Method of surgical hemostasis during robot-assisted partial nephrectomy for intraparenchymal tumors
The method of enucleoresection with circular sutures and hemostatic material addresses the challenge of ineffective hemostasis in robot-assisted kidney tumor resection, ensuring stable hemostasis and reducing renal parenchyma rupture risk, thereby enhancing surgical outcomes.
Patent Information
- Authority / Receiving Office
- RU · RU
- Patent Type
- Patents
- Current Assignee / Owner
- GOSUDARSTVENNOE BYUDZHETNOE UCHREZHDENIE ZDRAVOOKHRANENIYA GORODA MOSKVY MOSKOVSKIJ KLINICHESKIJ NAUCHNO PRAKTICHESKIJ TSENTR IMENI A S LOGINOVA DEPARTAMENTA ZDRAVOOKHRANENIYA GORODA MOSKVY
- Filing Date
- 2025-12-29
- Publication Date
- 2026-07-06
Abstract
Description
[0001] The invention relates to the field of medicine, namely, to urology, surgery and oncology and can be used in robot-assisted resection of the kidney for intraperitoneal tumors.
[0002] A known method for resecting a kidney for tumors involves preventative suturing of the renal parenchyma before resection to improve hemostasis and increase the reliability of wound closure. This method is accepted as an analogue [1 - Invention Application 2012133743 / 14, August 7, 2012].
[0003] A method for simultaneous closure of a wound and the renal cavitary system during laparoscopic resection of a renal tumor is known [Application for Invention 2013125438 / 14, May 31, 2013]. Laparoscopic resection of a kidney with a tumor is performed with the cavitary system opened. A continuous suture is applied from the outside inward through the fibrous capsule of the kidney, the entire thickness of the parenchyma, with the needle punctured at the wound bed. The thread is passed, capturing the ipsilateral and contralateral walls of the opened cavitary system. A resorbable clip is pre-fixed to the distal end of the absorbable thread under the knot. The first puncture is made at a distance of 5 mm from the corner of the wound. The thread is pulled until the applied clip touches the fibrous capsule of the kidney. Traction of the thread is performed. A resorbable clip is applied to the suture at a right angle to the contralateral wound edge. This method has been adopted as a prototype. However, it does not provide effective hemostasis during surgical treatment of kidney tumors.
[0004] Objective: To improve the efficiency of hemostasis during robot-assisted partial nephrectomy for intraparenchymal tumors.
[0005] The technical result is that when performing robot-assisted resection of an intraparenchymal kidney tumor, enucleoresection of the tumor is performed, then a circular locking suture is made with a step of 4-5 mm on the parenchyma and hemostatic material is placed at the bottom of the resection zone, then a second matching suture is made on the parenchyma with a step of 8-10 mm using retaining plastic clips with injection sites in the zone of the previously applied locking suture.
[0006] The method is as follows.
[0007] Under combined general anesthesia, urinary bladder catheterization is performed with a #18 Foley urethral catheter with a 15 ml balloon. The patient is placed in the lateral position. A 2 cm skin incision is made 4 cm below and 3 cm to the right or left of the xiphoid process, Hasson pneumoperitoneum is established, a 12 mm port is inserted, which is then used for an assistant, and an optical system is inserted. The abdominal organs are inspected: no organ metastases, no abdominal effusion, and no adhesions are found. Under optical control, robotic trocars are inserted linearly along the midclavicular line at 10 cm intervals: 3-8 mm for the robotic camera and two manipulators, and 1-5 mm in the left hypochondrium below the xiphoid process for liver retraction. Perform docking and positioning of the Da Vinci Xi robotic system.
[0008] Next, the parietal peritoneum is opened using monopolar scissors. The colon and its hepatic or splenic flexure are mobilized and retracted caudally. The retroperitoneal space is exposed. The renal vessels are accessed. The renal vessels are represented by an artery and vein. The vessels are mobilized and secured with holders. Next, the kidney is mobilized. Using an endoscopy transducer, the tumor is localized along the posterior surface. It is located entirely intraparenchymatously, measuring 4-15 x 4-15 cm. Using monopolar coagulation, the resection margins are marked. The renal artery and vein are clamped. Using monopolar scissors, the renal parenchyma is dissected along the previously marked boundaries. Enucleoresection of the renal tumor is performed without violating the integrity of the tumor capsule. The removed kidney tumor was placed in a sealed container. A circular, 4-5 mm-long, encircling suture was placed around the parenchyma using 3 / 0 Monocryl thread.At the last external puncture point from the renal capsule, the suture is secured with a retaining plastic clip. Clamps are removed from the renal artery and vein; the renal warm ischemia time was 26 minutes. Bleeding is minor (50-70 ml). Hemostatic material (cellulose wool) is placed in the resection area. The edges of the parenchymal defect are brought together with Monocryl 2 / 0 thread using retaining plastic clips with puncture points in the area of the previously applied locking suture with a step of 8-10 mm along the edges of the resection area to prevent renal parenchyma cutting through. Hemostasis is stable. A safety drain is placed in the resection area through a lateral port and fixed to the skin with an interrupted suture. The tumor in the container is removed from the 12 mm port wound extended to 4 cm. Hemostasis is controlled by keeping the area dry. Desufflation is performed. The trocars are removed. The integrity of the aponeurosis is restored with interrupted sutures using 0.0 Nylon thread. The wounds are sutured layer by layer. Skin sutures are applied. Aseptic dressings are applied.
[0009] The method is confirmed by the following examples.
[0010] Example 1
[0011] Patient M., 54 years old. Admitted on May 23, 2024, with a diagnosis of a left kidney tumor. A three-zone contrast-enhanced CT scan revealed a mass in the lower segment of the left kidney measuring 45 × 37 mm. The RENAL scale score was 9 points. No extracapsular invasion, regional lymph node involvement, or distant metastases were detected. Given the patient's age, intact somatic status, and localized nature, a decision was made to perform robotic-assisted resection of the left kidney. Robotic-assisted resection of the left kidney was performed on May 24, 2024.
[0012] Under combined general anesthesia, a urinary bladder catheter is inserted using a #18 Foley urethral catheter with a 15 ml balloon. The patient is positioned in the right lateral decubitus position. A 2 cm skin incision is made 4 cm below and 3 cm to the left of the xiphoid process. A Hasson pneumoperitoneum is established, a 12 mm port is inserted, which is then used for an assistant, and an optical system is inserted. The abdominal organs are inspected: no organ metastases, no abdominal effusion, and no adhesions are present. Under optical guidance, robotic trocars are inserted in a line along the midclavicular line at 10 cm intervals: 3-8 mm for the robotic camera and two manipulators.
[0013] Perform docking and positioning of the Da Vinci Xi robotic system.
[0014] Next, the left parietal peritoneum is opened using monopolar scissors. The descending colon and its splenic flexure are mobilized and retracted caudally. The retroperitoneal space is exposed. Access to the renal vessels is gained. The renal vessels are represented by 1 artery and 1 vein. The vessels are mobilized and secured with holders. Next, the left kidney is mobilized. Using an endoscopic ultrasound sensor, the tumor is localized on the anterior surface. It is located entirely intraparenchymatously, measuring 4.0 × 4.0 cm. Using monopolar coagulation, the resection margins are marked. The renal artery and vein are clamped. Using monopolar scissors, the renal parenchyma is dissected along the previously marked boundaries. Enucleoresection of the left kidney tumor is performed; the integrity of the tumor capsule is intact. The removed tumor from the right kidney is placed in a sealed container.A circular, 4-mm-incremental, encircling suture is applied to the parenchyma using 3 / 0 Monocryl thread. The suture is secured with a plastic retaining clip at the last external puncture point from the renal capsule. The clamps are removed from the renal artery and vein; the renal warm ischemia time was 23 minutes. Bleeding is minor. Hemostatic material is placed in the resection area. The edges of the parenchymal defect are brought together with 2 / 0 Monocryl thread using plastic retaining clips with puncture points in the area of the previously applied encircling suture at 8-mm increments along the edges of the resection area to prevent renal parenchyma from cutting through. Hemostasis is stable. A safety drain is placed in the resection area through one of the ports and fixed to the skin with an interrupted suture. The tumor in the container is removed from the 12-mm port wound extended to 4 cm. Hemostasis is monitored by keeping the area dry. Desufflation is performed. The trocars were removed. The integrity of the aponeurosis was restored with interrupted sutures using 0.00 Nylon thread. The wounds were sutured layer by layer. Skin sutures were applied. Aseptic dressings were applied.
[0015] The early postoperative period was uneventful. The urethral catheter was removed on the first day, and the drainage was removed on the third day. The patient was mobilized on the first day after surgery. The patient was discharged on the fifth day after surgery.
[0016] Example 2
[0017] Patient I., 57 years old. Admitted on February 11, 2025, with a diagnosis of a tumor in the right kidney. A three-zone contrast-enhanced CT scan revealed a tumor in the upper segment of the right kidney measuring 35 x 31 mm. The RENAL score was 9 points. No extracapsular invasion, regional lymph node involvement, or distant metastases were detected. Given the patient's age, intact somatic status, and localized nature, a decision was made to perform robot-assisted resection of the right kidney.
[0018] On 12.02.2025, a robot-assisted resection of the right kidney was performed.
[0019] Under combined general anesthesia, urinary bladder catheterization is performed with a #18 Foley urethral catheter with a 15 ml balloon. The patient is placed in the lateral position. A 2 cm skin incision is made 4 cm below and 3 cm to the right of the xiphoid process, Hasson pneumoperitoneum is established, a 12 mm port is inserted, which is then used for an assistant, and an optical system is inserted. The abdominal organs are inspected: no organ metastases, no abdominal effusion, and no adhesions are found. Under optical control, robotic trocars are inserted along the midclavicular line at 10 cm intervals: 3-8 mm for the robotic camera and two manipulators, 1-5 mm in the left hypochondrium below the xiphoid process for liver retraction.
[0020] Perform docking and positioning of the Da Vinci Xi robotic system.
[0021] Next, using monopolar scissors, the parietal peritoneum is opened on the right. The ascending colon and its hepatic flexure are mobilized and retracted caudally. The retroperitoneal space is exposed. Access to the renal vessels is achieved. The renal vessels are represented by two arteries and one vein. The vessels are mobilized and secured with holders. Next, the right kidney is mobilized. Using an endoscopy transducer, the tumor is localized in the anterior segment. It is located entirely intraparenchymatously, measuring 3.5 × 5.0 cm. Using monopolar coagulation, the resection margins are marked. The renal arteries and vein are clamped. Using monopolar scissors, the renal parenchyma is dissected along the previously marked boundaries. Enucleoresection of the right kidney tumor is performed, maintaining the integrity of the tumor capsule. The removed tumor from the right kidney is placed in a sealed container.A circular, 5-mm-incremental, encircling suture is applied to the parenchyma using 3 / 0 Monocryl thread. The suture is secured with a plastic retaining clip at the last external puncture point from the renal capsule. The clamps are removed from the renal arteries and vein, and the renal warm ischemia time is 20 minutes. Bleeding is minor. Hemostatic material is placed in the resection area. The edges of the parenchymal defect are brought together with 2 / 0 Monocryl thread using plastic retaining clips with puncture points in the area of the previously applied encircling suture at 10-mm increments along the edges of the resection area to prevent renal parenchyma from cutting through. Hemostasis is stable. A safety drain is placed in the resection area through one of the ports and secured to the skin with an interrupted suture. The tumor in the container is removed from the 12-mm port wound extended to 4 cm. Hemostasis is monitored dry. Desufflation is performed. The trocars are removed. The integrity of the aponeurosis is restored with interrupted sutures using 0.0 Nylon thread. The wounds are sutured layer by layer. Skin sutures are applied. Aseptic dressings are applied.
[0022] The early postoperative period was uneventful. The urethral catheter was removed on the first day, and the drainage was removed on the second day. The patient was mobilized on the first day after surgery. The patient was discharged on the fourth postoperative day.
[0023] Example 3
[0024] Patient M., 46 years old, was admitted on May 23, 2024, with a diagnosis of a left kidney tumor. A three-zone contrast-enhanced CT scan revealed a mass in the anterior lip of the left kidney, measuring 43 x 33 mm. The RENAL score was 10. No extracapsular invasion, regional lymph node involvement, or distant metastases were detected. Given the patient's age, intact somatic status, and localized nature, a decision was made to perform robot-assisted resection of the left kidney.
[0025] On May 24, 2024, a robot-assisted resection of the left kidney was performed.
[0026] Under combined general anesthesia, urinary bladder catheterization is performed with a #18 Foley urethral catheter with a 15 ml balloon. The patient is placed in the right lateral decubitus position. A 2 cm skin incision is made 4 cm below and 3 cm to the left of the xiphoid process, Hasson pneumoperitoneum is established, a 12 mm port is inserted, which is then used for an assistant, and an optical system is inserted. The abdominal organs are inspected: no organ metastases, no abdominal effusion, and no adhesions are found. Under optical guidance, robotic trocars are inserted in a line along the midclavicular line at 10 cm intervals: 3-8 mm for the robotic camera and two manipulators.
[0027] Perform docking and positioning of the Da Vinci Xi robotic system.
[0028] Next, the left parietal peritoneum is opened using monopolar scissors. The descending colon and its splenic flexure are mobilized and retracted caudally. The retroperitoneal space is exposed. Access to the renal vessels is gained. The renal vessels are represented by 1 artery and 1 vein. The vessels are mobilized and secured with holders. Next, the left kidney is mobilized. Using an endoscopy transducer, a tumor measuring 4.0 × 3.8 cm is identified in the area of the anterior lip, near the hilum of the left kidney. Using monopolar coagulation, the resection margins are marked. The renal artery and vein are clamped. Using monopolar scissors, the renal parenchyma is dissected along the previously marked boundaries. Enucleoresection of the left kidney tumor is performed; the integrity of the tumor capsule is intact. The removed tumor from the right kidney is placed in a sealed container.A circular, 4.5 mm-incremental, encircling suture is applied to the parenchyma using 3 / 0 Monocryl thread. The suture is secured with a plastic retaining clip at the last external puncture point from the renal capsule. The clamps are removed from the renal artery and vein. The renal warm ischemia time was 23 minutes. Bleeding is minor. Hemostatic material is placed in the resection area. The edges of the parenchymal defect are brought together with 2 / 0 Monocryl thread using plastic retaining clips with puncture points in the area of the previously applied encircling suture at 9 mm increments along the edges of the resection area to prevent renal parenchyma from cutting through. Hemostasis is stable. A safety drain is placed in the resection area through one of the ports and fixed to the skin with an interrupted suture. The tumor in the container is removed from the 12 mm port wound extended to 4 cm. Hemostasis is controlled by keeping the area dry. Desufflation is performed. The trocars were removed. The integrity of the aponeurosis was restored with interrupted sutures using 0.00 Nylon thread. The wounds were sutured layer by layer. Skin sutures were applied. Aseptic dressings were applied.
[0029] The early postoperative period was uneventful. The urethral catheter was removed on the first day, and the drainage was removed on the third day. The patient was mobilized on the first day after surgery. The patient was discharged on the fifth day after surgery.
[0030] This method enables surgical hemostasis with a suture while preserving the renal pelvis-calyceal system during enucleoresection of complex intraparenchymal tumors. This ensures reliable hemostasis and improves functional outcomes by reducing ligature compression of the renal parenchyma and the volume of ischemic parenchyma. The method was performed in 6 patients. The goal of the invention is achieved by reducing the risk of renal parenchyma rupture. No complications were noted during follow-up.
[0031] Sources of information
[0032] 1. Invention application 2012133743 / 14, 07.08.2012.
[0033] 2. Invention application 2013125438 / 14, 31.05.2013.
Claims
A method of surgical hemostasis during robot-assisted kidney resection for intraparenchymal tumors, including enucleoresection, characterized in that after enucleoresection of the kidney tumor, a circular locking suture is made with a step of 4-5 mm on the parenchyma and hemostatic material is placed in the bottom of the resection zone, then a second matching suture is made on the parenchyma with a step of 8-10 mm using retaining plastic clips with injection sites in the zone of the previously applied locking suture.