Following mobilisation of colon and spleen or liver retraction the renal hilum is dissected to allow hilar clamping. The dissection is limited to the point where sufficient visualisation of the renal artery and vein is achieved to allow safe clamp application. The small amount of perivascular tissue may provide cushioning effect to the vessels and helps to minimise trauma. In the majority of cases arterial clamping alone is sufficient to achieve a bloodless surgical field. In cases with a smaller peripheral tumour selective clamping may be adequate. When clamping the renal artery and vein, it is important to ensure that all arterial branches are clamped as venous obstruction with continuous arterial inflow will lead to bleeding and poor vision. There are different clamping techniques available – laparoscopic “bulldog” clamps (most favoured by the authors), laparoscopic Satinsky clamp and vascular loops.

Example of using vascular loop to control hilum; the loop is snugged down onto the artery using a 1–2 cm short piece of drain tubing and clipped with Haem-o-lok clip on the other side.

Preoperative imaging is used to guide surgical planning and initial dissection. Intracorporeal ultrasound probe is used for finer tumour localisation and identification of tumour margins and depth. Ultrasound scan can be especially useful in cases with dense perinephric fat that is adherent to the renal capsule.

A window is made in Gerota’s fascia away from the tumour to avoid unexpected tumour spillage. Gerota’s fascia is opened in line with the long axis of the kidney which allows subsequent closure over the renorrhaphy. The tumour is isolated circumferentially with the overlying tumour fat left intact. The line of resection is marked with diathermy a few millimetres from the tumour margin, Ultrasound scan is used to ensure accuracy. Cutting with cold scissors is used after clamping of the hilar vessels. This provides sufficient visibility and avoids thermal artefact which can obscure the plane between tumour and normal renal parenchyma. The assistant rests the sucker in the dissection field and uses it as a gentle retractor. This helps to maintains the surgical field blood free.

The sliding renorrhaphy technique is used for closure of the tumour defect. A continuous 3-0 PDS suture with Haem-o-lok clips at either end is applied as a first layer at the cortico- medullary junction. After tensioning the suture (sliding the Haem-o-lok clips and pulling on the suture at the same time) the hilar clamp can be released. The authors prefer 3-0 PDS with 26 mm/MH needle due to the ability to slide the clips on it, both from the starting and finishing points. This suture is usually sufficient to control the majority of the bleeding and thus allows early clamp release to minimise WIT. Individual interrupted 3-0 PDS sutures can be applied if required to control bleeding points. These bleeding points will not be visible if the vascular clamp is removed after the second layer is closed.

A second sliding renorrhaphy layer is applied with 3-0 V-loc 26 mm needle 30 cm. Haemostatic agents such as Floseal are used in the resection bed prior to fully tensioning that suture line. Finally, Gerota’s fascia is closed over the renal defect to provide another layer for better haemostasis and to prevent renal torsion.

Sliding renorrhaphy stitch for internal layer. Suture should aim at the cortico-medullary junction where most intrarenal vessels travel.

Bed rest is recommended overnight, as well as mechanical deep vein thrombosis prophylaxis with TED stockings and calf compressor devices for 24 h. After this period low molecular weight heparin can be commenced. Patients are allowed a clear fluid diet immediately post surgery.