SELECTIVE CLAMPING ROBOTIC-ASSISTED NEPHRECTOMY

Overview

Introduction:
Currently, kidney-sparing interventions (partial nephrectomies) are recommended for all patients with T1 or T2 tumors. Minimally invasive surgical approaches for interventions on the kidneys are associated with a lower morbidity without the deterioration of oncological results. The modern robotic system da Vinci with the possibility of fluorescent imaging using indocyanine green (ICG) facilitates the identification of segmental renal arteries and ensures safe selective clamping. Nowadays, robotic assistance offers minimally invasive surgery for all candidates of open partial nephrectomy.

Description of the clinical case:
Since January 2014, we performed 52 robot-assisted partial nephrectomies using ICG using the Da Vinci robotic system type Si. Operations are performed in the lumbotomy position. Camera port is introduced through the umbilicus, for patients with higher BMI in the pararectal line. Two 8 mm robotic ports are located in the medioclavicular line. One 12 mm port for the assistant is located cranial or caudal to the camera port depending on the tumor location in the kidney. The identification of the renal artery and the preparation of the segmental branches are the first steps. After loading the vascular clamps ICG is applied intravenously. The starting dose is 1.5 ml with the concentration of 2.5 mg/ml ICG. After 5 to 10 seconds we are able to identify with fluorescent imaging the individual parts of the kidney without blood flow. The partial nephrectomy is then performed in the displayed ischemic segment. Upon finishing the suture and removal of vascular clamps, ICG is reapplyed to check the quality of blood flow of the kidney and the range of the ischemic area given the suture of the defect.

Conclusion:
Robot-assisted partial nephrectomy is a safe method for the treatment of renal cell carcinoma. Selective clamping with fluorescence control reduces the risk of ischemic renal damage.

Key words:
Indocyanine green, minimally invasive approaches, partial nephrectomy, robotic-assisted surgery