Description of a multicenter safety checklist for intraoperative hemorrhage control while clamped during robotic partial nephrectomy

Abstract

BackgroundThe adoption of robotic assistance has contributed to the increased utilization of partial nephrectomy for the management of renal tumors. However, partial nephrectomy can be technically challenging because of intraoperative hemorrhage, which limits the ability to identify the tumor margin and may necessitate the conversion to open surgery or radical nephrectomy. To our knowledge, a comprehensive safety checklist does not exist to guide surgeons on the management of hemorrhage during robotic partial nephrectomy. We developed such an safety checklist based on the cumulative experiences of high volume robotic surgeons.MethodsA treatment safety checklist for the management of hemorrhage during robotic partial nephrectomy was collaboratively developed based on prior experiences with intraoperative hemorrhage during robotic partial nephrectomy.ResultsReducing the risk of hemorrhage during robotic partial nephrectomy begins with reviewing the preoperative imaging for renal vasculature and tumor anatomy, with a focus on accessory vessels and renal tumor proximity to the renal hilum. During hilar exposure, an attempt is made to identify additional accessory renal arteries. The decision is then made on whether to clamp the hilum (artery +/- vein). If bleeding is encountered during resection, management is based on whether the bleeding is suspected to be arterial or from venous backbleeding. Operative maneuvers that may increase the chance of success are highlighted in safety checklists for arterial and venous bleeding.ConclusionsSafely performing robotic partial nephrectomy is dependent on attention to prevention of hemorrhage and rapid response to the challenge of intraoperative bleeding. Preparation is essential for maximizing the chance of success during robotic partial nephrectomy.

Robot-assisted partial nephrectomy in contemporary practice

“…Direct pressure is immediately applied and the insufflation pressure increased while the renorrhaphy clips are re-tightened. Emergent open conversion or conversion to robotic total nephrectomy may be necessary for uncontrolled bleeding (Nepple et al, 2012). …”

Use of the Satinsky clamp for hilar clamping during robotic partial nephrectomy: indications, technique, and multi-center outcomes

“…A Satinsky clamp could be a backup option for hilar clamping if the renal hilar vessels are difficult to identify for clamping of individual vessels with bulldog clamps or if there are dense adhesions around the hilum that could increase the risk of vascular injury with further dissection. If bulldog clamps were to ''fail'' with bleeding from the resection bed in spite of bulldog placement, the Satinsky clamp could provide a backup option to definitively ''shut down'' blood flow to the kidney after other hemostatic maneuvers have failed [8]. The Satinsky clamp also provides a relatively easy way to ''flash'' the clamp and to quickly open the clamp to minimize warm ischemia time, such as in the cases of early unclamping [9].…”

Robotic partial nephrectomy: Current technique and outcomes

“…suggested that once the mass is excised, further hemostatic measures can be carried out, including cauterizing the base of the resection bed, suturing the resection bed and placing sliding clip renorrhaphy sutures, which ultimately provides compression of the parenchyma. However, if bleeding is not manageable, emergent open conversion (OPN or complete nephrectomy) or robotic nephrectomy might be necessary …”

“…Our preference is to only clamp the renal artery even with hilar lesions. If bleeding is encountered during resection, management is based on whether the bleeding is suspected to be arterial or from venous back bleeding . Today, it is believed that the only reliable hemostasis is the suture.…”