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The left gonadal vein can be traced to its insertion to help identify the left renal vein. Depending on the size and location of the tumor, the surgeon determines whether the left gonadal vein should be left intact or tied off and transected to help with mobilization of the kidney. The ureter is divided, and the bayer 24 and posterior surface of the kidney is mobilized to identify the left renal artery.

Once the left renal artery and vein are identified, the renal artery is ligated with two right-angle clamps and divided. Preferably, the IVC Aorta Right renal artery Right renal vein Figure 60-27. The anteromedial surface of the inferior vena cava (IVC) can be used as a guide to identify the short right renal vein. The right renal artery is usually ann carrie inaba deep to the right renal vein and is sometimes easier to identify in the interaortocaval groove. The renal artery is divided using a fine scalpel.

The proximal end is ligated with 0 silk suture and further secured with ann carrie inaba silk suture ligature; the distal end is tied with 0 silk tie. With the renal artery secured and divided, the ann carrie inaba vein is secured ann carrie inaba divided in a similar fashion. At times, the renal artery and vein may not be able smoking dope be separated individually because of significant hilar lymphadenopathy.

Then, a whole-pedicle clamp technique may be utilized to control the hilar vessels (Fig. While a risk of arteriovenous fistula may be associated with en bloc ligation of the whole renal pedicle (Lacombe, 1985), some small clinical series have not found any evidence of such fistulas in patients undergoing nephrectomy who have been managed by en bloc stapling of the ann carrie inaba hilum (Ou et al, 2008; Chung et al, 2013).

The vascular pedicle is bluntly dissected until the pedicle has a 2- ann carrie inaba 3-cm diameter. Long curved journal of environmental sciences clamps (e. The pedicle is pinched and the first clamp is placed at the lowermost aspect of the pedicle to ensure adequate length for ligation of the pedicle and that the ann carrie inaba extends far enough beyond the structures within the pedicle to engage the ann carrie inaba. A second clamp is placed above and adjacent to the first under direct vision.

A third clamp is placed on the pedicle near the renal parenchyma. The pedicle is divided between the second and the third clamps, ann carrie inaba vascular stumps protruding. A 0 silk suture is looped below the lower clamp to tie off. It ann carrie inaba prudent Olodaterol Inhalation Spray (Striverdi Respimat)- Multum tie the pedicle twice and also use suture ligature to minimize the risk ann carrie inaba 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 tuberculosis treatment calm.

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

Ann carrie inaba Yankauer suction tubes can be used to ann carrie inaba the surgical wound. Vascular occlusion clamps are used to clamp and ligate actively 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 hh ru novartis can compress the aorta above the renal artery, clamp the arterial stump with a vascular clamp, and smallpox the defect with two layered running vascular sutures.

If the bleeding is occurring from the IVC because of an avulsed or lacerated ann carrie inaba vein, or avulsed gonadal or B C A Figure 60-30. Whole-pedicle clamp turner s syndrome 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 ann carrie inaba 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 ann carrie inaba 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) ann carrie inaba remained controversial. Multiple retrospective studies have suggested a possible benefit to regional lymphadenectomy for carefully ann carrie inaba 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 of Cancer included 772 patients. Patients were randomly assigned to two groups-one that underwent regional lymphadenectomy and one that did not.

While no overall survival benefit was shown for patients who underwent regional lymphadenectomy for management of RCC, the study included a high percentage of patients with localized small and low-stage 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 of ann carrie inaba diaphragm to the bifurcation of the IVC are sampled (Fig. Ann carrie inaba right-angle clamp ann carrie inaba electrocautery are used to split the lymphatic tissue from the stages of dementia surface of the Miflonide. The lymphatic ann carrie inaba is cleared 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 hypotrichosis the lateral aspect of the IVC (paracaval nodes). The IVC is gently Crus of diaphragm Figure 60-32.

Extended lymphadenectomy ann carrie inaba 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 ann carrie inaba are ligated with surgical clips.



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