Editing Open Kidney Surgery (section)

==== Level 1 vena caval thrombectomy ====

* '''Can usually be treated in a similar fashion to level 0 thrombi by reducing the thrombus into the renal vein'''
**Usually, level I thrombi are partially occlusive, are nonadherent, and do not require extensive IVC dissection or any form of bypass. 
* '''Surgical plan'''
**Position: anterior midline or anterior subcostal
**'''Step-by-step'''
***Position a self-retaining retractor
***Medialize the colon and develop the anterior pararenal space
***'''Identify and expose the great vessels and the renal hilum'''
***'''Identify and ligate the renal artery''' 
****Renal artery can be ligated in the intera-ortocaval region, if right-sided, or para-aortic if left-sided
****Take care care not to manipulate the renal vein or IVC too much. 
****Secure the renal artery with 0 silk ligature or a large clip. 
****Ligating the renal artery early will help reduce the blood flow to the kidney and minimize the amount of potential blood loss.
***'''Gently mobilize the kidney outside the renal fascia, divide the ureter, and dissect the IVC above the right renal vein.'''
****Some groups mobilize the kidney after the thrombectomy is complete, in order to minimize the risk of embolization, while others mobilize the kidney first followed by thrombectomy
***Identify and secure the contralateral renal vein, suprarenal IVC, and infrarenal IVC with vessel loops.
****To help with temporary ligation of these vessels, 3- to 6-inch portions of an 18-Fr red rubber catheter are passed through the vessel loop and used as Rummel tourniquets.
*****While this degree of vascular control may not be necessary for all level I thrombi, it is prudent to have adequate vascular control if there is any doubt about the extension of the level of thrombus.
****Starting cranially, the IVC is gently pinched closed, and then the Rummel tourniquets are applied so that the infrarenal IVC, contralateral renal vein, and suprarenal IVC are closed in that order. 
***'''Using the left hand, milk the IVC toward the ostium of the renal vein. Place a C-shaped Satinsky vascular clamp around the ostium of the renal vein''' partially occluding the IVC, ensuring that the thrombus is located within the jaws of the clamp before complete closure. 
****Palpate the IVC for evidence of any other thrombus.  
****Suction and two sponge sticks (to compress the IVC if necessary) are readied and laparotomy sponges are placed around the renal vein to collect any spillage of tumor thrombus after opening of the renal vein. 
***'''Incise the renal ostium circumferentially using a scalpel or fine-tipped Metzenbaum or Potts scissors.''' 
***'''Extract the thrombus''' by gentle downward traction on the renal vein.
****A gauze is wrapped around the renal vein stump and secured with a silk ligature to prevent tumor spillage. 
***Dissect medial and other remaining attachments of the kidney 
***Deliver specimen 
*** '''Inspect the IVC for evidence of residual thrombus'''
***'''Close the IVC defect with a running closure using a 4-0 Prolene suture''' on a BB vascular needle.
****Prior to tying the knot, ask anesthesia to apply positive airway pressure, then pinch the infrarenal IVC closed and release the Satinsky clamp. Allow 5 to 10 mL of blood to escape from the caval defect to flush out any residual thrombus fragments and debris before pulling the suture tight and tying the closure.
***A regional lymphadenectomy is performed, irrigating the wound copiously with sterile water. 
***Consider placement of a closed suction catheter to monitor for bleeding.