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De Nunzio et al. Mini-invasive Surg 2024;8:22 https://dx.doi.org/10.20517/2574-1225.2023.138 Page 3 of 10

offer recommendations regarding the best renorrhaphy technique due to inconclusive evidence supporting
a preferred approach. In this context, our attention is directed toward studies that investigate the influence
of various renorrhaphy techniques on renal function outcomes, subsequent to RPN.

CONVENTIONAL INTERRUPTED SUTURE REPAIR
[24]
Classical renorrhaphy technique has been described by Desai and Gill at the Cleveland Clinic . Following
the enucleation of the tumor mass, a diluted solution of indigo-carmine is retrogradely injected through the
ureteric catheter. This injection verifies the entry into the renal collecting system, which is then specifically
repaired using 2-0 polyglactin sutures on a CT-1 needle. A subsequent injection of indigo-carmine confirms
the integrity of the closure. Any transected vessels in the resection area are also sutured to control bleeding.
Hemostatic renorrhaphy is carried out by using simple 1/0 polyglactin sutures on a CT-X needle, with pre-
fashioned Surgicel bolsters in place. Most suturing procedures are performed under warm ischemic
conditions and streamlining the process by eliminating the need for knot tying can save valuable time and
reduce warm ischemia. Utilizing the da Vinci robot (Intuitive Surgical, Inc., Sunnyvale, CA) in robotic-
assisted LPNs enables the accurate positioning of sutures. Precise suturing seems to be superior to
[23]
indiscriminate deep suturing .
RUNNING KNOTLESS SUTURING
Sliding clips
Many tools may be used to avoid suture application in the kidney, including Lapra-Ty (absorbable
Polyglactin) clips, Suture-clips (Applied Medical, Rancho Santa Margarita, CA), Endoclips (US Surgical,
Norwalk, CT) or Hem-o-lok clips (Weck, Research Triangle Park, NC. It is important to note that Lapra-Ty
is designed for anchoring purposes, whereas the other options are specifically intended for vascular
ligation .
[23]

[25]
The sliding clip renorrhaphy has been described by Benway et al. at Washington University . If the
collecting system is breached or significant blood vessels are still open, it is necessary to use absorbable
sutures for repair before proceeding with renorrhaphy. Typically, the cortex is cauterized using monopolar
cautery.

In the renorrhaphy process, sutures are initially prepared on the surgical table. A knot is formed at the end
of a 15-centimeter-long polyglactin suture, which can be either size 0 or 1. Just above the knot, a LapraTy is
positioned, followed by a 10-millimeter Weck Hem-o-Lock. These sutures are then inserted through the
renal capsule at a 1-centimeter distance. When securing the end of each suture, the assistant attaches a
second Hem-o-Lock to the loose end. Aiming for the center of the clip's jaws is important, ensuring smooth
sliding. Before tightening any sutures, ensure all sutures are in place and clipped. To achieve tightening, the
surgeon uses ProGrasp forceps to grip the loose end of each suture and applies tension perpendicular to the
renal capsule to reduce the risk of tearing. With the robotic needle driver slightly open, the surgeon gently
moves the clip toward the kidney. The correct tension is reached when the kidney's surface shows a slight
dimpling effect. The assistant secures the closure using a LapraTy clip. It is possible to readjust the tension
sliding the clip. However, be cautious not to apply excessive force when readjusting the LapraTy clip, as it
can be challenging. After finishing the suture, remove the clamps and inspect the site to ensure no bleeding
[Figure 1]. If needed, extra sutures or thrombogenic material can be employed.

Orvieto et al. introduced a suturing technique involving an absorbable clip known as Lapra-Ty in a cohort
of 32 patients undergoing Laparoscopic Partial Nephrectomy (LPN) for cT1a tumors . In this approach,
[26]
they conducted freehand sutures on the collecting system and parenchyma with 2-0 and 1-0 polyglactin