For left partial nephrectomy we generally use 4 trocars on a diamond shape (Figure 3.1): Pararectal Hasson´s trocar Left iliac fossa 12 mm trocar. Subcostal 5 or 11 mm Trocar. Lateral 5 mm trocar on the mid-axillary line Figure 3.1: Trocar insertion This preferred trocar disposition admits great variations for partial nephrectomy depending of each […]
3. Trocar placement Read More »
Access is performed with a left pararectal minilaparotomy and placement of a Hasson´s trocar at the upper umbilical line, or slightly higher. Veress needle is another acceptable option. Hasson mini laparotomy and trocar insertion technique: – A 2.0-3 cm incision is performed and deepen to the anterior abdominal fascia. Two reference stitches are taken on
2. Laparoscopic approach and pneumoperitoneal Read More »
We place the patient on right side decubitus (lumbotomy position) with lumbar lift (roller) and the table flexed. It is important to protect the pressure areas and place an axillary roll to avoid brachial plexus injuries. The right arm lies on an armrest and the left on a stirrup above, to avoid instrument clashing during
1. Patient positioning and operating room disposition Read More »
Specimen bagging may be performed either at the end of the procedure or at the time of excision, if there are oncological or procedural risks involved. We generally complete excision and leave the specimen in an area of the field where it is easy to find and does not bother during renorraphy. As we said
14. Specimen bagging and extraction Read More »
Once we complete renorraphy we try to close Gerota’s fascia-peritoneum. The closure of Gerota’s fascia has a triple objective: First, get back the kidney to its original positionSecond, to cover the renal surgical field with a layer of perirrenal fat, contributing to hemostasis.Third, to fix the kidney which was mobilized for optimal performance. Gerota’s fascia
13. Closure of Gerota’s fascia and nephropexy Read More »
Pedicle clamping is a very important part of partial nephrectomy. By clamping we suppress, completely or partially, the inflow of blood into the kidney, and by doing so we can perform tumor excision and surgical bed repair/hemostasis with good control and less bleeding. The variety of case scenarios in partial nephrectomy is wide. From off
10. Pedicle clamping Read More »
We usually perform a two-layer renorraphy. The first suture, the deep surgical bed layer, has the objective of closing the urinary tract and to perform hemostasis of the main vessels. We generally perform it under ischemia, so we add the pressure of warm ischemia time to the difficulties of suturing the parenchymal breach. The most
The objectives of tumor excision are: To obtain the complete tumor keeping a margin of healthy renal tissue around To spare the maximum healthy renal parenchyma. The main risk is to enter the tumor leaving a positive surgical margin or seeding tumor cells in the field. Another risk, not as important, is to take excessive normal parenchyma. Preliminary considerations
11. Tumor excision Read More »
Once we expose the tumor and normal parenchyma around the kidney we proceed to score the margins to help tumor excision. Partial nephrectomy must be oncologically safe. Thus, the tumor comes out surrounded by a margin of healthy tissue. Traditionally this margin was as wide as 5 mm, but several studies have demonstrated that smaller
9. Scoring the margins of the tumor Read More »
