Editing Open Kidney Surgery (section)

===== Enucleation (for small tumours) =====

* Two cylinder shaped cigarette-like bolsters are prepared by rolling Nu-Knit Absorbable Hemostat (Ethicon, Cincinnati, OH) and tying each end with absorbable sutures. Two pledgets are prepared by folding Nu-Knit into a double-layer strip 5 to 10 cm wide and 1 cm long.
* The kidney is exposed using either the anterior subcostal or flank approach as described earlier. The entire surface of the kidney is freed of perirenal fat, with the exception of the perirenal fat overlying the tumor. While removing the perirenal fat, special care should be taken to avoid injury to the ureter, particularly for lower pole tumors.
* Intravenous mannitol and furosemide are administered and the renal pedicle is exposed sufficiently to allow safe application of a vascular clamp if necessary. Vessel loops are placed around the renal vein and artery individually.
* The renal cortex surrounding the tumor is marked circumferentially using electrocautery. The plane outside the tumor pseudocapsule and within the normal parenchyma is identified and bluntly dissected with small closed Metzenbaum scissors. For enucleation of small lesions, renal occlusion is usually not necessary. However, if there is excessive bleeding that hampers proper visualization of the resection margin, then manual compression of the kidney or clamping of the renal pedicle can help. When small vessels within the kidney are encountered they are divided sharply with scissors. The tumor is excised and the margins are examined for gross evidence of a positive surgical margin
* Small bleeding vessels in the renal parenchyma are controlled with 4-0 absorbable figure of-eight sutures on a tapered needle or by coagulation with an argon beam coagulator or bipolar electrocautery. The integrity of the collecting system is verified by checking for injury and repairing with absorbable suture if necessary.
* A Nu-Knit pledget that was prepared earlier is placed along each border of the excised renal parenchyma and in the bottom of the excised parenchyma (Fig. 60-40). The defect is closed with 2-0 absorbable horizontal mattress sutures on a long tapered 1 2 circle needle.
* If clamping was used, the pedicle is unclamped and inspection is done for bleeding, ischemia, or urine leakage of the kidney and for adjacent organ trauma. The perirenal fat and renal fascia are replaced around the kidney. A closed suction drain in the pararenal space is placed to monitor for bleeding and urine leaks. The closed suction drain is removed after 2 to 5 days when the output is minimal. A Foley catheter is used to monitor the urine output. Unless there is a large renal collecting system defect, a ureteral stent is not typically required.