Using a Harmonic Scalpel "Drilling and Clamping" Method to Implement Zero Ischemic Robotic-assisted Partial Nephrectomy: An Observation Case Report Study

Abstract

Robot-assisted partial nephrectomy (RAPN) has gradually become a popular minimally invasive nephron-sparing surgical option for small renal tumors. Ischemic injury should be minimized because it impacts renal function outcomes following partial nephrectomy. Herein, the authors detail the technique and present initial perioperative outcomes of our novel harmonic scalpel "drilling and clamping" method to implement zero-ischemic RAPN. The authors prospectively collected baseline and perioperative data of patients who underwent zero ischemic RAPN performed by our harmonic scalpel "drilling and clamping" method. From April 2012 to December 2014, a total of 19 consecutive zero ischemic RAPN procedures were performed by a single surgeon. For 18 of the 19 patients, RAPN using our harmonic scalpel "Drilling and Clamping" method was successfully completed without the need for hilar clamping. The median tumor size was 3.4 cm (range: 1.8-6.2); operative time was 3.2 hours (range: 1.9-4.5); blood loss was 100 mL (range: 30-950); and postoperative hospital stay was 4 days (3-26). One patient required intraoperative blood transfusion. Two patients had intra or postoperative complications: 1 was converted to traditional laparotomy because of massive bleeding, whereas another had postoperative stress ulcer. Pathology confirmed renal cell carcinoma in 13 patients (63.2%), angiomyolipoma in 6 patients: (31.5%), and oncocytoma in 1 patient (5.3%). Mean pre- and postoperative serum creatinine (0.82 mg/dL and 0.85 mg/dL, respectively), estimated glomerular filtration rate (84.12 and 82.18, respectively), and hemoglobin (13.27 g/dL and 12.71 g/dL, respectively) were comparable. The authors present a novel zero-ischemic technique for RAPN. They believe that this technique is feasible and reproducible.

FIGURE 1

Preoperative CT scans showing the renal tumor to be treated with zero ischemia robot-assisted partial nephrectomy: A 51-year-old female patient with a left 3.6 cm exophytic midpole renal tumor.

FIGURE 2

Patient position: The patient was secured to the operation table, with a modified lateral position. The table was positioned at 20 to 30° contralateral tilt and 30° angle relative to the robot. Illustration of trocar placement: a 12 mm camera port, 2 8 mm robotic working ports, and a 12 mm assistant port.

FIGURE 3

Docking the robot: The robot was docked over the ipsilateral shoulder at a 30° angle from the patient's spine.

FIGURE 4

Harmonic scalpel (Intuitive Surgical, Sunnyvale, CA) used for zero ischemia robot-assisted partial nephrectomy.

FIGURE 5

A, Drill holes by robotic harmonic scalpel around the tumor, with a 5 mm distance from the tumor margin. The distance between each hole was approximately 3 mm. B, Insert the scalpel blades into the created holes, clamp, and cut. C, Repeat the drilling and clamping method around the tumor outline to excise the mass. E, The drilling angle should be beveled tangent to the surface arc of the tumor. F, For a larger tumor, the technique can be performed again on the second layer until the whole mass is completely resected.