A novel technique for laparoscopic or robotic partial nephrectomy: Feasibility study

Objective: Laparoscopic partial nephrectomy is a technically challenging procedure with concern over limiting warm ischemia time in order to prevent irreversible injury. We investigate the feasibility of a novel approach with the potential to minimize ischemia time as well as maximize precision of tumor excision. Materials and Methods: Seven partial nephrectomies were performed in 45-50 kg female pigs with excisions ranging in size from 2 x 2 cm to 5 x 3 cm using the following technique. The renal hilum is dissected in standard fashion and the excision site marked with cautery. Prior to vascular clamping, sutures needles are placed in the renal parenchyma along the length of the simulated tumor under laparoscopic ultrasound guidance. The needles remain in the tissue for optimal visualization during resection, which is performed within the inner surface of the needles. Suture material is left attached to the needles with a single LapraTy clip on the end. Vascular clamping is only performed after placing all needles. The base of the resection site is oversewn, and the pre-placed needles are then passed out of the parenchyma until the distal LapraTy clip is against the renal capsule. A second LapraTy clip is then placed proximally under tension completing the bolsters. Results: All animals survived for 2 weeks without complications. Seven resections were performed: two wedge resections, three polar nephrectomies and two heminephrectomies. The mean and median warm ischemia times (WIT) were 14 min and 41 sec and 15 min and 22 sec, respectively. Estimated blood loss was less than 50 ml. Conclusions: Preplacement of needles with attached bolster sutures before vascular clamping under laparoscopic ultrasound guidance is a technically feasible approach to performing laparoscopic partial nephrectomy. In addition to using the preplaced needles as a guide for resection, the preplaced bolsters may reduce warm ischemia time.