Renal tumor is a common disease of the urinary system, and surgery is the most effective method to treat renal tumor. The first laparoscopic nephrectomy reported by Clayman in 1991 marked the advent of minimally invasive renal surgery. In recent years, more and more minimally invasive urological surgeries have been performed in China, and almost all surgeries in the abdominopelvic cavity can be handled using laparoscopy. The number of partial nephrectomies has exceeded that of radical nephrectomies every year in recent years. The following is a discussion of the common problems, difficulties and countermeasures of such surgery. I. Choice between radical and partial nephrectomy for kidney cancer Radical nephrectomy can completely remove the kidney and the mass, but the defect is that more kidney units are lost. If the patient has high-risk factors, such as diabetes, hypertension, proteinuria, recurrent kidney stones, blood creatinine close to the high limit of normal, there is a greater possibility of postoperative renal insufficiency. It is generally believed that partial nephrectomy for kidney cancer less than 4cm can achieve the same goal of radical resection to treat the tumor. Radical resection may be overtreatment, but for CT stage III scan without fast-in and fast-out tumor, attention should be paid to identify renal papillary-like renal carcinoma type II, sarcoma, medullary carcinoma and invasive uroepithelial carcinoma, etc., and do puncture biopsy when it is difficult to identify them. Although the proportion of these tumors is low, the malignancy is high. Partial nephrectomy can maximize the preservation of effective renal units, and its indications include absolute indications (anatomic/functional isolated renal carcinoma, bilateral renal carcinoma), relative indications (presence of benign disease in the contralateral kidney, such as stones, chronic pyelonephritis, hypertensive nephropathy, diabetic nephropathy, renal artery stenosis, etc.) and optional indications (peripheral small renal carcinoma, diameter <4 cm). The size of tumor is the deciding factor for partial nephrectomy, while the location of tumor is more important. For example, if central type renal carcinoma with no obvious elevation on the surface of kidney, partial nephrectomy is performed under ultrasound positioning during surgery, it is better to have a clinically experienced ultrasound surgeon on the stage; in addition, both Trocar under the rib margin are used 10mm, which is helpful to locate the tumor from different angles. Hilar tumor refers to those whose tumor edge is less than 0.5cm from renal vessels. The key point of resecting this type of tumor is to firstly separate the renal vessels around the tumor, and the direction of needle when suture is passed from hilar to outward. In recent years, there are many reports of partial nephrectomy for tumors larger than 4cm in diameter, and good results have been obtained. 2. Renal vascular variation and renal vascular treatment For surgery, bleeding is a common risk. Preoperative renal enhancement CT+CTU+CTA should be performed to clarify the site of tumor and the number of branches of renal vessels. About 80% of renal arteries are one main artery, which originates from the abdominal aorta below the superior mesenteric artery, but about 20% of patients have multiple renal arteries or renal veins. If the main renal artery is found to be thin intraoperatively (the diameter of renal artery is mostly around 0.8cm, if the renal artery is only 0.3~0.4cm, be alert to the presence of the second artery) or the distal end of the Hem-o-lok clip on the main renal vein is rapidly filling. The possibility of branching should be considered when filling, and the larger tumor may also come from the collateral circulation. During surgery, the perinephric fat capsule can be freed and the surrounding tissue can be cut off in a small bundle by ultrasonic knife at the middle dorsal pulsation of the kidney to reveal the renal artery. The renal artery should be separated close to the psoas major muscle and near the beginning of the renal artery, so that the artery does not split into multiple branches near the renal hilum. If multiple renal arteries are found, blocking forceps can be used to clamp each branch when performing partial nephrectomy, and Hem-o-lok clamps can be used to clamp the renal artery when performing radical nephrectomy, and it is best to have the tip of a Hem-o-lok clamp visible at the proximal end to avoid locking the surrounding tissues and avoiding Hem-o-lok clamp slippage; usually multiple renal arteries will combine with multiple renal veins, and care should be taken to find and separate them. Several points need to be noted in the process of dealing with the vessels: ① The arteries are often surrounded by abundant lymphatic vessels, which can be gradually cut off with the ultrasonic knife in slow gear to prevent postoperative lymphatic leakage; ② Pay attention to the separation along the longitudinal direction of the arteries; lateral separation can cause damage to the surrounding tissues or tear the vessels; cut the arterial sheath with the ultrasonic knife and free the renal arteries by 1.5~2 cm, then close them with Hem-o-lok clamps (2 at the proximal end and 1 at the distal end) and close them with Hem-o-lok clamps. 1 at the distal end) and cut the artery, be sure to see that the tip of Hem-o-lok completely wraps the renal artery to confirm complete clamping; if using a linear cutter to deal with the renal artery also ensure that the horizontal line of its front end crosses the renal artery; ③ the renal vein has a thin wall and more branches, so the separation process with curved forceps and ultrasonic knife must be seen to separate along the longitudinal axis of the vein, otherwise it is easy to tear the vein. The same need to free the renal vein 1.5~2cm, and then use Hem-o-lok or linear cutter to deal with it. When cutting the right renal vein it is important to distinguish whether it is a renal vein or a vena cava. When we separate the right renal vein, we routinely divide it to the upper and lower corners of the confluence of the renal vein and the inferior vena cava. The gonadal vein, the central adrenal vein and the lumbar vein that converge into the left renal vein are closed with Hem-o-lok clamps or with titanium clamps if necessary and then cut with scissors, or they can be cut directly with the ultrasonic knife in slow gear, while the rest of the branches are usually cut directly with the ultrasonic knife in slow gear. The ultrasonic knife slow file is first clamped on both sides of about 5mm to be cut off, and the ultrasonic knife slow file is used to act until the vessel is white, and then cut off in the middle, so that each vessel stump is coagulated in two places; ④ The Hem-o-lok plastic clamps and sizers are smaller than the linear cutter and require relatively less space for operation, which can avoid the complications that may be brought about by the linear cutter to deal with the kidney tip, such as the tip of the cutter The overall cost is relatively lower than that of the linear cutter, so we generally choose to use Hem-o-lok clamps; ⑤ tissue between the clasps is one of the main reasons for Hem-o-lok slippage, so we must ensure that the vessels are free enough, and if the Hem-o-lok is found to be slipping during surgery, the renal vessels should be free again, and if the right renal vein is too short, a linear cutter can be used instead of Hem-o-lok. If the right renal vein is too short, a linear cutter can be used instead of Hem-o-lok; (6) During partial nephrectomy, the renal artery is blocked with blocking forceps, and the renal vein does not need to be blocked. The time of thermal ischemia during partial nephrectomy is obviously related to the postoperative renal function, and it is generally believed that the time of blocking renal artery should be less than 30 min. The renal artery can be blocked after searching and freeing the renal vessels first and then freeing the kidney to clarify the tumor site and resection range. Suturing is performed immediately after removal of the tumor. Generally, one can choose to suture without knotting (i.e. clip a Hem-o-lok fixation after every 1 stitch is stretched tightly) or use a suture with barbed thread, which can omit the step of knotting to shorten the blocking time. There is also the option of decreasing the renal temperature (using methods such as ice chip coverage, renal artery perfusion or retrograde ureteral perfusion) to reduce renal blood flow and metabolism.