This video highlights the precision and expertise of robotic-assisted partial nephrectomy. Using cutting-edge robotic technology, Dr. Dipen J. Parekh, the founding director of the Desai Sethi Urology Institute and director of robotic surgery, who has performed over 5,000 robotic urologic procedures, removes kidney tumors while preserving as much healthy kidney tissue as possible. Narrated by Dr. Archan Khandekar, clinical instructor at the Desai Sethi Urology Institute, this technique also ensures proper cancer margins while maintaining kidney function, offering patients an advanced approach to cancer treatment with better outcomes.
The first step of a partial nephrectomy entails dropping of the colon, the colon is dropped. So as to achieve proper access to the kidney and the structures lying behind it. This particular case is a 58 year old male having a an interior three centimeter renal mass. There is a fine plane that defines the gerota facia, which is the facia around the kidney and the colon, this space is separated. So as to get access to the blood supply of the kidney, which is the renal hyalon seven, the gonadal vein is traced that in turn gets inserted into the renal vein. One of the essential things that needs to be done in a case of a partial nephrectomy is to stop the blood supply to the kidney. When removing the tumor to do this, getting access to the Harlem, which is the artery and the vein that supply the kidney is extremely important. Okay. The guan inserting into the renal vein is dissected out here. The arteries that gives the blood supply to the kidney lies just behind it. Thereby dissection is started through the JDA space which is the fascia overlying the kidney to get access to the tumor. Once the tumor is dissected, all around, sufficient margin on the kidney step, this helps in the eventual suturing of the normal kidney once the tumor has been excised. Yeah. Yeah. Yeah. A blessing. The next step involves the marin of the demon. This marking is done around the tumor on the normal barony of the kidney and this is where the dissection of the tumor will proceed. A bulldog tamp is then applied to the artery. Correct. As you can see, this molo clamp goes on the previously dissected artery and it stops the blood supply to the kidney. But two such bulldogs are applied sequentially on the same artery so that the blood supply to the kidney is completely blocked off. Ok. As you can see gradually, the tumor is cut from the parent of the kidney. Ok. Because the blood supply of the kidney has been stopped by the use of the bulldogs. There is minimal bleeding that can be seen at this stage. It is extremely important to have the complete circumferential dissection and removal of the tumor. So as to not leave any positive margins, that is any remnants of the tumor to have a recurrence. What? Yeah. In this particular case, the more difficult dissection is around the medial aspect where the tumor is very close to the hy I think. Yeah. No, he's never shape here. Once the tumor has been completely dissected out, it gets banned. But like I think the best way to do it just like this. Yeah. The next step involves suturing of the parent. This parent is sutured in two layers. The first layer is done by Avilo 30 switcher with a lady at the end. This is done in a continuous manner. It is important to note that during all these procedures of resection of the tumor, as well as suturing the blood supply of the kidney is severed and this constitutes the Isaia time that the first layer which is with the wheel of 30 is primarily for hemostasis. OK. Put a yeah. As we begin suturing with the second layer, it is important to note that the ureter which is the pipe that is draining the kidney into the bladder is kept out of the way. The second layer is closed with a rather bigger suture on a bigger needle. The parent timer with the suture is approximated together. As you can see it is a large GS 21 needle and a wheel lock zero switcher with a lata as well as hemo lo a wet clip. At the end, you can see that the assistant applies a wet clip after every throw. How are we doing with that hau thing? Oh I thought it was just there to be careful. You can be very deep here. See the wet clips that a re applied help evenly distribute tension and make sure that the parent is closely approximated it is also important to note that all these suitors a re passed through the renewal capsule and not just the parent time, it's very easy for the renal pan and time to cut through if no part of the caption. Me too. And sometimes it's ok to keep it open as long as it's not, you know, it doesn't look bad. Actually put the clamp, we'll see what to do, but he's obviously at a high risk for a urinary leak. Oh, careful. After the final we clip has been applied and the pan approximate reserve, you can see that the bulldog lamps that were applied to the RP are remote. This leak constitutes the blood supply to the kidney. After the kidney has been unclamped, you look at any oozing or any bleeding from the renal Panama and yeah, traditional uh hemostatic agents such as s are applied to the parent came edge to prevent any oozing from any small oozers that may not be controlled by the wet clips. A variety of hemostatic agents are available for this particular case scenario. In this case, as we discussed previously, we a re using Suris now, but agents such as a VCL, also po as vista CLS flow and different such hemostatic agents. A re available that a re absolutely on surgeon preference. In this particular case, an additional throw of the suture was taken around the hemostatic agent to make sure that the fascia or the parent was completely opposed to each other 20 points. Ok. Is that ok? Don't do anything. I just said that. Yeah, I, all that. Yep. A he MOOC clip was placed at the end and put under tension. Ok. Good. The abdominal pressure was decreased to look for any small ozers or bleeding. The bad specimen was retrieved. They take this evangel needle instructed to the procedure. Suck on this. Good.
