Surgery
Left Partial Nephrectomy
PREOPERATIVE DIAGNOSIS: Left, angiomyolipoma.
POSTOPERATIVE DIAGNOSIS: Same.
PROCEDURE: Left partial nephrectomy.
SURGEON: H, MD.
ASSISTANT SURGEON: H, MD.
ANESTHESIA: General endotracheal.
INS AND OUTS: EBL:
Approximately 100 cc. Urine
output: 375 cc. IV
crystalloid: 3,400 cc were given.
DRAINS: Foley catheter to gravity, and JP to bulb suction.
COMPLICATIONS: None.
DISPOSITION: PACU stable.
INDICATIONS FOR PROCEDURE: This is a 40-year-old female that has had left renal mass consistent with angiomyolipoma that had been followed for several years. On a recent follow up CT scan, there showed evidence of increase in size to approximately 4.5 cm. At that point, the patient, after having extensive discussions, decided that it would be appropriate to have it removed. She comes in for definitive treatment today.
OPERATIVE PROCEDURE: After informed consent was obtained, the patient was brought to the Operating Room and general anesthesia was induced. She was then placed in the flank position over the break in the table on a beanbag. An axillary roll was placed. The table was broken to hyperextend the flank and the beanbag placed to suction. All of her extremities were well padded and pressure free. Once this was done, she was prepped and draped in the usual sterile manner. Examination under anesthesia identified the 12th rib, and the 11th rib, and the 10th rib. Decision was made to proceed along the course of the 11th rib, with excision of the rib if necessary. A flank incision was made on the 11th rib, extending anteriorly approximately 3 cm from the tip of the rib. Bovie electrocautery was used to dissect through the subcutaneous fat as well as the abdominal wall musculature. Once the dissection was carried out to the level of the rib, a periosteal elevator was used to clean the rib of its overlying intercostal muscles. A Doyen periosteal elevator was then used to remove the intercostal muscles from the rib on the anterior, inferior, and posterior surfaces. Once the rib was significantly skeletonized, it was transected and sent to pathology for evaluation. Once this was done, the pleural was then carefully dissected off of the rib. The pleural cavity was not entered during this dissection, and it was safely retracted out of the field. At this point the transversalis muscle was incised. We remained retroperitoneal throughout the operation and the peritoneum was carefully off of Gerota’s fascia and allowed to fall out of the field of view. The kidney was then mobilized with Gerota’s fat. Once adequate mobilization was obtained, Gerota’s fascia was incised and the perinephric fat was dissected away. The kidney was then shelled out of Gerota’s fascia with care taken to avoid entering the renal capsule. A large piece of fat was allowed to stay on the tumor that was easily palpated through the Gerota’s fascia. The adrenal was then carefully dissected off of the upper pole of the kidney with the assistance of the right angle dissector, and 2- and 3-0 silk ties. Once the kidney was mobilized the renal hilum was identified, and the renal vein was carefully dissected free of its surrounding tissues. The renal artery was also identified and carefully dissected free of its surrounding tissue. Once the kidney was adequately mobilized and the vessels clearly identified and skeletonized, the Lahey bag was placed around the kidney. It was cinched around the renal hilum and the body end of the bag opened. A bulldog clamp was then placed on the renal artery and the kidney was then placed on ice. Slush was poured into the bag, allowing the kidney to cool. We waited 15 minutes for cooling. Upon the completion of the cooling, a small incision was made circumferentially around the lesion through the kidney capsule. The blunt end of the scalpel handle was then used to gently dissect the renal parenchyma surrounding the tumor off of the renal parenchyma. Care was taken not to enter the collecting system. 4-0 Vicryl sutures were then used to ligate any obvious vessels that were seen on end during dissection. Once this was done, the specimen was removed and sent to pathology for evaluation. The bulldog was then released. There was minimal oozing from the renal parenchyma. At this point, the flow-seal product was applied to the fossa created by this dissection. This was allowed to sit for 5 minutes to have its full hemostatic effect. Upon completion of the application of flow-seal, bleeding was at a minimum. At this point, the capsule was reapproximated. This was done with 2-0 Vicryl sutures using Surgicel as pledgets. Horizontal mattress sutures were used to bolster the pledgets. Once the capsule was reapproximated, the Lahey bag was removed, and the remaining slush was removed. Evaluation of the surrounding tissues revealed no evidence of any bleeding, nor did it reveal any evidence of arterial injury. The spleen was identified and there was no evidence of any trauma to the spleen by the retractor. The kidney was allowed to fall back into place. At that point, the Gerota’s fascia was closed over the kidney. A number 8 Jackson-Pratt round drain was placed within Gerota’s fascia, and brought out through a separate stab incision. Once this was done, the pleural was reexamined to insure that there was no damage to the pleural or lung during the case. There did not appear to be any defects in the pleura. The wound was then started to undergo closure. Posteriorly, number 1 PDS was used to close the posterior portion of the incision in one layer. Anteriorly, the wound was closed in two layers: One incorporating the deep musculature of the abdominal wall, with the more superficial layer only incorporating the external oblique and its associated fascia. Once this was completed, the wound was infiltrated with Marcaine. Meticulous hemostasis was maintained throughout the entire closure. The skin incision was then closed with staples, and the wound dressed with bacitracin and Xeroform and the skin infiltrated with Marcaine as well.
At this point, the patient was rolled back into the supine position, and extubated, and transferred to the PACU in stable condition, tolerating the procedure well.
A chest x-ray was obtained in the PACU. It did not reveal any evidence of pneumothorax.
ESTIMATED BLOOD LOSS: 100 cc.
Dr. H was scrubbed and present during the entire procedure.