Laparoscopic Renal Cryoablation: A Step-by-Step Guide.pdf

Patients are informed to fast after midnight the day prior to the procedure. No bowel preparation is needed unless the patient previously had any extensive abdominal surgery. General anesthesia with muscle paralytics and endotracheal intubation are required. The patient is placed in a modified flank position at a 30-degree angle. The lower leg is flexed while the upper leg is extended. All pressure points are padded and the patient is secured to the table with 3 inch cloth tape. Special attention is required to prevent injury to the fibular, radial, brachial, and axillary nerves and plexus. The cloth tape is applied to the pelvis, shoulder, and legs above the knees to ensure the patient's safety. Pneumoperitoneum is accomplished by placing a Verres needle in the umbilicus for patients who haven’t had previous abdominal surgery; or in the upper quadrant (left or right) with a CO2 insufflation pressure of 15 mHg-20 mmHg. For all anterior tumors, a LESS technique is performed through a single, peri-umbilical incision of 2.5 cm. For other tumor locations, the placement requires one 5 mm trocar at the sub-xiphoid site; one 10 mm trocar at the umbilicus for a deflectable Endo-Eye camera; and another 12mm trocar at the mid-clavicular line as the entry point. Visceral rotation of the colon is performed and only the tumor region should be carefully dissected. The kidney is exposed with minimal dissection after intraoperative ultrasonography is performed through the 12 mm trocar. The Gerota’s fascia is opened at the lesion site to expose the tumor. Perinephric fat surrounding the tumor is sent for pathology. An initial 1.7 mm cryoprobe is inserted into the mass transabdominally through a skin puncture and placed into the lesion. The probe is anchored by freezing the tumor 1 mm-2 mm from the probe. Triangulation of the cryoprobe is performed to ensure active formation of the ice ball with proper surgical margins. Two freezing cycles of at least 6 minutes and two active thawing cycles are performed to effectively treat renal cancer and the cycles are monitored using real-time laparoscopic ultrasound.