Hand-assisted laparoscopic partial nephrectomy

Background and Purpose: The indications for partial nephrectomy are expandi ng as newer and more complete data come forth. A partial nephrectomy has tr aditionally required a generous flank incision. We report our experience us ing hand-assisted laparoscopy (HAL) as a less-invasive approach to partial nephrectomies. Patients and Methods: Between October 1999 and May 2000, we performed II HA L partial nephrectomies. The average age of the patients was 55.7 years, th e average body mass index was 25.6, and the average ASA class was 2.2. The indications for partial nephrectomy were enhancing solid renal lesions (N = 9) and nonfunctioning renal moiety in a duplicated system (N = 2). In the majority of cases, access to the renal pedicle was obtained prior to the pa rtial nephrectomy. However, in no case did the renal artery or vein require occlusion. Several excisional techniques were employed, but all relied hea vily on the Harmonic Scalpel in conjunction with the argon beam coagulator. Different hemostatic agents were applied to the renal defect, including Su rgical, Avitene, and fibrin-soaked Gelfoam activated by thrombin. In severa l instances, pledget reinforced sutures were placed in the renal capsule to aid with hemostasis. Results: The average operative time was 273 minutes, the estimated blood lo ss 319 mL, and the change in hematocrit 7.3 points. No patient required a t ransfusion, and there was one conversion to open. Postoperatively patients, required an average of 35.6 mg of morphine sulfate equivalent and 8.2 narc otic tablets, resumed oral intake in 1.7 days, and were discharged home in 3.3 days. There were no major complications and only two minor complication s. Postoperatively, five lesions were found to be benign, four lesions were confirmed to be malignant, and two lesions were consistent with a nonfunct ioning duplicated renal moiety. Specimen size averaged 180 cc, and the tumo r diameter averaged 1.9 cm. There were no positive surgical margins. Conclusions: Hand-assisted laparoscopic partial nephrectomy is feasible and reproducible. The surgeon's hand in the operative field facilitates dissec tion, vascular control, hemostasis, and suturing. Further long-term and pro spective studies are underway.