V5-06: 3 MM Off-Clamp Partial Nephrectomy: Pros, Cons, Tips and Tricks
VideoIntroductions and Objectives
Nephron sparing surgery is the treatment of choice for the majority of T1 kidney tumors. Over the past years it has appeared clear that a short warm ischemia (WIT) time is important in order to reduce the damage to the kidney. Therefore different techniques have been developed to shorten WIT including off clamp techniques. As a further evolution, minimizing the trauma to the abdominal wall is becoming of some interest. As such NOTES and single port techniques have been developed. However these techniques have been described by the majority of the authors to be extremely challenging. With this concept, 3 mm instruments (mini-lap) have been developed with the idea of diminishing the surgical abdominal wall aggression maintaining the general principle of laparoscopy. We present a case of clamp-less partial laparoscopic nephrectomy with 3 mm ports and laparoscope.
A 78 year-old patient was incidentally diagnosed with a contrast enhancing 3.5 cm left exophytic renal mass. Due the reduced GFR a decision to perform an off-clamp laparoscopic partial nephrectomy was discussed with the patient and a consent was obtained. Three 3mm trocars were inserted in a diamond shape position, including a 3 mm trocar for the 3 mm laparoscope. In order to maintain the pneumoperitoneum and a good access for Hem-o-locks use an 11mm forth trocar was placed through a 2.5 cm Pfannestiel incision. Furthermore the same incision was used to remove the specimen and to place an abdominal drain. Tips and triks are described and commented in this video.
The procedure was completed successfully with no need for clamping of the hilum. The blood loss was 900 cc, however this was clinically well tolerated and the patient did not require any blood transfusion. The 3 mm instruments were considered to work appropriately for this surgery and no additional trocar was deemed necessary. The postoperative recovery was excellent and the patient was discharged from the hospital postoperative day 5 after drain removal. Final pathology revealed a papillary renal cell carcinoma Type 1, Grade 1, and stage pT1a, with negative margins. As far as pain control, the patient did not required any morphine. Furthermore the cosemsis was considered to be excellent.
The 3mm access enabled us to perform a complex surgery without adding any trocar or convert to conventional laparoscopic surgery. We believe that minimizing trocar incision may result in better cosmetic results and possibly minimize the use of pain medication.