PS 24. Laparoscopic nephron-sparing surgery with selective clamping of renal arterial branches using Laparoscopic Ultrasonography

This study describes a novel technique of selective clamping of renal arterial branches during laparoscopic nephronsparing surgery (LNSS) with the assistance of laparoscopic ultrasonography.

Between March and November 2011, thirty patients (20 males and 10 females) with small renal mass (SRM) were planned to perform LNSS at our institution with selective clamping of renal arterial branches using the laparoscopic ultrasonography. The renal artery, branches and segmental arteries (the tertiary branches) for clamping were isolated carefully using ultrasonic scalpel and/or monopolar hook. Laparoscopic ultrasound was utilized to direct the surgeon to identify the location, size, depth, blood supply, and the boundary of the renal tumor. The boundary of the renal tumor was marked by monopolar hook. Laparoscopic bulldog were utilized to clamp the segmental arteries associated with the tumor according to the preoperative CTA image, direction of the segmental arteries and the location of the tumor. Then laparoscopic ultrasound was performed to make sure that the blood supply to the tumor was blocked while the normal part of the kidney was spared. Bulldog clips could be adjusted in a real time manner according to the results of ultrasound scanning. Tumors were completely excised with scissors. Parenchymal bleeding was controlled using argon beam coagulation and bipolar coagulation. 2 to 3 layers of suturing were used, of which 2-0 absorbable running suture was used to close the collecting system or the inner part of parenchyma while one to two 1-0 running suture for outside part of the parenchyma. In patients with central tumors or tumors close to the collecting system, a 5Fr ureteral catheter was inserted into the renal pelvis before the laparoscopic procedure. Methylene blue was instilled through the catheter to test the integrity of the collecting system. The renal blood supply was checked again by laparoscopic ultrasound after the bulldog clamps were removed. The perioperative data of all cases were presented.

LNSS was successfully performed in all patients. Two cases required conversion to clamping the main renal artery because of intensive bleeding. The mean operative time was 130 min (range, 100-210), mean estimated blood loss was 120 mL (range, 30-400), mean time for the clamping of renal arterial branches was 28 min (range, 15-36). There was no blood transfusion or conversion to open surgery. The mean stay of drainage tube was 5 days. The mean postoperative hospital stay was 7 days. The serum Cr were not significantly different before operation and 3 months after operation. The recovery of all patients was uneventful.

Selective clamping of renal arterial branches is a new technique to protect renal function in LNSS. The laparoscopic ultrasonography is a very useful tool in the process of surgery.