Baumert H et al. (2007) Reducing warm ischemia time during laparoscopic partial nephrectomy: a prospective comparison of two renal closure techniques. Eur Urol 52: 1164–1169

Laparoscopic partial nephrectomy (LPN) is effective for the removal of small tumors. A warm ischemia period >30 min during surgery, however, raises the risk of ipsilateral renal function impairment. Although renal cooling can reduce this risk, minimally invasive techniques are awkward. Baumert et al. investigated whether releasing the arterial clamp before complete closure of the renal parenchyma could reduce warm ischemia time (WIT) without affecting surgical outcome.

Over a 33-month period one experienced laparoscopic surgeon conducted 40 consecutive LPNs. During these, standard complete closure with interrupted sutures before renal arterial clamp release was used in 20 (control), and two running sutures (group 1a) or one running suture (group 1b) before clamp release and continued closure were used in 10 procedures, respectively. Clinically, the only difference between groups was tumor size (larger in groups 1a and 1b).

In the control group, WIT was longer (mean 27.2 ± 5 min versus 13.7 ± 4 min, P <0.01) and hemoglobin loss greater (P <0.01) than in the alternative closure groups; patients in group 1a experienced longer WIT than those in group 1b (mean 16.8 ± 3.6 min versus 10.3 ± 1.2 min, P <0.01). Complications were more frequent in the control group. Early clamp release enabled bleeding vessels to be seen and sutured before parenchymal closure.

This simple change to the LPN technique seemed to reduce WIT effectively without a loss of hemostasis or increased risk of complications. A high degree of suturing skill is, however, still required for success.