Partial Nephrectomy

Surgery 1

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15. End of the procedure: drain tube insertion, bag extraction and incision closure

[vc_row][vc_column][vc_column_text]To finish the procedure: We review the field for bleeding. We suck accumulated blood from the field We check the count of materials is complete: needles, lap sponges, vessel loops, tourniquets, etc We insert a 15 F Blake’s round drainage tube through one of the 5 mm trocars. We retrieve the trocars under direct vision …

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14. Specimen bagging and extraction

[vc_row][vc_column][vc_column_text]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 …

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13. Closure of Gerota’s fascia and nephropexy

[vc_row][vc_column][vc_column_text]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 position Second, 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. …

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10. Pedicle clamping

[vc_row][vc_column][vc_column_text]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 …

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12. Renorraphy

[vc_row][vc_column][vc_column_text]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 …

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11. Tumor excision

[vc_row][vc_column][vc_column_text]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 …

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9. Scoring the margins of the tumor

[vc_row][vc_column][vc_column_text]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 …

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8. Opening of Gerota’s fascia and tumor identification

[vc_row][vc_column width=”2/3″][vc_column_text]This phase has two main objectives Tumor identification Exposition of a safety area of normal renal parenchyma around the tumor The first objective, identification of the tumor, is of the utmost importance but not always easy. Intracavitary ultrasound is recommendable. Many tumors, like the one in figure 8.1, are easily visible even from the …

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7. Dissection of the renal pedicle

[vc_row][vc_column][vc_column_text]The objectives of right renal pedicle dissection for partial nephrectomy are: Identification of the renal artery behind the renal vein Dissection of the renal vein, including its upper side and the superior angle with the IVC Dissection of the artery near the posterior-lateral side of the IVC, before it branches. To rule out possible accessory …

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