Renal ischemia and approach to the renal hilum in robotic partial nephrectomy: Tips and tricks

This chapter covers tips and tricks for approaching the renal hilum and for minimizing the impact of warm ischemia during robotic partial nephrectomy. Surgeons performing robotic partial nephrectomy should have experience with laparoscopic vascular dissection, management of vascular complications, actively guiding a bedside assistant, and open partial nephrectomy. Novice robotic surgeons should begin with anterior or lower pole exophytic tumors and then gradually progress to more complex tumors. Routine hilar dissection and clamping are recommended earlier in the learning curve even for tumors that appear superficial. Adequate mobilization of the bowel to provide an unobstructed view of the hilum and lateral aspect of the ipsilateral great vessel and retracting the lower pole of the kidney to stretch the hilar vessels during dissection are key initial maneuvers. Only minimal renal artery and vein dissection is needed to allow placement and full engagement of the body of the bulldog clamp across the vessels. Additional steps taken in case there is bleeding despite clamping and bleeding after unclamping, use of hemostatic agents and sealers (and their differences), use of Doppler and near-infrared imaging, and various practical strategies to reduce ischemia time are discussed.