Editing Open Kidney Surgery (section)

==== Indications ====

* '''Tumors in non-functional kidneys'''
* '''Large tumors replacing the majority of renal parenchyma'''
* '''Tumors associated with detectable regional lymphadenopathy'''
* '''Tumors associated with renal vein thrombus'''

'''Radical nephrectomy with adrenalectomy'''

* '''See Management of Localized and Locally Advanced Kidney Cancer Chapter Notes'''

'''Radical nephrectomy with lymphadenectomy'''

* '''See Management of Localized and Locally Advanced Kidney Cancer Chapter Notes'''
* '''Regional lymphadenectomy'''
** '''Includes ipsilateral great vessel and interaortocaval regions, extending from the crus of the diaphragm to the common iliac artery'''
*** For right-sided renal masses when lymphadenectomy is considered, the paracaval, precaval, retrocaval, and interaortocaval nodes from the right crus of the diaphragm to the bifurcation of the IVC are sampled.
** '''Employed in select cases of advanced local disease and when technically feasible'''
* '''Surgical description (for right-sided lymphadenectomy)'''
** Right-side lymphadenectomy
*** A right-angle clamp and electrocautery are used to split the lymphatic tissue from the anterior surface of the IVC. The lymphatic tissue is cleared cranially from the right crus of the diaphragm (located 3 to 4 cm above the right renal vein) and caudally until the bifurcation of the IVC.
*** The right gonadal vein is ligated at its insertion into the IVC with 2-0 silk suture, in order to avoid avulsion of the vein. Next the lymphatic tissue is cleared off the lateral aspect of the IVC (paracaval nodes).
*** The IVC is gently elevated with a vein retractor to expose the lumbar branches. The lumbar veins (typically four or five branches on either side of the IVC) are carefully ligated with 3-0 silk ties and transected.
*** '''The lymphatic trunks located above the renal vein are ligated with surgical clips.'''
**** '''Care to adequately ligate the lymphatic trunks is essential since large quantities of lymph and chyle drain through the cisterna chyli and thoracic duct, and failure to appropriately control them can result in chylous ascites''' .
*** Once the lumbar veins are secured and the superior aspect of the lymphatic trunk above the renal vein is secured, the assistant rolls the IVC medially with gentle pressure using two sponge sticks. Next the lymphatic tissue is cleared off the retrocaval region. The nodal tissue overlying the anterior surface of the aorta is then split and divided to the superior border of the left renal vein. Division of the nodal packet is followed to the medial border of the IVC and the aortocaval nodal packet is cleared to the level of the common iliac vessels.
** Left-side lymphadenectomy
*** For left-sided renal masses, the lymphatic tissue on the anteromedial surface of the aorta is clipped and divided and rolled laterally. The split is continued cranially along the aorta to the level of the superior mesenteric artery (SMA) and caudally past the inferior mesenteric artery (IMA) to the bifurcation of the aorta.
**** While the SMA and the celiac trunk have to be preserved, the IMA can be tied and divided in case of involved lymphadenopathy.
*** Once the lymphatics are dissected off the anterior and lateral surface of the aorta, the assistant gently elevates the aorta on either side to expose, secure, and divide the lumbar arteries. Once the lumbar arteries are properly secured, the aorta is rolled medially and the tissue between the anterior longitudinal vertebral ligament and the aorta (retroaortic lymph nodes) is resected.
*** The interaortocaval nodes are resected only if they are palpable or visualized on preoperative imaging, or if there is extensive nodal involvement around the aorta.