNANI Mohamed Chirurgie Générale
Pr. KABIRI EL Hassane* Chirurgie Thoracique Pr. LAMRANI Moulay Omar Traumatologie Orthopédie
Pr. LEKEHAL Brahim Chirurgie Vasculaire Périphérique Pr. MAHASSIN Fattouma* Médecine Interne
Pr. MEDARHRI Jalil Chirurgie Générale
Pr. MIKDAME Mohammed* Hématologie Clinique
Pr. MOHSINE Raouf Chirurgie Générale
Pr. NOUINI Yassine Urologie - Directeur Hôpital Ibn Sina
Pr. SABBAH Farid Chirurgie Générale
Pr. SEFIANI Yasser Chirurgie Vasculaire Périphérique Pr. TAOUFIQ BENCHEKROUN Soumia Pédiatrie
DECEMBRE 2002
Pr. AL BOUZIDI Abderrahmane* Anatomie Pathologique
Pr. AMEUR Ahmed * Urologie
Pr. AMRI Rachida Cardiologie
Pr. AOURARH Aziz* Gastro-Entérologie
Pr. BAMOU Youssef * Biochimie-Chimie
Pr. BELMEJDOUB Ghizlene* Endocrinologie et Maladies Métaboliques
Pr. BENZEKRI Laila Dermatologie
Pr. BENZZOUBEIR Nadia Gastro-Entérologie
Pr. BERNOUSSI Zakiya Anatomie Pathologique
Pr. BICHRA Mohamed Zakariya* Psychiatrie
Pr. CHOHO Abdelkrim * Chirurgie Générale
Pr. CHKIRATE Bouchra Pédiatrie
Pr. EL ALAMI EL Fellous Sidi Zouhair Chirurgie Pédiatrique
Pr. EL HAOURI Mohamed * Dermatologie
Pr. FILALI ADIB Abdelhai Gynécologie Obstétrique
Pr. HAJJI Zakia Ophtalmologie
Pr. IKEN Ali Urologie
Pr. JAAFAR Abdeloihab* Traumatologie Orthopédie
Pr. KRIOUILE Yamina Pédiatrie
Pr. MABROUK Hfid* Traumatologie Orthopédie
Pr. MOUSSAOUI RAHALI Driss* Gynécologie Obstétrique Pr. OUJILAL Abdelilah Oto-Rhino-Laryngologie Pr. RACHID Khalid * Traumatologie Orthopédie
Pr. RAISS Mohamed Chirurgie Générale
JANVIER 2004
Pr. ABDELLAH El Hassan Ophtalmologie
Pr. AMRANI Mariam Anatomie Pathologique
Pr. BENBOUZID Mohammed Anas Oto-Rhino-Laryngologie
Pr. BENKIRANE Ahmed* Gastro-Entérologie
Pr. BOULAADAS Malik Stomatologie et Chirurgie Maxillo-faciale
Pr. BOURAZZA Ahmed* Neurologie
Pr. CHAGAR Belkacem* Traumatologie Orthopédie
Pr. CHERRADI Nadia Anatomie Pathologique
Pr. EL FENNI Jamal* Radiologie
Pr. EL HANCHI ZAKI Gynécologie Obstétrique
Pr. EL KHORASSANI Mohamed Pédiatrie Pr. EL YOUNASSI Badreddine* Cardiologie
Pr. HACHI Hafid Chirurgie Générale
Pr. JABOUIRIK Fatima Pédiatrie
Pr. KHARMAZ Mohamed Traumatologie Orthopédie
Pr. MOUGHIL Said Chirurgie Cardio-Vasculaire
Pr. OUBAAZ Abdelbarre * Ophtalmologie
Pr. TARIB Abdelilah* Pharmacie Clinique
Pr. TIJAMI Fouad Chirurgie Générale
Pr. ZARZUR Jamila Cardiologie
JANVIER 2005
Pr. ABBASSI Abdellah Chirurgie Réparatrice et Plastique Pr. AL KANDRY Sif Eddine* Chirurgie Générale
Pr. ALLALI Fadoua Rhumatologie
Pr. AMAZOUZI Abdellah Ophtalmologie
Pr. AZIZ Noureddine* Radiologie
Pr. BAHIRI Rachid Rhumatologie Directeur Hôp. Al Ayachi Salé
Pr. BARKAT Amina Pédiatrie
Pr. BENYASS Aatif Cardiologie
Pr. DOUDOUH Abderrahim* Biophysique
Pr. EL HAMZAOUI Sakina * Microbiologie
Pr. HAJJI Leila Cardiologie (mise en disponibilité
Pr. HESSISSEN Leila Pédiatrie
Pr. JIDAL Mohamed* Radiologie
Pr. LAAROUSSI Mohamed Chirurgie Cardio-vasculaire
Pr. LYAGOUBI Mohammed Parasitologie
AVRIL 2006
Pr. ACHEMLAL Lahsen* Rhumatologie
Pr. AKJOUJ Said* Radiologie
Pr. BELMEKKI Abdelkader* Hématologie
Pr. BENCHEIKH Razika O.R.L
Pr. BIYI Abdelhamid* Biophysique
Pr. BOUHAFS Mohamed El Amine Chirurgie - Pédiatrique
Pr. BOULAHYA Abdellatif* Chirurgie Cardio – Vasculaire. Pr. CHENGUETI ANSARI Anas Gynécologie Obstétrique
Pr. DOGHMI Nawal Cardiologie
Pr. FELLAT Ibtissam Cardiologie
Pr. FAROUDY Mamoun Anesthésie Réanimation
Pr. HARMOUCHE Hicham Médecine Interne
Pr. HANAFI Sidi Mohamed* Anesthésie Réanimation Pr. IDRISS LAHLOU Amine* Microbiologie
Pr. JROUNDI Laila Radiologie
Pr. KARMOUNI Tariq Urologie
Pr. KILI Amina Pédiatrie
Pr. KISRA Hassan Psychiatrie
Pr. KISRA Mounir Chirurgie – Pédiatrique
Pr. LAATIRIS Abdelkader* Pharmacie Galénique Pr. LMIMOUNI Badreddine* Parasitologie
Pr. MANSOURI Hamid* Radiothérapie
Pr. OUANASS Abderrazzak Psychiatrie
Pr. SAFI Soumaya* Endocrinologie
Pr. SEKKAT Fatima Zahra Psychiatrie
Pr. SOUALHI Mouna Pneumo – Phtisiologie
Pr. TELLAL Saida* Biochimie
Pr. ZAHRAOUI Rachida Pneumo – Phtisiologie DECEMBRE 2006
Pr SAIR Khalid Chirurgie générale Dir. Hôp.Av.Marrakech OCTOBRE 2007
Pr. ABIDI Khalid Réanimation médicale
Pr. ACHACHI Leila Pneumo phtisiologie
Pr. ACHOUR Abdessamad* Chirurgie générale
Pr. BOUTIMZINE Nourdine Ophtalmologie Pr. CHERKAOUI Naoual * Pharmacie galénique Pr. EHIRCHIOU Abdelkader * Chirurgie générale
Pr. EL BEKKALI Youssef * Chirurgie cardio-vasculaire Pr. EL ABSI Mohamed Chirurgie générale
Pr. EL MOUSSAOUI Rachid Anesthésie réanimation
Pr. EL OMARI Fatima Psychiatrie
Pr. GHARIB Noureddine Chirurgie plastique et réparatrice
Pr. HADADI Khalid * Radiothérapie
Pr. ICHOU Mohamed * Oncologie médicale
Pr. ISMAILI Nadia Dermatologie
Pr. KEBDANI Tayeb Radiothérapie
Pr. LALAOUI SALIM Jaafar * Anesthésie réanimation
Pr. LOUZI Lhoussain * Microbiologie
Pr. MADANI Naoufel Réanimation médicale
Pr. MAHI Mohamed * Radiologie
Pr. MARC Karima Pneumo phtisiologie
Pr. MASRAR Azlarab Hématologie biologique
Pr. MRANI Saad * Virologie
Pr. OUZZIF Ez zohra * Biochimie-chimie
Pr. RABHI Monsef * Médecine interne
Pr. RADOUANE Bouchaib* Radiologie
Pr. SEFFAR Myriame Microbiologie
Pr. SEKHSOKH Yessine * Microbiologie
Pr. SIFAT Hassan * Radiothérapie
Pr. TABERKANET Mustafa * Chirurgie vasculaire périphérique
Pr. TACHFOUTI Samira Ophtalmologie
Pr. TAJDINE Mohammed Tariq* Chirurgie générale Pr. TANANE Mansour * Traumatologie-orthopédie
Pr. TLIGUI Houssain Parasitologie
Pr. TOUATI Zakia Cardiologie
DECEMBRE 2008
Pr TAHIRI My El Hassan* Chirurgie Générale MARS 2009
Pr. ABOUZAHIR Ali * Médecine interne
Pr. AGADR Aomar * Pédiatrie
Pr. AIT ALI Abdelmounaim * Chirurgie Générale Pr. AIT BENHADDOU El Hachmia Neurologie
Pr. ARKHA Yassir Neuro-chirurgie Directeur Hôp.des Spécialités Pr. BELYAMANI Lahcen* Anesthésie Réanimation
Pr. BJIJOU Younes Anatomie
Pr. BOUHSAIN Sanae * Biochimie-chimie
Pr. BOUI Mohammed * Dermatologie
Pr. BOUNAIM Ahmed * Chirurgie Générale
Pr. BOUSSOUGA Mostapha * Traumatologie-orthopédie
Pr. CHTATA Hassan Toufik * Chirurgie Vasculaire Périphérique
Pr. DOGHMI Kamal * Hématologie clinique
Pr. EL MALKI Hadj Omar Chirurgie Générale Pr. EL OUENNASS Mostapha* Microbiologie
Pr. ENNIBI Khalid * Médecine interne
Pr. FATHI Khalid Gynécologie obstétrique
Pr. HASSIKOU Hasna * Rhumatologie
Pr. KABBAJ Nawal Gastro-entérologie
Pr. KABIRI Meryem Pédiatrie
Pr. KARBOUBI Lamya Pédiatrie
Pr. LAMSAOURI Jamal * Chimie Thérapeutique Pr. MARMADE Lahcen Chirurgie Cardio-vasculaire
Pr. MESKINI Toufik Pédiatrie
Pr. MESSAOUDI Nezha * Hématologie biologique
Pr. MSSROURI Rahal Chirurgie Générale
Pr. NASSAR Ittimade Radiologie
Pr. OUKERRAJ Latifa Cardiologie
Pr. RHORFI Ismail Abderrahmani * Pneumo-Phtisiologie OCTOBRE 2010
Pr. ALILOU Mustapha Anesthésie réanimation
Pr. AMEZIANE Taoufiq* Médecine Interne
Pr. BELAGUID Abdelaziz Physiologie
Pr. CHADLI Mariama* Microbiologie
Pr. CHEMSI Mohamed* Médecine Aéronautique
Pr. DAMI Abdellah* Biochimie- Chimie
Pr. DARBI Abdellatif* Radiologie
Pr. DENDANE Mohammed Anouar Chirurgie Pédiatrique
Pr. EL HAFIDI Naima Pédiatrie
Pr. EL KHARRAS Abdennasser* Radiologie
Pr. EL MAZOUZ Samir Chirurgie Plastique et Réparatrice
Pr. EL SAYEGH Hachem Urologie
Pr. ERRABIH Ikram Gastro-Entérologie
DECEMBRE 2010
Pr.ZNATI Kaoutar Anatomie Pathologique
MAI 2012
Pr. AMRANI Abdelouahed Chirurgie pédiatrique Pr. ABOUELALAA Khalil * Anesthésie Réanimation Pr. BENCHEBBA Driss * Traumatologie-orthopédie
Pr. DRISSI Mohamed * Anesthésie Réanimation
Pr. EL ALAOUI MHAMDI Mouna Chirurgie Générale Pr. EL KHATTABI Abdessadek * Médecine Interne Pr. EL OUAZZANI Hanane * Pneumophtisiologie
Pr. ER-RAJI Mounir Chirurgie Pédiatrique
Pr. JAHID Ahmed Anatomie Pathologique
Pr. MEHSSANI Jamal * Psychiatrie
Pr. RAISSOUNI Maha * Cardiologie
* Enseignants Militaires FEVRIER 2013
Pr.AHID Samir Pharmacologie
Pr.AIT EL CADI Mina Toxicologie
Pr.AMRANI HANCHI Laila Gastro-Entérologie
Pr.AMOR Mourad Anesthésie Réanimation
Pr.AWAB Almahdi Anesthésie Réanimation
Pr.BELAYACHI Jihane Réanimation Médicale
Pr.BELKHADIR Zakaria Houssain Anesthésie Réanimation
Pr.BENCHEKROUN Laila Biochimie-Chimie
Pr.BENKIRANE Souad Hématologie
Pr.BENNANA Ahmed* Informatique Pharmaceutique
Pr.BENSGHIR Mustapha * Anesthésie Réanimation
Pr.BENYAHIA Mohammed * Néphrologie
Pr.BOUATIA Mustapha Chimie Analytique et Bromatologie Pr.BOUABID Ahmed Salim* Traumatologie orthopédie
Pr BOUTARBOUCH Mahjouba Anatomie
Pr.CHAIB Ali * Cardiologie
Pr.DENDANE Tarek Réanimation Médicale
Pr.DINI Nouzha * Pédiatrie
Pr.ECH-CHERIF EL KETTANI Mohamed Ali Anesthésie Réanimation Pr.ECH-CHERIF EL KETTANI Najwa Radiologie
Pr.EL JAOUDI Rachid * Toxicologie
Pr.EL KABABRI Maria Pédiatrie
Pr.EL KHANNOUSSI Basma Anatomie Pathologique
Pr.EL KHLOUFI Samir Anatomie
Pr.EL KORAICHI Alae Anesthésie Réanimation
Pr.EN-NOUALI Hassane * Radiologie
Pr.ERRGUIG Laila Physiologie
Pr.FIKRI Meryem Radiologie
Pr.GHFIR Imade Médecine Nucléaire
Pr.IMANE Zineb Pédiatrie
Pr.IRAQI Hind Endocrinologie et maladies métaboliques
Pr.KABBAJ Hakima Microbiologie
Pr.KADIRI Mohamed * Psychiatrie
Pr.MAAMAR Mouna Fatima Zahra Médecine Interne
Pr.MEDDAH Bouchra Pharmacologie
Pr.MELHAOUI Adyl Neuro-chirurgie
Pr.MRABTI Hind Oncologie Médicale
Pr.NEJJARI Rachid Pharmacognosie
Pr.OUBEJJA Houda Chirugie Pédiatrique
Pr.OUKABLI Mohamed * Anatomie Pathologique
Pr.RAHALI Younes Pharmacie Galénique
Pr.RATBI Ilham Génétique
Pr.RAHMANI Mounia Neurologie
Pr.REDA Karim * Ophtalmologie
Pr.REGRAGUI Wafa Neurologie
Pr.RKAIN Hanan Physiologie
Pr.ROSTOM Samira Rhumatologie
Pr.ROUAS Lamiaa Anatomie Pathologique
Pr.ROUIBAA Fedoua * Gastro-Entérologie
Pr SALIHOUN Mouna Gastro-Entérologie
Pr.SAYAH Rochde Chirurgie Cardio-Vasculaire
Pr.SEDDIK Hassan * Gastro-Entérologie
Pr.ZERHOUNI Hicham Chirurgie Pédiatrique
AVRIL 2013
Pr.EL KHATIB MOHAMED KARIM * Stomatologie et Chirurgie Maxillo-faciale MAI 2013
Pr.BOUSLIMAN Yassir Toxicologie
MARS 2014
Pr. ACHIR Abdellah Chirurgie Thoracique
Pr.BENCHAKROUN Mohammed * Traumatologie- Orthopédie
Pr.BOUCHIKH Mohammed Chirurgie Thoracique
Pr. EL KABBAJ Driss * Néphrologie
Pr. EL MACHTANI IDRISSI Samira * Biochimie-Chimie
Pr. HARDIZI Houyam Histologie- Embryologie-Cytogénétique
Pr. HASSANI Amale * Pédiatrie
Pr. HERRAK Laila Pneumologie
Pr. JANANE Abdellah * Urologie
Pr. JEAIDI Anass * Hématologie Biologique
Pr. KOUACH Jaouad* Gynécologie-Obstétrique
Pr. LEMNOUER Abdelhay* Microbiologie
Pr. MAKRAM Sanaa * Pharmacologie
Pr. OULAHYANE Rachid* Chirurgie Pédiatrique
Pr. RHISSASSI Mohamed Jaafar CCV
Pr. SABRY Mohamed* Cardiologie
Pr. SEKKACH Youssef* Médecine Interne
Pr. TAZI MOUKHA Zakia Gynécologie-Obstétrique
AVRIL 2014
PROFESSEURS AGREGES :
DECEMBRE 2014
Pr. ABILKASSEM Rachid* Pédiatrie
Pr. AIT BOUGHIMA Fadila Médecine Légale
Pr. BEKKALI Hicham * Anesthésie-Réanimation
Pr. BENAZZOU Salma Chirurgie Maxillo-Faciale
Pr. BOUABDELLAH Mounya Biochimie-Chimie
Pr. BOUCHRIK Mourad* Parasitologie
Pr. DERRAJI Soufiane* Pharmacie Clinique
Pr. DOBLALI Taoufik* Microbiologie
Pr. EL AYOUBI EL IDRISSI Ali Anatomie
Pr. EL GHADBANE Abdedaim Hatim* Anesthésie-Réanimation
Pr. EL MARJANY Mohammed* Radiothérapie
Pr. FEJJAL Nawfal Chirurgie Réparatrice et Plastique
Pr. JAHIDI Mohamed* O.R.L
Pr. LAKHAL Zouhair* Cardiologie
Pr. OUDGHIRI NEZHA Anesthésie-Réanimation
Pr. RAMI Mohamed Chirurgie Pédiatrique
Pr. SABIR Maria Psychiatrie
Pr. SBAI IDRISSI Karim* Médecine préventive, santé publique et Hyg. AOUT 2015
Pr. MEZIANE Meryem Dermatologie
Pr. TAHRI Latifa Rhumatologie
JANVIER 2016
Pr. BENKABBOU Amine Chirurgie Générale
Pr. EL ASRI Fouad* Ophtalmologie
Pr. ERRAMI Noureddine* O.R.L
Pr. NITASSI Sophia O.R.L
JUIN 2017
Pr. ABI Rachid* Microbiologie
Pr. ASFALOU Ilyasse* Cardiologie
Pr. BOUAYTI El Arbi* Médecine préventive, santé publique et Hyg.
2 - ENSEIGNANTS-CHERCHEURS SCIENTIFIQUES
PROFESSEURS/Prs. HABILITES
Pr. ABOUDRAR Saadia Physiologie
Pr. ALAMI OUHABI Naima Biochimie-chimie
Pr. ALAOUI KATIM Pharmacologie
Pr. ALAOUI SLIMANI Lalla Naïma Histologie-Embryologie
Pr. ANSAR M’hammed Chimie Organique et Pharmacie Chimique
Pr .BARKIYOU Malika Histologie-Embryologie
Pr. BOUHOUCHE Ahmed Génétique Humaine
Pr. BOUKLOUZE Abdelaziz Applications Pharmaceutiques Pr. CHAHED OUAZZANI Lalla Chadia Biochimie-chimie
Pr. DAKKA Taoufiq Physiologie
Pr. FAOUZI Moulay El Abbes Pharmacologie
Pr. IBRAHIMI Azeddine Biologie moléculaire/Biotechnologie
Pr. KHANFRI Jamal Eddine Biologie
Pr. OULAD BOUYAHYA IDRISSI Med Chimie Organique
Pr. REDHA Ahlam Chimie
Pr. TOUATI Driss Pharmacognosie
Pr. ZAHIDI Ahmed Pharmacologie
Mise à jour le 10/10/2018 Khaled Abdellah
To Allah
First and Foremost I would like to praise and thank Allah, the Almighty. Thank You for being there when nobody else was. Thank You for helping me to
find peace when I was facing trials beyond my understanding. Thank You for the things that didn’t work out the way I once wanted them to, for your plan is
always better. Thank You for steering my life in the path of science and knowledge. Thank You for every breath and for every second. Thank You for
everything. Alhamdulillah.
To myself
I dedicate this work to myself, with pride and honor. When I look back over the past three years, I see the pain I have endured, the mistakes I have made, the fear, weakness, failure and all the hard times I have suffered all on my own. There were
lots of tears, sleepless nights and moments when I couldn’t believe in myself; it was very hard getting to this point and not giving up the fight. Now, when I look in the mirror, I see how strong I have become, and all the lessons I have learned, particularly
how to walk alone, pick myself back up and rise from the ashes. I’m grateful for the storm, I’m grateful for the closed doors, I’m grateful for all the hardships and turmoil
To my loving father M’feddal AGHOUTANE
“A father is always making his baby into a little woman. And when she is a woman he turns her back again.” ―Enid Bagnold
The most amazing father! My source of inspiration and knowledge.. No words can express my respect, recognition and deep love. I want to thank you for raising me to become the person I am today. You always believed in me, showered me with infinite wisdom, taught me the value of hard work, and perseverance and pushed me to aspire to greatness rather than simply being content; all of this has shaped my objectives and
interests, and helped me to achieve them. I wouldn’t be where I am today if it wasn’t for your never ending support, guidance and encouragement. I hope to keep making
you proud and never disappoint you.
May Allah the Almighty grant you good health and long life. I love you baba, thanks!
To my loving mother SETITAH Fatima
“Most mothers are instinctive philosophers.” —Harriet Beecher Stowe
The world’s most wonderful mother! Words can never describe my great affection and deep gratitude. Thanks to your sacrifices, endless prayers and your inexhaustible patience, I persevered and never gave up. You’re my source of strength and my rock,
the thing that kept me going when I wanted to quit. I want you to know that your love and encouragement have been the foundation for my success, which is your success because without your values and wisdom, I never would have grown into the
woman I am today. I would not be standing here today if it wasn’t for your unconditional support. I hope to never disappoint you nor betray your trust.
To my sister Kawthar
You are more than just a sister; you are my friend and my confident. Thank you for all the immeasurable effort you have invested in order to help me. You have encouraged me every step of the way, your unconditional support, especially through this past period, kept me strong and pushed me to do my best and follow my dreams. I
love you!
I also would like to dedicate this work to your baby, Salma, the most wonderful niece in the world; her little bright smiles and kisses were like a stress relief medication that
helped me through my difficult times. May Allah bless her and protect her. My thanks go also to your husband Marouane El Rhazi, who strongly encouraged
me and always amused me with his funny and sarcastic comments.
To my brother Ahmed
Your brotherly love is out of the common! You had faith in me even when I doubted myself. I can’t thank you enough for putting up with my constant complaining and
my endless solicitations. I will forever be grateful to you for your help, support, encouragement, and the countless car rides. I love you!
To my brother Omar
You are my little piece of heaven. Thank you for always being there to provide me with whatever I ask for, and for tolerating my mood swings. I am so proud to be your
sister. I will always be there for you, to hold you and inspire you; and I cannot wait to see you become the successful decent man I know you can be. I love you!
To my sister Bouchra
I would like to express my deepest gratitude to you, my dear sister. Thank you for your encouragement and motivation during all these years. I feel really privileged to
have you as a sister. I dedicate this work to you, as an expression of my most sincere affection. I love you !
This work is also dedicated to your husband Zoubir Frej and your sons, my two lovely nephews Anas and Ilyas. May Allah bless them and protect them.
To my cousin Jalal
You are like a brother to me. You have given me so much needed encouragement and support that has helped me tremendously. I also would like to mention your adorable wife Meryem Bellarbi and your lovely son El Yazid, whom I love so much, may Allah bless him and protect him. I dedicate this work to the three of you, as an expression of
my most sincere affection.
To my soul sister Abenyoujil Fatima Ezzahrae
Thank you for the 13 years of loyalty. Words can never suffice to properly give you your merit. I affectionately dedicate this work to you. May Allah protect you, your
husband and your son. I love you!
To my dear friends
Aboulmakarim Aïda, Harmouch Fadwa, Adil Hajar, Ait Ahmed Sahar, Arbouni Hind, Arhoutane Safae, Askaioui Laila, Azriouil Manal, Baba Safaa, Eddouali Wafae, Chater Meryem, Chaoubi Ikram, Elbhali Hajar, El mahi Jihane, Elmeliani
Amal, Essabani Sheimae, Oumachtaq Hajar, Blali Fadoua, Soukaina Alami… I dedicate this work to you as an expression of my gratitude for all the great memories, all the fun, laughter and smiles, and all the beautiful crazy moments we
To my dear grandmother, grandfather, aunties, uncles, cousins and all my family
Thank you for your countless prayers and encouragement.
To the memory of my paternal grandparents and my uncle
I wish you were among us on this memorable day. May Allah rest your souls in peace and grant you the best place in paradise.
To my friends and colleagues who I inadvertently failed to mention To all my teachers in the Second Royal Military High School of Ifrane
Especially: Mr Rayane Mohammed, Mr Oumachtaq Youssef, Mr Sabri Kamal, Mr Achir, Mr Chadli Hasan and Mr Ferhane Zouhair
I feel really privileged to have been taught by you, for teachers as devoted as you are rather few. I would like to dedicate my work to you as an expression of my deep
gratitude. Thank you !
To all my teachers in primary and secondary school To all my professors in medical school of Rabat To all those who have touched my life in any way.
I would like to express my sincere gratitude to the reviewers of this thesis.
To our master and jury president Professor AL BOUZIDI Abderrahmane
Professor of anatomic pathology
You granted us a great honor by accepting to preside over the jury of our thesis. This work will be an opportunity to express our consideration and deep
admiration for all of your scientific and human qualities. Please accept the expression of my deep gratitude for your time and effort to go through my
To our master and thesis director Professor AMEUR Ahmed Professor of urologic surgery
You have honored me by agreeing to entrust me with this work. I would like to express my deepest heartfelt thanks and appreciation for your precious assistance, patience, dynamism and kindness; also for providing me with all that was needed to complete this project. Without your continuous motivation, support and encouragement, it could not be possible to conduct this research. I
To our master and thesis judge Professor ALAMI Mohammed Professor of urologic surgery
I owe you my deepest gratitude for accepting to judge this thesis work and to be a member of this honorable jury. Your presence is a great honor and will definitely be a strong add-on for the evaluation of my work. Please accept the
To our master and thesis judge Professor ELSAYEGH Hachem
Professor of urologic surgery
Your kindness of agreeing to be a member of this honorable jury is deeply appreciated; thank you for honoring us with your presence and your interest in
our thesis topic. Your knowledge and your expertise will absolutely be generously valuable in this thesis work. Please find here the expression of my
To Dr Tetou, Dr EL Bahri, Hajar and all the urology department team
Thank you for your helpfulness and kindness; and for making my time in the department’s archives so enjoyable.
List of Abbreviations
ADH : Antidiuretic hormoneAMP : Antimicrobial prophylaxis CDD : Charge coupled devices CO : Cardiac output
CO2 : Carbon dioxide
COTT : Cuffed oral tracheal tube CT : Computed tomography DVT : Deep venous thrombosis
eGFR : Estimated glomerular filtration rate ETCO2 : End tidal carbon dioxide
FDA : Food and Drug Administration FRC : Functional residual capacity GIA : Gastrointestinal anastomosis
HALN : Hand-assisted laparoscopic nephrectomy IAP : Intra-abdominal pressure
IVC : Vena cava
LBP : Low back pain LK : Left kidney
LMA : Laryngeal mask airway
MAC : Main renal artery clamping
MDRD : Modification of Diet in Renal Disease MRI : Magnetic resonance imaging
N2O : Nitrous oxide
NSAIDs : Nonsteroidal anti-inflammatory drugs PaCO2 : Partial pressure of carbon dioxide PCD : Pneumatic compression devices PE : Pulmonary embolism
PEG : Polyethylene glycol
PONV : Postoperative nausea and vomiting PP : Pneumoperitoneum
PT : Prothrombin time RCC : Renal cell carcinoma RK : Right kidney
SAC : Selective renal artery clamping SMA : Superior mesenteric artery SVR : Systemic vascular resistance TIVA : Total intravenous anesthesia UH : Unfractionated heparin VTE : Venous thromboembolism
ILLUSTRATIONS
List of figures
Figure 1: Gross anatomy of the kidney (anterior view) ... 8 Figure 2: Horizontal section through the abdomen to show renal fascia... 10 Figure 3: Coronal section of the left kidney ... 12 Figure 4: Section of kidney showing the position of nephrons. The nephron is the functional unit of the kidney ... 13 Figure 5: Posterior relations of the kidneys ... 16 Figure 6: Anterior relations of the kidneys ... 17 Figure 7: Renal and related vessels. ... 19 Figure 8: Vascular anatomy of the kidney. ... 20 Figure 9: Graves’ anatomic classification of segmental renal arteries ... 21 Figure 10: Blood flow in the kidney. ... 22 Figure 11: Instrumentation of visualization. ... 32 Figure 12: Examples of insufflator units and their control inputs. ... 34 Figure 13: The Veress needle ... 36 Figure 14: Examples of bladed and non-bladed trocars ... 37 Figure 15: Retractor systems ... 43 Figure 16: LigaSure device ... 44 Figure 17: EnSeal sealing device ... 45 Figure 18: Harmonic Scalpel ... 45 Figure 19: Argon beam coagulation ... 46 Figure 20: Caiman radiofrequency sealing device ... 46 Figure 21: Thunderbeat device ... 47 Figure 22: A,Bulldog clamp. B, Laparoscopic clamping performed with a bulldog clamp .... 49 Figure 23: Deployment of an Endo Catch ... 51 Figure 24: The operating room configuration ... 54 Figure 25: Laparoscopy instruments tray ... 55
Figure 28: Patient and laparoscopic cart ... 57 Figure 29: The Veress technique ... 60 Figure 30: Port placement: three-trocar configuration ... 63 Figure 31: Port placement: four-trocar configuration ... 64 Figure 32: Triangulation rule. ... 65 Figure 33: Port placement : three-trocar configuration ... 66 Figure 34: Incision of the white line of Toldt ... 69 Figure 35: Division of the colorenal attachments during a left-sided nephrectomy ... 70 Figure 36: Mobilization of the duodenum for right-sided radical nephrectomy, using a Kocher maneuver ... 70 Figure 37: Colon mobilization and dissection. ... 71 Figure 38: Dissection of the ureter. ... 73 Figure 39: Dissection of the ureter. ... 73 Figure 40: Exposure and dissection of the hilum ... 75 Figurre 41: Exposure (A) and dissection (B) of the renal hilum. ... 76 Figure 42: Renal hilum ligature (left side) ... 78 Figure 43: En bloc stapling of the renal hilum. ... 78 Figure 44: Renal hilum transection ... 79 Figure 45: Mobilization of the kidney and the adrenal gland (right side) ... 81 Figure 46: Mobilization of the kidney and the adrenal gland (left side) ... 81 Figure 47: Mobilization of the kidney : upper pole dissection. ... 82 Figure 48: Transection of the ureter. ... 82 Figure 49: Specimen entrapment. ... 85 Figure 50: Specimen entrapment. ... 85 Figure 51: Removal of an intact specimen ... 86 Figure 52: Specimen removal. ... 86 Figure 53: Laparoscopic ultrasound to locate the mass. ... 91
Figure 57: Tumor resection ... 93 Figure 58: Repair of a collecting system injury. ... 93 Figure 59: Application of a biological hemostatic agent ... 94 Figure 60: Bolstered renorrhaphy. ... 94 Figure 61: Patient position for retroperitoneoscopic surgery... 99 Figure 62: Balloon dilation displaces Gerota fascia and the kidney anteromedially. P, Posterior abdominal wall musculature. ... 99 Figure 63: Patients’ ages by years ... 113 Figure 64: Gender distribution of the study population. ... 114 Figure 65: Discovery circumstances. ... 115 Figure 66: Type of resection. ... 119 Figure 67: Side operated. ... 119 Figure 68: Conversion ... 120 Figure 69: Anatomic pathology results ... 121 Figure 70: Complications ... 122
LIST OF TABLES
Table 1: Graspers for traditional laparoscopic surgery ... 40 Table 2: Different types of laparoscopic dissectors ... 41 Table 3: Different types of laparoscopic scissors ... 41 Table 4: Instruments for suturing and knot tying ... 42 Table 5: Various types of clip appliers and clamps ... 50 Table 6: Extractor specifications ... 50 Table 7: Operating room set-up check list ... 53 Table 8: Summary of our patients’ clinical data ... 105 Table 9: Summary of biological tests’ results ... 107 Table 10: Summary of radiological examinations’ results ... 108 Table 11: Summary of our patients’ operative data... 110 Table 12: Summary of our patients’ postoperative data ... 111 Table 13: Patients’ past histories. ... 114 Table 14: Circumstances of discovery. ... 115 Table 15: Reports of laparoscopic nephrectomy. ... 132 Table 16: Comparison of laparoscopic and open nephrectomy ... 141
INTRODUCTION ...1 HISTORY AND BACKGROUND ...3 ANATOMY...6 I) External anatomy...7 1) Gross anatomy ...7 2) Capsules of the kidney ...9 II) Internal and microscopic anatomy ... 11 a- Cortex ... 11 b- Medulla ... 11 c- The calyceal system and the renal pelvis ... 11 III) Anatomical relations ... 14 1) Superior ... 14 2) Inferior ... 14 3) Posterior ... 14 4) Anterior... 15 5) Peritoneal relations ... 15 IV) Vasculature ... 18 1) Arterial ... 18 2) Venous ... 23 3) Lymphatic ... 23 4) Nerve supply ... 23 V) Applied surgical anatomy... 24
1) Physiological effects of laparoscopic surgery ... 26 a- Pulmonary and respiratory changes ... 26 b- Cardiovascular changes ... 27 c- Miscellaneous changes ... 28 2) Anesthesia in laparoscopic surgery ... 29 II) Laparoscopic instrumentation ... 30 1) Instrumentation for visualization ... 30 a- Light source ... 30 b- Light cable transmitter ... 30 c- Camera ... 31 d- Scope ... 31 e- Monitor ... 32 2) Insufflation system ... 33 a- Insufflator unit ... 33 b- Tubing equipment ... 33 c- Insufflation gas ... 33 3) Suction-irrigation system ... 35 4) Operating instruments ... 35 4.1- Access instruments ... 35 4.2- Manipulation instruments... 38 a- Instruments for dissection ... 38 b- Needle drivers and suturing instruments ... 39 c- Retractors ... 39
b- Mechanical vascular control ... 47 c- Biologic hemostasis ... 47 4.4- Specimen retrieval ... 48 III) Transperitoneal approach ... 52 1) Patient positioning and initial preparation ... 52 a) Operating room and equipment set-up ... 52 b) Patient positioning ... 56 2) Access and port placement ... 58 A. Obtaining the pneumoperitoneum ... 58 B. Port placement... 61 3) Surgical technique ... 67 3.1- Simple / Radical nephrectomy... 67 a) Colon mobilization ... 67 b) Ureter and gonadal vessels identification ... 72 c) Exposure and dissection of the renal hilum ... 74 d) Renal hilum ligature and transection ... 77 e) Mobilization of the kidney and the adrenal gland ... 80 f) Ligation and transection of the ureter ... 80 g) Entrapment and specimen extraction ... 83 3.2- Partial nephrectomy ... 87 a) Vessels dissection ... 87 b) Tumor localization ... 87 c) Tumor dissection and resection ... 87
3.5- Postoperative management ... 95 IV) Alternative approaches ... 96 1) Hand-assisted approach ... 96 2) Retroperitoneal approach ... 97 MATERIAL AND METHODS ... 100 I- Type of study ... 101 II- Objective... 101 III- Inclusion criteria ... 101 IV- Exclusion criteria ... 101 V- Data collection ... 102 A- Preoperative data ... 105 B- Operative data ... 110 C- Postoperative data ... 111 RESULTS ... 112 A) Preoperative Data ... 113 I- Epidemiology ... 113 II- Clinical data ... 114 1. Past history of the patients ... 114 2. Discovery circumstances ... 115 III- Paraclinical data ... 116 1. Biological assessment ... 116 2. Imaging examinations ... 116 a) Ultrasound scan ... 116
d) Magnetic resonance imaging (MRI) ... 117 B) Operative data ... 118 I- Preoperative preparation ... 118 1. Bowel preparation ... 118 2. Antibiotic prophylaxis ... 118 3. Anti-thrombotic prophylaxis ... 118 4. Skin preparation ... 118 II- Type of resection ... 118 III- Intraoperative complications ... 120 IV- Conversion ... 120 V- Anatomic pathology results ... 121 C) Postoperative data ... 122 I- Complications ... 122 II- Length of hospital stay ... 122 III- Postoperative pain management... 122 DISCUSSION ... 123 I- Indications ... 124 II- Preoperative preparation ... 125 1) Patient selection ... 125 2) Consent ... 126 3) Preoperative evaluation should include ... 127 4) Bowel preparation ... 128 5) Antibiotic prophylaxis ... 128
III- Postoperative management ... 130 1) Postoperative pain management ... 130 2) Length of hospital stay ... 131 IV- Conversion ... 133 V- Complications ... 134 1) Physiological complications ... 134 2) Access related complications ... 135 3) Intra-operative complications ... 136 4) Postoperative complications ... 137 5) Complications in the literature ... 138 VI- Laparoscopy versus open surgery ... 139 CONCLUSION ... 142 ABSTRACTS ... 144 REFERENCES ... 148
The modern endoscopic/laparoscopic era’ beginning is in the early 19th century with the description of a cystoscope by Phillip Bozzini.1
Since the mid-1990s, there has been an evolution in surgical practice from traditional open approaches toward minimally invasive means of treating operative lesions. In 1991, Clayman and associates reported the first simple laparoscopic nephrectomy (LN) on a 54-year-old woman with oncocytoma.7, 75
Nowadays, LN is ubiquitous at all major institutions, and due to continued improvement in instrumentation, the procedure has replaced open nephrectomy as the preferred approach for treating most pathologic conditions of the kidney requiring extirpative surgery.127 The advantages of reduced blood loss, decreased analgesia requirements for postoperative pain, shorter hospital stay, earlier return to normal activities, and improved cosmesis compared to the open approach are well documented.71 Other laparoscopic kidney procedures have also followed suit, namely, laparoscopic donor nephrectomy (LDN), laparoscopic partial nephrectomy (LPN), and laparoscopic pyeloplasty (LP).127
There are three basic laparoscopic approaches for nephrectomy: transperitoneal, retroperitoneal, and hand-assisted. The transperitoneal route is the traditional method used to perform laparoscopic surgery.72
Our study is retrospective over a period of 2 years between April 2015 and July 2017 regarding 18 patients who have undergone a transperitoneal laparoscopic nephrectomy (simple/radical) for a variety of pathologies, in the department of urology in Mohammed V Military Instruction Hospital of Rabat (HMIMV). The purpose of this study is to report the experience of our department regarding the transperitoneal laparoscopic nephrectomy technique: namely, discussing the preoperative and postoperative management, and analyzing the results in terms of feasibility and morbidity.
HISTORY AND
BACKGROUND
The beginning of the modern endoscopic/laparoscopic era is the early 19th century when Phillip Bozzini described a cystoscope (1805). This early endoscope consisted of a complex system of reflecting mirrors, candles, and a urethral cannula.1
It’s in 1901 that the term coelioscopy was firstly used, when George Kelling, a surgeon from Desden, Germany, examined the peritoneal cavity of a living dog by using pneumoperitoneum. He applied the method in humans in 1910 but he failed to publish his work.2; 3
The investigator generally considered to be the man responsible for popularizing the technique in humans, was the Stockholm-born physician Hans Christian Jakobaeus, who is credited with coining the term “laparoscopy” (“laparothorakoskopie”) when he published his clinical experience in 1910; at almost the same time, Bertram Bernheim performed the first laparoscopic procedure In the United States at Johns Hopkins University Hospital. 2; 4; 5; 6
This had opened up to different stages of technological development; the most critical one was the invention of the Hopkins rods-lens system in 1952, which have paved the way to the modern laparoscopy.
In urological surgery, the first interventions date back to the 1980s, but they were limited to rare indications such as varicoceles, testicular ectopias and lymph node dissection. But in fact, the real development of laparoscopic urology started after the first transperitoneal laparoscopic nephrectomy performed by Ralph Clayman and his team at Washington University in 1991, followed a few months later, by a same case performed in Dijon by a French team: Ferry.7; 8 Two years later, GAUR was the first to propose the retroperitoneal approach to perform simple nephrectomies.9
From 1991 to 1994, small series publications appeared, with a high complication rate, related to both the learning curve and the less standardized techniques. It is only since 1994 that considerable progress has been made along with more expanded series and better standardized techniques.10
In fact, we can say that from 1998 laparoscopy has become a useful and reliable technique in urology, owing to better codified interventions, and thus better defined laparoscopy. This evolution has allowed more meticulous gestures thanks to a finer anatomy (the image is enlarged by more than 15 times), but the most interesting aspect of laparoscopy is that of the intracorporeal construction: Ureteral reimplantation, pyeloplasty, colposuspension...7; 11
I) External anatomy
1) Gross anatomy
(Figure 1)- Location and measurements :
The kidneys are a pair of highly vascular (receiving 20% of the cardiac output) solid organs located in the retroperitoneal space against the posterior abdominal wall between the transverse processes of T12-L3 vertebrae. Kidneys are mobile and their position changes during respiration. The right kidney is lower than the left pushed down by the liver.13
Each kidney weighs between 130 and 150g and is about 10-12 cm long, 5-7 cm wide, and 3-4 cm thick. 13
- External features :
Kidneys have a very distinct shape and color; they are bean-shaped and dark-red in color.
Each kidney has:
Two poles : superior and inferior
Two surfaces : anterior and posterior
Two borders: the lateral bulges outward (convex) and the medial is indented (concave).
Hilum : In the medial surface of the indented section of each kidney there is a depression, known as the hilum which opens into the renal sinus – a central space surrounded by the renal parenchyma where structures servicing the kidneys -vessels, nerves, lymphatics, and ureters- enter and exit.14; 152) Capsules of the kidney
(Figure 2)Each kidney is covered by a thin fibroelastic structure, the renal capsule; which is surrounded by a protective layer of fat, peri-renal fat or the adipose capsule of the kidney. Another layer of connective tissue termed the renal fascia (Gerota’s fascia) encapsulates the kidney along with the peri-renal fat and the suprarenal gland. The anterior and posterior leaves of Gerota’s fascia extend anterior and posterior to the kidney to fuse laterally, medially (where they extend across the midline and fuse densely to great vessels) and superiorly (where they fuse and disappear over the inferior diaphragmatic surface). A second layer of fat, para-renal fat, lies external to the renal fascia.13; 14
Thus, the renal capsules are not only a storage container for internal components of the kidneys, but they also protect against infections and trauma.15
P.s: The kidneys perform multiple functions:
- Filtration and excretion of metabolic waste products
- Regulation and maintenance of fluid, electrolyte and acid base balance - Regulation of blood pressure via the renin–angiotensin–aldosterone system
- Stimulation of production of erythrocytes via secretion of erythropoietin - Calcium regulation via calcitriol production and vitamin D activation.13
Figure 2: Horizontal section through the abdomen to show renal fascia, as described in the text. The arrow indicates the lumbar approach to the kidney.18
II) Internal and microscopic anatomy
(Figures 3 and 4)
A Coronal section through the kidney reveals 3 regions: an outer cortex, a medulla in the middle, and the renal pelvis in the hilum.
a- Cortex
The renal cortex, the paler layer, is packed with glomeruli, proximal and distal convoluted tubules of nephrons and collecting tubules.
b- Medulla
The renal medulla, the darker layer, is composed of 7-18 triangular masses of tissue called renal pyramids (Malpighi’s pyramids).13Each pyramid- containing Henle loops of nephrons with their 2 limbs (descending and ascending), and collecting ducts of Bellini- creates urine and terminates into a renal papilla16. In between the pyramids are spaces called renal columns (columns of Bertin) through which the blood vessels pass. 17
c- The calyceal system and the renal pelvis
Each renal papilla drains into a collecting pool called a minor calyx; several minor calyces connect to form a major calyx; all major calyces connect to the single renal pelvis which connects to the ureter through the ureteropelvic junction (UPJ). 13; 16
III) Anatomical relations
1) Superior
- The superior pole of the kidney is covered by the suprarenal glands.
- The upper part of the kidney is usually separated by the diaphragm from the pleura and lung. However, in the vertebrocostal trigone, the kidney and the pleura may be separated only by connective tissue. 18
2) Inferior
Inferiorly, the two leaves of Gerota’s fascia do not fuse, and there remains an open potential space containing the ureter and gonadal vessels on either side which thins and is continuous with the retroperitoneal fascia.14
3) Posterior
(Figure 5) Right:- Diaphragm - 12th rib
- Psoas major, quadratus lumborum and transversus abdominis - Subcostal vessels and nerve/ iliohypogastric and ilioinguinal nerves
Left :
- Diaphragm - 11th and 12th ribs
4) Anterior
(Figure 6) Right : - Liver - Duodenum- Right colic flexure ( hepatic flexure) - Small intestine
Left : - Spleen - Stomach - Pancreas
- Left colic flexure (splenic flexure) - Small Intestine 19
5) Peritoneal relations
The kidneys are retroperitoneal. Certain areas of each kidney are covered anteriorly by the peritoneum (the hepatorenal and the hepatocolic ligaments in right; the splenorenal and splenocolic ligaments in left) whereas others are bare.14; 18
Figure 5: Posterior relations of the kidneys. The posterior Relations of 2 kidneys are the same, with the exception of that right kidney is related to 1 rib while left kidney is associated with
Figure 6: Anterior relations of the kidneys. The areas covered by peritoneum are shown in blue. In addition to the renal vessels, the origins of the celiac, superior mesenteric, gonadal (testicular or ovarian), and inferior mesenteric arteries are included, as are the terminations of the gonadal
IV) Vasculature
The kidneys are well vascularized and receive 25 percent of the cardiac output at rest.16 The vascular pedicle composed of the posterior sited renal artery and more interiorly sited renal vein enters the kidney via the renal hilum medially. 14
1) Arterial
(Figures 7 ; 8 ; 9 ; 10)
The renal arteries come off perpendicularly from the lateral aspect of the aorta just below the level of the SMA at L2 level.13 The right renal artery is longer than the left because it passes posteroinferiorly behind the IVC to the lower right kidney. 14
The first branch of the renal artery is to the respective suprarenal gland (the inferior suprarenal artery). It also provides branches to the renal pelvis and upper part of the ureter. 13
Thereafter, as approaching the hilum, the renal artery subdivides into five segmental arteries, one posterior (dorsal) and four anterior or ventral (apical, upper, middle and lower). All five are end arteries, without anastomosis or collaterals. 14
These branches undergo further divisions to supply the renal parenchyma:
Each segmental artery divides to form interlobar arteries. They are situated either side every renal pyramid.19
At the junction of the renal cortex and medulla, the interlobar arteries branch into arcuate arteries, interlobular arteries and then into afferent arterioles. 17 The afferent arterioles form a capillary network where filtration takes place,
the glomerulus. The glomerular capillaries come together to form the efferent arterioles. 19
Figure 8: Vascular anatomy of the kidney. A 25° left posterior oblique image obtained during selective renal arteriography, shows bifurcation of the main renal artery into dorsal (D) and
Figure 9: Graves’ anatomic classification of segmental renal arteries. The illustration features the right kidney; the left is similar. In addition to the classical variant, a high percentage of patients show anatomic variations. Courtesy of V. Ficarra, University of Udine, and V. Macchi,
2) Venous
(Figures 7 and 10)The venous drainage of each kidney is carried out by the corresponding renal vein. Veins trace the path of the arteries and have similar names except there are no segmental veins. 17
Veins from all the segments communicate extensively with each other unlike the arteries which are end arteries. 13
The efferent arterioles turn into peritubular capillaries (in the outer two-thirds of the cortex) and vasa recta (in the inner third of the cortex and the medulla) that merge to form five to six veins. These in turn unite in the region of the sinus to become the renal veins. 19; 14
The renal veins leave the renal hilum anteriorly to the renal arteries, and empty directly into the IVC. 19
The left renal vein is longer than the right, as it crosses the midline anterior to the abdominal aorta below the origin of the SMA to reach the IVC. It also receives the left gonadal vein, left suprarenal vein and lumbar veins whereas on the right side they drain directly into the IVC. 13
3) Lymphatic
The lymphatic drainage is similar to the venous drainage. The renal lymph nodes anatomical distribution area is very extensive and varies from one individual to another.24
Generally, the ultimate lymph drainage for the left kidney is to the left paraaortic lymph nodes and on the right to the right interaortocaval and paracaval lymph nodes.14
4) Nerve supply
The preganglionic sympathetic nervous innervation to the kidneys arises from the spinal cord at the level of T10 to L1 27. They synapse onto the coeliac and aorticorenal ganglia and follow the thoracolumbar splanchnic nerve to provide vasomotor supply 26.
Parasympathetic fibers from the vagus nerve as well as fibers from the intermesenteric plexus (S2 to S4) also innervate the kidneys.
Branches that include pain fibers from the renal pelvis and calyces travel via the coeliac plexus to the sympathetic trunk by route of the splanchnic nerves. 26
V) Applied surgical anatomy
The kidneys are retroperitoneal organs and therefore they can be operated on surgically with laparoscopic or open approaches – both can be either transperitoneal or retroperitoneal.28 Depending on which surgical approach is used, the patient may need to be positioned either supine, prone or in the lateral position. It should be noted that the lower ribs are closely related to the kidneys, which increases the risk of potential pleural/lung injury during surgery or percutaneous interventions of the kidney. 13
The kidneys are extremely vascular and hence the risk of bleeding must be taken into account.28 Moreover, it is worth to highlight that the internal anatomy is radially oriented; the intrarenal arteries, veins and calyces fan out radially from the hilar sinus towards the lateral convex border of the kidney. Thus, a radial nephrotomy incision during unclamped partial nephrectomy may result in less bleeding than for a nonradial incision.29 Furthermore, as quoted previously, the line of Brodel is avascular; therefore it provides safe access to the pelvicalyceal system for procedures such as nephrostomy insertion or stone retrieval. 13
In the case of renal masses an understanding of the renal anatomy and vasculature is essential for preoperative surgical planning. For this reason, three anatomy-based nephrometry scoring systems have been proposed to provide standard, more objective
LAPAROSCOPIC
NEPHRECTOMY: GENERAL
CONSIDERATIONS,
DESCRIPTION AND
TECHNICAL ASPECTS
I) Fundamentals of laparoscopy
Most of the organs in the genitourinary system lie within the retroperitoneum or in the extraperitoneal space. The retroperitoneum can be entered either directly or transperitoneally; that being so, there are three basic laparoscopic approaches for nephrectomy: transperitoneal, retroperitoneal, and hand-assisted. There are no prospective perioperative or postoperative outcome data supporting one approach or the other; therefore, the decision of which approach to choose is left to the surgeon’s discretion relying on his personal skills and experience; it also depends upon many other factors such as the operation to be performed, the patient’s body habitus and a prior history of abdominal surgery. 32 ; 33 ; 48
1) Physiological effects of laparoscopic surgery
Laparoscopic surgery affects haemodynamics and respiration, even in healthy patients. These physiological effects can be deleterious for patients with cardiopulmonary comorbidity. Those influences are related to the combination of the various means used to allow surgeons to see the surgical field during laparoscopic operation: Elevated intra-abdominal pressure (IAP) / the gas used (absorption of the the insufflated gas) / the patient positioning.
a- Pulmonary and respiratory changes
The pneumoperitoneum is created by insufflation of carbon dioxide (CO2) which is the gas of choice during laparoscopic surgery. The raised intra-abdominal pressure during pneumoperitoneum alters respiratory mechanics.
Pneumoperitoneum transmits pressure to the thorax, the upward pressure reduces diaphragmatic excursion and shifts the diaphragm cephalad; it also compresses the lungs and chest cavity and impedes their expansion, in other words, decreases thoraco-pulmonary compliance which leads to a reduction in the functional residual capacity (FRC). This circumstance exacerbates the decrease in FRC and lung compliance associated with the patient positioning and the induction of general anesthesia.
The decreased end-expiratory lung volume leads in turn to atelectasis and ventilation-perfusion mismatch with a higher degree of intra-pulmonary shunting, which worsens the increase in the partial pressure of carbon dioxide (PaCO2) caused by absorption of insufflated CO2 ( but, in routine cases, it is easily anesthetically managed by increasing minute ventilation)
Those pulmonary physiological changes may result in significant hypoxemia especially in older patients and those with compromised cardiopulmonary function. 36 ; 37 ; 38 ; 39
b- Cardiovascular changes
The extent of alterations in the cardiovascular function depends on the interaction of several patient’s and surgical factors including the IAP attained, volume of CO2 absorbed, patient position, ventilatory strategy, anesthetic agents used, the surgical technique and the nature and duration of the procedure.38; 40
Basically, those cardiovascular changes can be resumed in: an increase in arterial pressures/ elevation of pulmonary and systemic vascular resistance (SVR) and a decrease in cardiac output (CO).41
SVR is increased due to both mechanical compression of the abdominal aorta and neurohumoral factors such as release of catecholamines and vasopressin and activation of the rennin-angiotensin-aldosterone axis. 37
The decreases in CO are due to a decreased venous return (decreased cardiac preload) from compression of the inferior vena cava, from increased resistance in the venous circulation, from the pooling of blood in legs and from hypovolemia due to preoperative bowel preparation. 36P.s: it also should be noted that peritoneal stretching may cause severe bradycardia and
disease may be at increased risk for further cardiac compromise. To mitigate these effects, we should use the lowest insufflation pressure required to achieve adequate surgical exposure; this latter should be less than 15mmHg. 36
c- Miscellaneous changes
Neurological system:
Raised intracranial pressure with consequent reduced cerebral perfusion pressure may occur due to hypercapnia, increased SVR, raised intra-abdominal pressures and head-down positioning.42
This increase in cerebral blood flow, which is usually tolerated, can be detrimental on patients with cerebral disease, reduced intracranial compliance or impaired cerebral physiology.41
Renal system :
There is usually a decrease in urine output due to reduced renal blood flow and glomerular filtration rate. There is also an increased release of rennin with sodium retention and a release of antidiuretic hormone (ADH) increasing water absorption in the distal tubules.34
Femoral circulation :
Lower extremity venous stasis may lead to deep venous thrombosis (DVT) and pulmonary embolism (PE). 34
Gastro-intestinal system :
Decreased sympathetic response, may lead to less ileus paralyticus. 34 Immunologic system :
Less pronounced immune suppression compared with open surgery. Thus, preserved postoperative immune defenses and less marked stress responses
2) Anesthesia in laparoscopic surgery
For most major laparoscopic urologic procedures, the preferred and safest anesthetic technique is the general endotracheal anesthesia with neuromuscular blockade. The neuraxial techniques alone are impractical, owing to the extreme patient positioning, the lengthy procedure, the prolonged abdominal insufflation, CO2 absorption and the patient discomfort.43
The choice of anesthetic agents should be governed by the skill of the anesthetist and their familiarity with the techniques and drugs.39
Propofol is the most frequently used sedative-hypnotic for induction of general anesthesia, although other agents may be of choice for some patients, such as: Etomidate and thiopentone.
Maintenance of anesthesia is accomplished through the use of an inhational agent (preferably sevoflurane or desflurane), opioid (use of ultra-short acting opioid analgesic remifentanil has gained popularity for fast-track laparoscopic procedures44) and muscle relaxant (succinylcholine/ mivacurium/ atracurium/ vecuronium) 38; 43
Alternatively, total intravenous anesthesia (TIVA) with propofol can be used in lieu of an inhalational anesthetic and is associated with less postoperative nausea and vomiting (PONV).45
The use of nitrous oxide (N20) has been controversial, because it creates suboptimal conditions by causing bowel distention which has led to infrequent use during laparoscopic procedures.43
Although the most common technique for airway management involves placement of a cuffed oral tracheal tube (COTT), the use of laryngeal mask airway (LMA) can avoid endotracheal intubation in selected non-obese patients, and reduces the incidence of post-operative sore throat. However, it should be restricted to short procedures with the use of low
