Instrument List

■ ■ 10- or 5-mm laparoscope (0° and 30°) ■ Maryland dissector aEthicon, Somerville, NJ.

FIGURE5 ■ Picture showing renal cryoablation in progress (A) with real time ultrasound monitoring (B).

■ Diamond flex triangle retractorb

■ Veress needle

■ Three nonbladed 10/12-mm trocars, one 5-mm nonbladed trocar

■ Blunt tip trocar

■ Trocar mounted preperitoneal balloon dilatord

■ 10-mni Optiview introducing cannulae

■ Endoshears

■ 5-mm harmonic shears

■ Irrigator-aspirator

■ 10-mm clip applier and vascular stapler in the room available

■ 10-mm right angle dissector

■ Carter-Thomason fascial closure devicec

■ 4-0-monocryl sutures

■ Flexible 10-mm laparoscopic ultrasound probe with ultrasound machine

■ Surgiceld, Tisseele, argon beam coagulator

■ Two laparoscopic needle drivers

■ Cryoprobes: 2.4,3.0,5 mm, Cryomachine (Accuprobef)

■ Benzoin, steristrips 1/4 in., three band aids

■ Standard open tray for flank surgery

Cryoablation is performed using an argon gas-based system that operated on Joule-Thompson principle (Accuprobe). Cryoprobes are available in diameters of 2.4 (sharp tip), 3.0, and 5.0 mm (blunt tips). The number and size of probes used in a case vary depending on the size and site of the tumor. The smaller probes (2.4 and 3.0 mm) are often passed percutaneously as a result of the relatively short shaft length; the 5-mm probe can be placed percutaneously or via a port.

Once exposed and verified by the ultrasound examination of the lesion,the tumor is biopsied prior to cryoablation.

■ Under direct laparoscopic and ultrasound guidance, the tumor is punctured with an appropriate sized probe and cryoablation is initiated using two 10-minute freeze cycles followed by passive thaws.

■ The freeze cycle is continued to 1 cm beyond the tumor margin.

■ The cryolesion is monitored with real time ultrasonography (Fig. 5).

FIGURE5 ■ Picture showing renal cryoablation in progress (A) with real time ultrasound monitoring (B).

bGenzyme Surgical Products, Tucker, GA. cInlet Medical, Eden Praire, MN. dEthicon, Somerville, NJ. eBoxter Healthcare, Dearfield, IL. fEndocare, Irvine, CA.

FIGURE 6 ■ Pre-and postoperative magnetic resonance imaging scans showing an exophytic enhancing renal mass (left) and nonenhancing cryoablated lesion.

FIGURE 6 ■ Pre-and postoperative magnetic resonance imaging scans showing an exophytic enhancing renal mass (left) and nonenhancing cryoablated lesion.

Failure of cryolesion regression after six months warrants renal biopsy, possible repeat cryoablation, or partial/radical nephrectomy.

When cryoprobes are placed percutaneously, a 14 French red rubber catheter tubing is placed around the probe to protect skin and abdominal wall from cryoinjury. Before removal, passive thawing is allowed until the probe loosened spontaneously, and a piece of tightly rolled surgicell is placed into the cryoprobe defect, or an injection of Tisseel1 is performed and held with direct pressure for 5 to 10 minutes. Next, the insufflation pressure is reduced to 5 mmHg to confirm hemostasis. Postoperatively, serial hematocrits are obtained for the first 24 hours. Magnetic resonance imaging is obtained at 3, 6, 9, and 12 months and then annually. We obtain magnetic resonance imaging scans with T1, T2 weighted, and gradient echo images performed before, during and after intravenous administration of gadalonium (Fig. 6).

Failure of cryolesion regression after six months warrants renal biopsy, possible repeat cryoablation, or partial/radical nephrectomy.

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