Gentle traction applied to the tissue strips (colored in blue) that are hooked around each kidney pole may be helpful while incising the renal parenchyma and working through the nephrotomy defect with “brain-spoon” spatula (red arrow). These hooks should be kept loose just like a hammock by the help of hemostatic clamps
Tips of the stone forceps should be closed while entering the calyceal system. It should be opened once you have stone contact. First clear the stone surface from the mucosa entirely before manipulating it. Do not use force to pull it out of the pyelocalyceal system. Break the stone either manually or by a special saw if needed for a safe extraction. If a profuse bleeding follows the stone extraction, irrigate the system with ice-cold water through a feeding tube, exert manual compression and wait patiently.
When searching for residual stones using intraoperative ultrasonography, keep in mind that air bubbles in the pyelocalyceal system may mimic stone echogenity.
Under cold ischemic conditions make sure that you wait 10 min for the kidney to cool down to 14–16 °C before you incise the parenchyma
If you are using a pedicle clamp, hold the pedicle stump with an Allis clamp before ligating to avoid any slip.
Since kidney has an end-arterial system there is no need to control the distal arterial end once you have controlled the proximal part of the renal artery. On the other hand, renal vein should be clamped both proximally and distally to avoid venous tumor spillage.
If xanthogranulomatous pyelonephritis or tuberculosis is the reason for nephrectomy, the kidney should be mobilized as if you are performing a radical nephrectomy. However, you can switch to subcapsular nephrectomy to visualize the renal pedicle more easily when you get close to the renal hilum.
Always start mobilizing the kidney first posteriorly and free the psoas muscle. Try to mobilize the adrenal gland en-bloc with the kidney not to violate the integrity of Gerota’s fascia. If that is not possible, dissect the adrenal gland separately after removing the kidney. Use vessel clips to secure the central vein, staying as close to the caval surface as possible.
One should always gain a readily available access to the inferior vena cava while removing the right kidney. In case of profuse venous bleeding from cava placement of a vascular clamp to the distal cava helps.
While removing vena caval tumor thrombi, avoid excessive mobilization of the kidney, try to free the renal artery, do not dissect the renal vein free. Cavotomy should be commenced only after the cranial and caudal limits of the thrombus as well as the contralateral renal vein is secured with vessel loops or extracorporeal circulation is initiated.
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