Partial Nephrectomy

3. Starting surgery

Forced lateral decubitus. In retroperitoneal access (Figure 12), a forced lateral decubitus is required in order to increase the distance 12th rib and iliac crest. The back of the patient must be on the edge of the surgical table. Preparation is completed with compression stockings in the lower limbs with a progressive pneumatic compression device, bladder

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2. Renal Retroperitoneal OR

Basic equipment for renal retropernitoneoscopic surgery: Specific equipment: Gaur’s balloon (comercial or home-made) for dissection of retroperitoneal space. Hasson’s trocar. Consumable material; tourniquet for kidney artery control, sutures for kidney parenchyma. Conventional laparoscopic equipment: Videolaparoscopic tower High flow insufflator Surgical instruments Generators for dissection and haemostasis. Aspirator/irrigator Trocars Figure 5. OR’s distribution for a right

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1. Introduction

Indications Retroperitoneoscopic approach allows direct access to the kidney to perform a nephron-sparing surgery. We will choose this approach in selected cases; either because lesion’s location (figure 1) or because the patient had with multiple abdominal surgeries or has catastrophic abdomen, in which transperitoneal access is not recommended or impossible (Figure 2). LOCALIZATION OF THE

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9. Marking the tumor margins

Once the healthy parenchyma has been exposed around the tumor we proceed to mark the margins for excision. Partial nephrectomy should be oncologically safe. This means that the tumor comes out surrounded by a margin of healthy tissue. Traditionally this margin was 5 mm, although different studies have shown that it may be smaller, minimal,

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6. Renal pedicle dissection

The OBJECTIVES of the left renal pedicle dissection include: Identification and dissection of the renal vein and its branches: gonadal, lumbar and adrenal veins Identification of the renal artery behind the renal vein, near its exit from the aorta To achieve enough dissection of the vessels to have vascular control and be able to perform clamping safely.

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5. Access to the retroperitoneum: peritoneal opening and colon mobilization

The objectives of this phase are: To open the parietal peritoneum, following the line of Toldt, from the iliac fossa up above the spleen To mobilize the descending colon and its mesentery following the avascular plane To identify retroperitoneal references:  gonadal vein, ureter and psoas muscle. Errors we should avoid include: To open through the mesocolon.

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