Handassisted Laparoscopic Partial Nephrectomy

In order to simplify and increase viability of laparoscopic partial nephrectomy, some surgeons have employed a hand-assisted laparoscopic approach of nephron-sparing surgery surgery. Stifelman and colleagues (128) reported their experience with handassisted laparoscopic partial nephrectomy (without hilar clamping) in 11 patients. Direct parenchymal compression through the hand port, argon-beam coagulator, and adjunctive agents (e.g., oxidized cellulose) were employed to control hemostasis. Mean operative time was 4.5 hours, mean blood loss 319 mL, and mean hospital stay 3.3 days. One patient required open conversion.

Comparing 10 LPNs (hand-assisted in eight patients) with a matched group of open partial nephrectomies, Wolf et al. (81) reported longer operative times (+24%) and increased blood loss in the hand-assisted group. However, pain medication requirements ( — 62%), hospital stay (—43%), and convalescence ( — 64%) were lesser in the hand-assisted group. In another study, Brown et al. (115) reviewed their initial series of 30 hand-assisted laparoscopic partial nephrectomy, comparing the results of central (<5 mm from the collecting system or hilum; n = 8) versus peripheral (n = 22) lesions. After tumor excision using endoscopic cold scissors, argon beam coagulation followed by fib-rinogen-soaked sponge application (subsequently activated with thrombin) was employed to control hemostasis. No hilar clamping was performed. As regards the entire series, mean tumor size was 2.6 cm (range, 1-4.7), mean blood loss 415 mL (range, 50-2100), and mean operative time 3.6 hours (range, 90-332). When compared with peripheral lesions, centrally located lesions were associated with greater blood loss (240 ± 113 vs. 894 ± 552 cm3, respectively), and higher rate of blood transfusion (9.1% vs. 50%, respectively) due to intraoperative or delayed hemorrhage, or symptomatic anemia. Resection of the laparoscopic partial nephrectomy bed was necessary in five cases due to positive initial resection margin on frozen section (100% negative margin after re-resection). Considering the 3-4-fold increase in blood loss, transfusion rate, and a urinary leak associated with laparoscopic partial nephrectomy for central lesion, the authors suggested the utility of hilar clamping in this setting.

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