Pre-Operative Diagnosis: Right kidney cancer. Positive surgical margin during previous partial nephrectomy.
Post-Operative Diagnosis: Same

Procedure: Right radical nephrectomy, retroperitoneal lymph node sampling.

Anesthesia: General Anesthesia
Complications: None
EBL: less than 100
Fluids: Crystalloids
Specimens: Right kidney and peri renal fat

Narrative of the Procedure:
After informed consent was obtained in preoperative area, the patient was taken back to the operating room. Anesthesia was induced and antibiotics had already been given. The patient was rolled onto the left side with the right flank toward the ceiling. An axillary roll placed. The patient was appropriately padded and strapped to the bed. The lower leg was bent and the upper leg remained straight. The lower knee and ankle were padded. Time-out occurred. Two patient identifiers were used. The previous incision was opened sharply. The fascial sutures were removed. We had access to the kidney. We found the plane between the Gerota’s fascia and the overlying peritoneum. Retractors were placed. The renal hilum was exposed as it had previously been dissected out. The renal artery and vein could be seen. Vessel loops were placed around the renal artery and the renal vein. At this time we stapled across the renal artery to devascularize the kidney. We carefully dissected the remainder of the hilum to ensure there was no further arterial supply to the kidney and there was none. At this time we obtained superior control around the top of the kidney and we stapled across the superior perirenal fat. The vein was then stapled across also. The kidney was completely freed from all of its surrounding attachments and the ureter was the only remaining attachment. We went ahead and stapled across this also. The kidney was then removed. The perirenal fat came with it. We then inspected the hilum. We noted that there was a prominent lymph node roughly 1.5 to 2 centimeters in greatest diameter. This was carefully dissected off of the surrounding tissues and sent separately for permanent pathologic analysis. Reinspection of the fossa demonstrated no bleeding. The fossa was then irrigated with a liter of normal saline. It was removed. One last inspection demonstrated complete hemostasis. We decided not to leave a drain. We then closed the patient’s fascia using 0 Vicryl figure-of-eight sutures. The layers were difficult to ascertain as she had previous surgery 1 week ago. Because of this we took large, single bites across all fascia layers. They were tied down. Once tied down, finger palpation demonstrated no gaps in the closure. The wound was irrigated. The subcutaneous Scarpa’s layer was re-approximated using 2-0 Vicryl. The skin was closed using 4-0 Monocryl in a running sub-cuticular manner. Patient was then awakened, extubated, and discharged back to the PACU in good stable condition.