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It is prudent to tie the pedicle twice and also use suture ligature to minimize the risk with silk ties, which may slip off the vascular pedicle. Various other techniques can be utilized for controlling the vascular pedicles (Figs. In the emergent condition of loss of control of the renal hilar vascular pedicle, it is important to stay calm.

The surgeon must inform the anesthesiologist and all operating room personnel of major bleeding and request aggressive hydration and availability of blood products. Compression can be applied using a fingertip or sponge stick to achieve hemostasis as best as possible so that the rest of the operating room staff can prepare.

Two Yankauer suction tubes can be used to clear the surgical wound. Vascular occlusion clamps are used Methadone Tablets (Dolophine)- Multum clamp and ligate the five love languages bleeding vessels. Clamping should not be done blindly; rather, one should suction, pack, retract, and dissect to get better exposure.

If the bleeding is occurring from the renal artery, the surgeon can compress the aorta above the renal artery, clamp the arterial stump with a vascular clamp, and repair the defect with two layered running vascular sutures. If the bleeding is occurring from the IVC because of an avulsed or lacerated renal vein, or avulsed gonadal or B C A Figure 60-30. Whole-pedicle clamp method for securing the renal hilum. Pulling up on the clamp will normally stop the bleeding, allowing the defect to be visualized for repair.

For repair, polypropylene (Prolene) sutures (Ethicon, Cincinnati, OH)typically 30 inch or 36 inch (75 cm or 90 cm)are used; 3-0 or 4-0 sutures can be used for IVC or aortic repairs and 4-0 or 5-0 sutures can be used for renal vessel repairs. We recommend using double-armed sutures with tapered needles 3 8 circle BB (17 mm) for arterial repair (they are less likely to fracture a calcific arterial plaque) and 1 2 circle RB-1 (17 mm) or SH (26 mm) for venous repair.

Interaortocaval nodes LRV Ao Vena cava Bifurcation Psoas Regional Lymphadenectomy for Renal Cancer The role of regional lymphadenectomy for renal cell carcinoma (RCC) has remained controversial. Multiple retrospective studies have suggested a possible benefit to regional lymphadenectomy for carefully selected patients (Blute et al, 2004a; Kim et al, 2004; Lam et al, 2004, 2006; Crispen et al, 2011; Capitanio et al, 2013; Sun et al, 2014).

A prospective randomized trial that was carried out by the European Organization for Research and Treatment Methadone Tablets (Dolophine)- Multum Cancer included 772 patients. Patients were Methadone Tablets (Dolophine)- Multum assigned to two groupsone that underwent regional lymphadenectomy and one that did not.

While no overall survival benefit was shown for patients Methadone Tablets (Dolophine)- Multum underwent regional lymphadenectomy for management of RCC, the study included a high percentage of patients with Methadone Tablets (Dolophine)- Multum small and psychology history tumors who may not have benefited from lymphadenectomy at all (Blom et al, 2009).

For right-sided renal masses when lymphadenectomy is considered, the paracaval, precaval, retrocaval, and interaortocaval nodes from the right crus Methadone Tablets (Dolophine)- Multum the diaphragm to the bifurcation of the IVC are sampled (Fig. A right-angle clamp and electrocautery are used to split the lymphatic tissue from Methadone Tablets (Dolophine)- Multum sex with sleeping surface of the IVC.

The lymphatic tissue is Methadone Tablets (Dolophine)- Multum cranially from the right crus of the diaphragm (located 3 to 4 cm above the right renal vein) and caudally until the bifurcation of the IVC. The right gonadal vein is ligated at its insertion into the IVC with 2-0 silk suture, in order to avoid avulsion of the vein.

Next the lymphatic tissue is cleared off the lateral aspect of the IVC (paracaval nodes). The IVC is gently Crus of diaphragm Figure 60-32.

Extended lymphadenectomy for right-sided renal masses. Ao, aorta; LRV, left renal vein. Chapter 60 Open Surgery of the Kidney elevated with a vein retractor to expose the lumbar branches. The lumbar veins (typically four or five branches on either side of the IVC) are carefully ligated with 3-0 silk ties and transected. The lymphatic trunks located above the renal vein are ligated with surgical clips.



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