Laparoscopic right nephrectomy using a novel technique to excise an inferior vena-caval cuff in a porcine model

Laparoscopic right nephrectomy has been performed using laparoscopic staplers to clamp and divide the renal vessels. In patients who have a tumor thrombus in the renal vein and in rightkidney donors, it is necessary to excise a cuff of the inferior vena cava (IVC) with the renal vein. We present a new technique for excising a cuff of the IVC and suturing it intracorporally using a new vascular clamp designed in our institution.

The vascular clamp was designed to be completely inserted into the peritoneal cavity through the hand-port incision. The renal vein with a cuff of the IVC was then excised, and the defect in the IVC was sutured with a vascular stitch intracorporally. This procedure was performed in the animal laboratory using a porcine model.

A total of 20 hand-assisted right laparoscopic nephrectomies were performed. In the first five operations, the clamp dimensions and angles were modified until the ideal design was reached. In the next five operations, different suture materials and needle sizes were tried to find the best combination for the intracorporal IVC sutures. The first and second operations were not completed because of the difficulty in applying the initial version of the clamp to the IVC. In the 4th and 6th operations, bleeding occurred from the suture line: because of a missed stitch in the back wall of the IVC in one case and a needle stick to the IVC in the other case. The last 14 operations were successful without any bleeding or injuries. Suturing of the IVC was completed in 13 to 22 minutes.

Right hand-assisted laparoscopic nephrectomy with excision of a cuff of the IVC using an intracorporal vascular clamp is safe and reproducible in a porcine model. In our hands, a learning curve of 10 cases was required.