I. Improvement of surgical exposure We are the first in China to report the application of the pulling hook in regional lymph node dissection of renal cancer. The hook has the function of multi-joint adjustment and multi-angle pulling, which can greatly improve the intraoperative exposure and increase the safety of surgery. In the selection of surgical incision, it was found that the intraoperative complication rate of combined thoracoabdominal incision and abdominal L-shaped incision was lower than that of simple transverse incision or longitudinal incision. The subcostal transverse incision was better than the longitudinal incision in revealing the lateral and superior pole of the kidney. The combined thoracoabdominal incision is suitable for the upper pole of the kidney, especially on the right side, and the L-shaped incision can satisfactorily reveal the middle and lower pole of the tumor. For tumor diameter >10 cm or obvious enlarged lymph nodes in the hilum and displaced blood vessels, L-shaped incision is used; for huge occupancy in the upper pole of the kidney, combined thoracoabdominal incision is chosen. Prevention of cancer embolus dislodgement Intraoperative cancer embolus dislodgement leading to pulmonary embolism is a fatal complication of kidney cancer surgery. For patients with high-grade cancer embolism, extracorporeal circulation assisted, deep hypothermic stop circulation or subdiaphragmatic block are often applied, but the trauma is huge and the hemodynamic impact is obvious. We borrowed a temporary venous filter from vascular surgery and placed it at the proximal end of the cancer embolus under DSA guidance before surgery, and successfully completed more than 20 cases of radical kidney cancer with cancer embolus in the inferior vena cava without any complication of dislodging the cancer embolus. III. Foreseeing bleeding sites Through the summary of 89 cases, we found that the incidence of unexpected major bleeding in the inferior vena cava and its branches intraoperatively is high. In most cases, the vena cava bleeding is due to the tearing or avulsion of the fragile branches of the inferior vena cava at foreseeable locations, mainly as follows: 1. At the level of each lumbar vertebra, the lumbar veins converge laterally and posteriorly to the vena cava, and if the vena cava is drawn carelessly, it is easy to avulse the confluence of the lumbar veins and cause bleeding; 2. The first pair of lumbar veins sometimes converge behind the renal veins. When the action of separating the renal vein is large, if the lumbar vein may be hidden behind it is not considered, leading to serious bleeding. Because of the posterior position of the lumbar vein here and the obstruction of the renal vein, it is difficult to control it intraoperatively; 3. The right adrenal vein converges into the inferior vena cava, which is brittle and thick with a high position and must be carefully separated to avoid tearing; 4. The gonadal vein converges into the anterolateral position of the vena cava, which can easily lead to tearing and bleeding when the vena cava is stretched too much near its convergence. The exact method of intraoperative hemostasis is proposed: at the possible bleeding site, the vena cava is often effectively stopped by pressing the vena cava with the fingers toward the inner lower spine. The use of two Sim’s forceps, large and small, allows the bleeding to be sought and effectively controlled. When the tumor is large and it is difficult to free the vessels, it is difficult to complete the requirement of ligating the artery first and then the vein. The vein can be ligated first, and the distal end of the renal vein should also be sutured, otherwise the ligature can also cause severe bleeding when the ligature is dislodged. When the kidney and tumor obstruct the repair or treatment of the vascular breach, the tumor can be removed first to gain room for operation. IV. Reducing adjacent organ injuries Liver and spleen injuries are more common during large kidney cancer surgery, mainly because the associated tether and ligament are not sufficiently free, and the force of pulling hook is directly transmitted to the brittle parenchyma of liver and spleen, which is mostly lacerated. In addition, after cholecystectomy, the adhesions near the gallbladder fossa are serious, and it is very difficult to separate the hepatocolic ligament. To prevent liver injury, the right triangular ligament, coronary ligament and hepatic colonic ligament of the liver should be fully freed intraoperatively, and a good gauze block should be padded under the liver hook. To prevent spleen injury, the gastrocolic mesentery, splenic colonic ligament, and splenorenal ligament should be fully freed intraoperatively. To increase the upward freeing of the pancreas and spleen, the submesenteric vein should be ligated and disconnected near the splenic vein. Intraoperative pancreatic injury is due to the large size of the tumor and alteration of the normal anatomical position of the pancreas; sometimes the tumor grows infiltratively and separation between the perirenal fascia and the pancreatic envelope is difficult. It is worth noting that small injuries to the pancreas are sometimes difficult to detect. The tail of the pancreas and the spleen should all be carefully examined after left radical surgery to observe the free degree of the pancreas and the integrity of the envelope, and whether there is bleeding. If pancreatic injury is found, it is not advisable to simply repair the wound. Standardized resection of the tail of the pancreas can prevent the occurrence of postoperative pancreatic fistula to the greatest extent possible by leaving a double trocar in place and postoperative medication to inhibit gastric and pancreatic fluid secretion.