Radical & Partial Nephrectomy (Open & Robotic)
IMAGING POST NEPHRECTOMY
Hemostatic agents can be read by radiologists as masses, abscess, fluid collections. One study looked at the prevalence and characteristics found that the average change in size of bolster masses was -1.19 mm/month. Air at the site can be found up to 40 days post-operatively. (1)
OPEN INCISIONS (click INCISIONS for more information)
midline transperitoneal
anterior
anterior subcostal
BIL subcostal chevron
hockey stick modified throacoabdominal
flank
foley muscle splitting
subcostal
supracostal
transcostal
thoracoabdominal
combined
STEPS (WITH ROBOTIC STEPS)
After positioned slightly bumped up on surgical side, insert ports, dock robot and:
1. Mobilize ipsilateral colon
30 degree lens down
Incise white line of told
Medially reflect colon
(LEFT - splenorenal attachments: take down spleen, tail of pancreas, descending colon)
*USE 4th ARM TO RETRACT GONADAL AND URETER
(RIGHT - mobilize duodenum & ascending colon medially. Gonadal vein stays medial.
*DO NOT RETRACT IVC
Liver retractor
2. Find Psoas and follow up to hilum
3. dissect and divid hilum vessels - skelatanize the hilum w/ maryland
4. dissect upper, medial and lateral attachments
PARTIAL NEPHRECTOMY:
Cold ischemia 35 min, warm ischemia 20 min
Prior to clamping, IV mannitol (12.5g IV 5 min then 10 prior to clamping
Enucleate margins - use US
Two 5-10cm bolsters (Nu-Knit. Tie w/ 4-0 suture)
Can control bleeding w/ figure of 8
Use bolsters to close in horizontal mattress, 1-2cm into parenchyma to prevent capsule tearing
Unclamp and inspect
Close pararenal fascia
Close suction drain and foley catheter
PARTIAL NEPHRECTOMY TIPS
Hemostatic agents can be read by radiologists as masses, abscess, fluid collections. One study looked at the prevalence and characteristics found that the average change in size of bolster masses was -1.19 mm/month. Air at the site can be found up to 40 days post-operatively. (1)
OPEN INCISIONS (click INCISIONS for more information)
midline transperitoneal
anterior
anterior subcostal
BIL subcostal chevron
hockey stick modified throacoabdominal
flank
foley muscle splitting
subcostal
supracostal
transcostal
thoracoabdominal
combined
STEPS (WITH ROBOTIC STEPS)
After positioned slightly bumped up on surgical side, insert ports, dock robot and:
1. Mobilize ipsilateral colon
30 degree lens down
Incise white line of told
Medially reflect colon
(LEFT - splenorenal attachments: take down spleen, tail of pancreas, descending colon)
*USE 4th ARM TO RETRACT GONADAL AND URETER
(RIGHT - mobilize duodenum & ascending colon medially. Gonadal vein stays medial.
*DO NOT RETRACT IVC
Liver retractor
2. Find Psoas and follow up to hilum
3. dissect and divid hilum vessels - skelatanize the hilum w/ maryland
4. dissect upper, medial and lateral attachments
PARTIAL NEPHRECTOMY:
Cold ischemia 35 min, warm ischemia 20 min
Prior to clamping, IV mannitol (12.5g IV 5 min then 10 prior to clamping
Enucleate margins - use US
Two 5-10cm bolsters (Nu-Knit. Tie w/ 4-0 suture)
Can control bleeding w/ figure of 8
Use bolsters to close in horizontal mattress, 1-2cm into parenchyma to prevent capsule tearing
Unclamp and inspect
Close pararenal fascia
Close suction drain and foley catheter
PARTIAL NEPHRECTOMY TIPS
- Use US with doppler with vessel loop clamped artery to see if you have correct vascular clamp
- Use firefly to see if have correct artery clamped (can also use w/ radical nephrectomy)
- Interlobar arteries run in same direction as collecting system, the big arteries run close to where sinus fat meats parenchyma: this is where you want to target your sutures
- To avoid urine leake don't cut with cautery because u wont be able to see it because its all charred
- Early unclamp after placing deep sutures prior to closing capsule so you can see if will bleed and correct it
- Capsule sutures go deep too, the same level as deep sutures. Need deep needle...ct1, ctx (will fit in 12 port but need to bend), xlh (have to put in percutaneously bc wont fit in port)
- Firefly dose must be small for differentiating normal parenchyma vs. Tumor....use 1/2 cc for SI, 1/4 cc for XI robot...(this works bc rcc has mutated transmembrane protein that doesnt keep ICG intracellular like normal parenchyma)
- Kim, Taek Sang, et al. “Computed Tomography Imaging Features and Changes in Hemostatic Agents After Laparoscopic Partial Nephrectomy.” Journal of Endourology, vol. 30, no. 9, 2016, pp. 950–957.