Surgical Technique
A transperitoneal approach was applied to all patients. LPN was carried
out as we described previously [10]. Briefly,
following general anesthesia, the left or right lateral decubitus
position was performed according to the side of the tumor.
Pneumoperitoneum was created with an intra-abdominal pressure of 12-15
mmHg by inserting a Veress needle 1-2 cm superior to the umbilical level
from the lateral of the rectus muscle. The optic port was placed at this
point where the pneumoperitoneum was created. A total of 4 ports were
placed for LPN, one for the camera, one for the right (12mm), and one
for left (5mm) hand due to dissection and one for the retraction (5mm)
port. If necessary, one more port (5mm) was placed for retraction or
traction.
RPN performed by using a four-arm da Vinci XI robotic system (Intuitive
Surgical, CA, USA). First, an 8 mm camera port was placed lateral to the
rectus muscle. Three robotic working ports (8 mm) and an assistant port
were then placed. The robotic system was docked from the back of the
patient, and the robotic arms were docking to the ports on the front of
the patient. The assistant was involved in the replacement of robotic
instruments, the use of aspirators, and the delivery of suture material
in the anterior-lateral part of the patient.
The colon deviated medially from the Toldt line. Following the
dissection of the hepatorenal or splenorenal ligament, ureter, and
gonadal vein identified on the psoas, renal hilum was revealed by
followed cranial dissection. The renal artery, vein, and hilum dissected
separately. Perinephric adipose tissue was released from the capsule
except the adipose tissue covering the tumor. Then the tumor was
resected with a cold scissor leaving an approximately 5 mm safety margin
after clamping the renal artery. The collector system and vascular
structures in the tumor bed were sutured with 3/0 V-Lock with fixed a
Hem-o-Lok clip at the end. Than renorrhaphy was completed using 2/0
Vicryl and 2/0 Monocryl suture material fixed with Hem-o-Lok clip to
bring the renal parenchyma closer. The bulldog clamps were opened and
warm ischemia was terminated. This procedure was applied similarly to
both LPN and RPN.