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Laparoscopic partial nephrectomy for large renal mass: No tissue sealant, no bolster technique

Surgical Technique

A 50-year-old man presented with intermittent right flank pain since six months. Detailed evaluation revealed (8.5 cms × 6.5 cms) a large exophytic renal neoplasm with an appearance suggestive of angiomyolipoma. Laparoscopic partial nephrectomy was contemplated. Five ports were employed – one 10 mm camera port (CP), two 10 mm working ports (WP), one 5 mm port for liver retraction (R), and one 10 mm port for insertion of the Satinsky clamp (S). Colonic mobilization was conducted. The plane between the Georta’s fascia and renal capsule was entered and dissection was carried out all around this plane except around the tumor, where a generous cuff of peritumoral cuff was preserved. The renal hilum was then dissected and the renal pedicle was delineated. A Satinsky clamp was introduced through a separate umbilical port and the hilum was clamped en masse. The periphery of the tumor was marked with hook electrocautery. Tumor resection was carried out along this margin. A generous cuff of renal parenchyma was removed from all around the tumor. Due to lack of availability, no intraoperative ultrasound was performed. After tumor resection the remnant renal bed was fulgurated with a laparoscopic spatula and monopolar electrocautery. This was followed by single layer renorrhaphy, using No. 1 polyglactin suture. Tension in the suture line was maintained with sequential hem-o-lok clips. No tissue sealant or surgicel bolster was employed during this step. After renorrhaphy, the pedicle was declamped and satisfactory restoration of vascular inflow to the renal parenchyma was achieved. No major bleeding were encountered. The specimen was retrieved in a specimen retrieval bag through a Pfannenstiel incision. Drain placement port and retrieval site closures were undertaken. The warm ischemia time was 21 minutes. The operative time was 165 minutes with a blood loss of 150 milliliters. The patient made an uneventful recovery post procedure. Histopathology revealed angiomyolipoma with negative surgical resection margins. Up to last follow-up the patient was stable, with a normal renal profile. A follow-up renogram revealed preserved function of the remnant renal parenchyma. No remnant or recurrent disease was seen in the follow-up CT urogram