Position: Lateral, one arm tucked
Time: 4+ hours (very long)
Blood Loss: High (200 – 500 ml)
Post-op Pain: Moderate (3-6)
Maintenance Paralytic: Yes

Approach – GETT. Standard induction. The patient should remain paralyzed throughout the entire procedure.

Lines and drains – two large bore IV, one arterial line and urethral catheter. 

Antibiotics – Cefazolin is the typical choice if not contraindicated.

Nitrous Oxide – It is recommended to AVOID nitrous oxide. Nitrous can expand the gases in the bowel and obstruct the surgical site. However, nitrous is often used at the end of the case for a faster wakeup.

Dialysis/ESRD – If the patient is anticipated to need dialysis or is currently on dialysis, avoid IV’s in the extremity where the fistula is/will be. Hemodynamics may be labile in these patients. Patients recently dialyzed will be fluid depleted. If the patient is showing signs of dehydration (dry mouth, tachycardia, etc) it is appropriate to give fluid resuscitation prior to induction to avoid excessive hypotension.

Blood Loss – while the RISK of blood loss is high, the actual amount is usually around 200 – 250 mL.

Tucked Arms (general considerations): Consider a second IV – once the procedure has started, it’s going to be VERY difficult to handle IV issues – especially if your only IV has problems. Ensure the IV is running and monitors are still functioning after tucking the patient’s arms

High Blood Loss (general considerations): Type and cross, CBC, and CMP should be done prior to the procedure. Consider having an A-line, blood tubing, and extra push-lines. Depending on the fragility of the patient, you may want to have blood in the room and available.

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Lateral position (general considerations): If an ETT has been placed, make sure ETT is secure with extra tape.  Unhook anesthesia circuit while turning lateral and be especially careful to keep patient’s head neutral and aligned with body to avoid neck injury. Once lateral, use pillows/blankets/foam headrest to keep the patient’s head in neutral position. The most common nerve injury for orthopedic lateral procedures are neurapraxias of the brachial plexus. These are motor and/or sensory loss for 6-8 weeks due to pressure on the contralateral (dependent) axilla. To prevent this, place an axillary roll under the patient (caudad to the axilla, on the rib cage, and NOT in the axilla). Check routinely to make sure the axillary roll does not migrate into the axilla. If the non-dependent arm is placed on a board, check padding and reposition regularly to avoid radial nerve compression. If a bean bag is employed, check the hard edges to ensure that unnecessary pressure isn’t being put on soft tissues. Pad all dependent bony prominences such as the fibular head (to prevent peroneal nerve injury), and place pillows between the knees and ankles (to prevent saphenous nerve injury). If anterior hip supports are in place, ensure they are properly padded or neuropraxias and/or occlusions of large blood vessels may result.

Long procedure (general considerations): Procedures anticipated to last longer than 2 hours generally require a urinary catheter. Also consider checking lines and positioning regularly as the risks of infiltration and nerve damage are increased with procedure time. Consider an IV fluid warmer and a forced air warmer to keep the patient euthermic.

Arterial line (general considerations): Preoperatively check pulses to gauge the best side to attempt the A-line. Perform an Allen test to ensure adequate blood flow. Have the A-line equipment set up and ready in the room.

Partial nephrectomy is the surgical excision of the segment of the kidney harboring the pathology. It is performed for small renal cell carcinomas and benign tumors of the kidney, such as angiomyolipomas, and for duplicated collecting systems with a diseased moiety. If the partial nephrectomy is being done for renal cell carcinoma, it may be accompanied with a regional lymphadenectomy.

A partial nephrectomy refers to the surgical removal of a kidney segment that contains pathological alterations. This procedure is typically conducted for renal cell carcinomas and benign kidney tumors.  Additionally, it is also performed in cases of duplicated collecting systems presenting with a diseased component.