Pedicle Control

Elevation of the lower pole of the kidney places the renal vessels "on the stretch" and facilitates identification (Fig. 4). Blunt dissection of the vessels using right-angled forceps and/or the sucker-irrigator tip is performed. The renal vein, lying more anterior, is normally identified first. On the left side, the renal vein may receive gonadal, adrenal, and lumbar branches that may require individual clipping.

The preoperative computed tomography scan may provide clues as to the position of the renal artery in relation to the vein; otherwise, further blunt dissection cranial, caudal, and deep to the vein, while observing for arterial pulsation, will clarify the vascular anatomy. The artery is clipped with laparoscopic clips (three on the "stay" side and two on the "go" side) and divided; this is followed by division of the renal vein using an endovascular gastrointestinal anastomosis stapler, which fires four rows of clips before cutting the vein. It is important to ensure that the path of the stapling device is clear of any clips, because their inadvertent inclusion in the closed jaws of the instrument will result in a misfire of the linear cutting/stapling device.

Arterial division may occasionally be postponed until after division of the vein if necessary, although the authors strongly recommend that this is a maneuver of last resort because it may result in considerable swelling of the renal vein and oozing from the hilum, which can hamper dissection. A far safer approach when space is limited is to place a single clip on the artery first and to complete its dissection once the vein has been divided.

In general, dissection of the renal artery and vein medially, as close to the great vessels as possible, is simpler because lateral dissection close to the hilum will result in more bleeding, and dissection of the branches of the renal artery and tributaries of the renal vein is also more likely.

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