Robot-Assisted Partial Nephrectomy: Early Unclamping Technique

Abstract

Robot-assisted partial nephrectomy (RAPN) is emerging as a viable minimally invasive surgical technique for small renal tumors. The warm ischemia time (WIT) during laparoscopic partial nephrectomy has been reduced using an early unclamping (EU) technique. We present our technique of EU technique in RAPN. From November 2009 to June 2010, 12 consecutive RAPNs were performed by a single surgeon (A.W.) using EU technique. The median operative time was 227 minutes (176-315); median WIT, 16 minutes (11-25). Median estimated blood loss was 150 mL (50-500) and length of stay 2 days. There were no intraoperative or postoperative complications. RAPN using EU technique is a safe and feasible option in experienced hands, allowing for a shorter WIT without increasing blood loss. This approach requires a highly skilled bedside assistant who is imminently familiar with the robotic system and advanced laparoscopic techniques.

Off-Clamp Robot-Assisted Partial Nephrectomy: Initial Washington University Experience

“…Among such techniques is the ''early unclamping technique,'' whereby the hilar vessels are clamped only during sharp dissection of the tumor, closure of exposed vessels, and repair of collecting system defects at the resection base. [23][24][25] Gill and associates 23 reported decreasing their WIT for LPN from 31.6 to 14.4 minutes using this technique. Another variation of renal hilar clamping aimed at minimizing WIT during PN is ''selective renal parenchymal clamping''; with this technique, the renal parenchyma is regionally clamped only in the area of planned excision.…”

Renal Cell Carcinoma: Clinical Surgery

“…Another method through which the warm ischemic time can be reduced is the early removal of the vascular clamps, so-called "early unclamping". Few sutures are used in order to avoid more bleeding before removal of the vascular clamps, to then care for the remaining still bleeding vessels without ischemia [17]. Also the selective disconnection of the tumour supplying segmental arteries can reduce the ischemic time, but at an increased risk of injury during preparation of the hilar vessels.…”

Current Status of Robot-Assisted Laparoscopic Partial Nephrectomy

“…This technique, initially developed during the era of laparoscopic partial nephrectomy, resulting in halving of warm ischaemia time [19], has been used in RLPN, with median warm ischaemia time of 16 min in one report [20].…”