Dept.

of Pediatric and Abdominal Emergency Surgery

SURGICAL MANAGEMENT OF WILMS TUMOR

SURGICAL TECHNIQUE
Incision and Exposure
The operation is performed through a large transverse, transperitoneal incision
placed above the umbilicus. The incision extends from the midaxillary line on the side
of the tumor to the anterior axillary line on the contralateral side (Fig. 155-1). In
instances in which very large tumors are associated with considerable elevation of the
diaphragm, a bilateral chevron-shaped subcostal incision or a thoracic extension of the
incision through the bed of the eighth or ninth rib may be useful (Fig. 155-2). A
potential risk of a combined thoracoabdominal procedure is possible tumor spill in
both the thoracic and peritoneal cavities.

Fig. 155-1

Fig. 155-2

Under general endotracheal anesthesia, the patient is positioned with the side
of the tumor elevated slightly at 30 degrees. The abdomen and lower chest are
prepared with an iodophor skin solution and draped appropriately with linens and an
adhesive plastic wound drape. The transverse skin incision is made two fingerbreadths above the umbilicus from the midaxillary line on the side of the tumor to the
anterior axillary line on the contralateral side. Subcutaneous bleeding points are
controlled with a fine-tip, handheld electrocoagulating device. The anterior rectus
sheath on the side of the tumor is incised, and the incision is extended laterally to
open the external oblique fascia and muscle (Fig. 155-3). The internal oblique fascia
and muscle are similarly incised. Bleeding points are controlled with the
electrocoagulator. The posterior rectus sheath, transversalis fascia, and peritoneum are
then incised to provide entrance into the abdominal cavity. A moist laparotomy pad is
placed over the tumor to protect it from injury, and the opposite side of the abdomen
is opened in a similar way. The umbilical vein is divided between clamps and tied
with 000 silk ties. The incision should be large enough to permit the operating surgeon
to inspect and palpate the opposite kidney to rule out a second tumor. This should be
accomplished before the attempted resection if possible. The liver should be inspected
and palpated for possible liver metastases.
In Fig. 155-4, a large left Wilms tumor displaces the colon. The left transverse
and descending colon and its mesentery are dissected free from the anterior surface of
the tumor by incising the lateral colonic attachment (white line) and dividing the
splenocolic and splenorenal ligaments.

Dept. of Pediatric and Abdominal Emergency Surgery

Fig. 155-3

Fig. 155-4

Resection
When possible, the medial aspect of the tumor should be mobilized and the
blood supply and drainage of the kidney exposed (Fig. 155-5). The left renal vein
crosses over the aorta. The left gonadal (testicular or ovarian) vein and the left adrenal
vein enter the left renal vein directly. After it is exposed, the renal vein should be
carefully palpated to rule out extension of tumor into the venous lumen or vena cava.
Careful dissection and double ligation of the renal vein are accomplished with 00 silk
ties (Fig. 155-6). The vein is then divided close to its entrance into the vena cava. The
renal artery can then be identified and carefully dissected free and doubly ligated with
00 silk ties and a 000 silk suture ligature on the aortic side (Fig. 155-7). The renal
artery is then divided between the ligatures. If vascular control can be established at
the beginning of the procedure, it lessens the chance of hemorrhage and of
hematogenous spread of the tumor through the vein during the resection.

Fig. 155-5

Fig. 155-6

A dissection plane should then be established outside Gerotas fascia with

sharp dissection. All perforating vessels from the retroperitoneal tissues should be
doubly clamped, ligated with 000 silk ties, and divided. This must be done with care
to avoid rupture of the tumor capsule and tumor spill, which is associated with
upstaging of the tumor and an increased risk of local recurrence. Elevating the spleen
and pancreas superior and medial to the tumor allows excellent exposure. If the
adrenal gland is adherent to an upper-pole Wilms tumor, it is resected en bloc with the
renal mass. In instances of lower-pole Wilms tumor, the adrenal gland can often be
spared. The main adrenal artery, multiple small arterial twigs, and the superior adrenal

Dept. of Pediatric and Abdominal Emergency Surgery

vein must be identified and doubly ligated and divided (Fig. 155-8). If the diaphragm
has been infiltrated by tumor, it should also be partially excised en bloc. Occasionally,
an accessory tumor vessel is seen extending from the neoplasm directly to the vena
cava. This should be carefully identified, ligated, and divided as described above.

Fig. 155-7

Fig. 155-8

The remainder of the resection is accomplished by a sweeping posterior

dissection, freeing the tumor from the retroperitoneal attachments of the kidney (Fig.
155-9), extending the dissection down to the pelvis to ligate the ureter near the
bladder. Most of the ureter should be resected with the tumor because of the potential
for urothelial spread of tumor cells arising from a lesion that extends into the
collecting system.

Fig. 155-9

Fig. 155-10

The resection is then brought superiorly and medially to include any enlarged
or suspicious lymph nodes along the periaortic chain or near the hilum of the kidney
(Fig. 155-10). Excision of lymph nodes is essential for staging purposes because
nodal metastases may adversely affect the prognosis, especially in instances of Wilms
tumor with unfavorable histology. While the efficacy of a formal lymph node
dissection has not been established, I routinely sample hilar and periaortic lymph
nodes for staging purposes and most of the time perform an ipsilateral lymph node
dissection inferiorly from the level of the aortic bifurcation to the superior mesenteric
artery superiorly (Fig. 155-11). The upper and lower aspects of the nodal groups
should be marked by sutures specifically labeling lymph nodes from the perirenal
hilar area and periaortic nodes (ipsilateral, suspicious contralateral). Titanium clips are
very useful during the lymph node dissection to control both hemorrhage and lymph

Dept. of Pediatric and Abdominal Emergency Surgery

leak. The clips can be used to outline the tumor margin for the radiation therapist as a
guideline for an irradiation port. In addition, titanium clips do not scatter an x-ray
beam or otherwise interfere with repeated CT scans of the abdomen, which are used
for follow-up evaluation of the local tumor bed during the course of treatment after
the initial procedure.

Fig. 155-11

Fig. 155-12

Closure
After the tumor resection is completed, the tumor bed is irrigated with
physiologic saline solution and inspected for any bleeding sites. The previously
mobilized colon is replaced laterally to partially fill the dead space left by the tumor
resection. Omentum is also useful in this regard. The wound is then closed in layers
with running 000 or 00 polypropylene suture on a tapered needle. The peritoneum,
transversalis fascia, and posterior rectus sheath are closed as the first inner layer. The
internal and external oblique fasciae and muscle are closed independently with
additional continuous 000 or 00 polypropylene suture. The fascial closure is
completed with interrupted 000 or 00 polypropylene suture (burying the knot beneath
the fascia to reduce the risk of suture sinus formation) to approximate the anterior
rectus sheath. The subcutaneous wound is irrigated with physiologic saline solution,
and closure is completed with running 40 white polyglactin suture on Scarpas
fascia. Skin closure is accomplished with a continuous 40 white polyglactin
subcuticular suture. Sterile adhesive strips are applied to coapt the skin edges.
Suture removal is a frightening, painful, and annoying event in the life of a
sick child and is obviated by the subcuticular closure. Skin sutures and staples are to
be avoided in young patients if possible. A dry sterile dressing is applied using a tape
(rubberized foam or paper tape) that does not contain mercury to hold the gauze in
place. Tape containing mercury sensitizes the skin of the abdominal wall and makes it
susceptible to radiation dermatitis should irradiation be necessary in the postoperative
treatment plan. Use of such tape in children with cancer should be avoided. An OpSite adhesive can be used as an alternative dressing. The gauze and outer dressing are
removed in 48 hours, when the wound edges are sealed.
Resection of a Tumor on the Right Side
Resection of a right Wilms tumor may present other problems to the surgeon
(Fig. 155-12). Exposure of the lesion necessitates separation of the hepatic flexure and
right and transverse colon from the liver, gallbladder, and duodenum. The duodenum
is retracted medially to expose the vena cava and shorter main right renal vein (Fig.
155-13). The vein is carefully isolated and doubly ligated with 00 silk ties. Because

Dept. of Pediatric and Abdominal Emergency Surgery

the right renal vein is short, the proximal end should be suture ligated. The vein is
divided between the ties. The right renal artery can usually be identified after the vein
is divided. The artery is mobilized, doubly ligated with 00 silk ties, and suture ligated
with 000 silk on the aortic side (Fig. 155-14). Some surgeons believe it is important to
ligate the artery before the renal vein, to avoid potential lymphatic spread. Because of
the effectiveness of chemotherapy in Wilms tumor, there are no data to indicate
whether ligation of the artery before the vein changes the outcome. The resection of a
right-sided Wilms tumor may also be hindered somewhat by the formation of a dense
pseudocapsule related to adherence of the renal neoplasm to the undersurface of the
liver. A clean plane can often be developed between the two organs; however, local
extension of tumor into the liver requires an en bloc wedge resection of the liver.

Fig. 155-13

Fig. 155-14

Fig. 155-15

Hepatic lobectomy may be necessary in a few patients. This should be done

with the usual precautions, including mobilization of the coronary and triangular
hepatic ligaments, control of the porta hepatis by careful dissection, and exposure and
control of the right hepatic artery, hepatic duct, and right branch of the portal vein,
respectively, before proceeding with the hepatic transection. An ultrasonic dissector
(CUSA) and intraoperative ultrasonic probe may be useful in identifying segmental
hepatic structures and in avoiding complete lobectomy in some patients.
If the tumor involves the upper pole of the kidney, the right adrenal gland is
excised en bloc with the lesion (Fig. 155-15). Careful identification of the main right
adrenal vein, which enters the vena cava directly, and the right adrenal artery is
important. Injury to these vessels can cause troublesome bleeding. These vessels are
doubly ligated with 000 silk ties and divided between the ligatures. The diaphragmatic
attachments of the adrenal gland include the superior adrenal vein and multiple small
arterial twigs. These vessels should be carefully controlled with the use of ties or
titanium clips.
The right kidney is then dissected free outside of Gerotas capsule. The
retroperitoneal attachments are carefully freed by sharp dissection with bleeding
points controlled with electrocautery, or titanium clips, or both. Any large tumor
vessels should be doubly ligated with 000 silk ties and divided between the ties.
The dissection is continued inferiorly, and the ureter is identified near the
bladder and doubly ligated and divided. The dissection is then continued upward
along the right iliac vessels, vena cava, and aorta, where the lymph nodes (para-aortic,
hilar) and perirenal tissues are removed en bloc with the tumor in a manner similar to
that previously described for a left Wilms tumor. Titanium clips are useful in
controlling bleeding and preventing lymph leak. The various lymph node groups
should be carefully marked for histologic evaluation.