Editing Open Kidney Surgery (section)

===== Wedge resection (for large cortical tumours) =====

* For large tumors, intravenous mannitol and furosemide are administered, then the renal artery is clamped with a vascular bulldog clamp. Based on the surgeon’s preference, when partial nephrectomy is being performed for larger tumor sizes or lesions that are close to the renal hilum, the renal vein may also be clamped after clamping the renal artery to provide better hemostasis during partial nephrectomy. A plastic bag or sheet is placed around the kidney and filled with ice slush. The kidney is allowed to cool to 20° C (approximately 15 minutes).
* The renal capsule is circumferentially incised 5 to 10 mm peripheral to the tumor with electrocautery. Using a combination of blunt and sharp dissection with Metzenbaum scissors, the tumor is excised with a small rim of normal parenchyma. The specimen is inspected for visible tumor at the resection margin, then submitted for frozen-section analysis.
* Bleeding vessels are controlled with figure-of-eight sutures or with argon beam or bipolar electrocautery. The deep resection margin of the kidney must be inspected for any residual tumor or any sign of collecting system injury. If there is any doubt about collecting system injury, 10 to 20 mL of diluted indigo carmine is injected into the renal pelvis while occluding the ureter to assess for leaks. The collecting system is closed with 4-0 absorbable suture on a tapered needle.
* The renal parenchymal defect is reconstructed using Nu-Knit bolsters and pledgets as described above. Fibrin glue is applied to the renal parenchymal defect. Finally, the renal vessels are unclamped—if the renal vein as well as the renal artery is clamped, the renal vein is unclamped first followed by unclamping the renal artery.
* [Further details in Campbell’s]