Laparoscopic repair of a stapler-induced lesion in the vena cava

Rev Mex Urol 2014;74(3):190-192
ÓRGANO OFICIAL DE DIFUSIÓN DE LA SOCIEDAD MEXICANA DE UROLOGÍA,
COLEGIO DE PROFESIONISTAS, A.C.
www.elsevier.es/uromx
Clinical case
Laparoscopic repair of a stapler-induced lesion in the vena cava
during laparoscopic nephrectomy
E. I. Bravo-Castroa,*, J. G. Campos-Salcedob, A. Sedano-Lozanoc, J. J. Torres-Salazarc, J.
J. Torres-Gómeza, J. A. Castelán-Martíneza, J. C. López-Silvestrec, M. Á. Zapata-Villalbac,
C. E. Estrada-Carrascoc, H. Rosas-Hernándezc, C. Díaz-Gómezc, J. J. Islas-Garcíaa, J.
Aguilar-Colmeneroa and I. A. Martínez-Alonsoa
a
Urology Speciality Residency, Escuela Militar de Graduados de Sanidad, Mexico City, Mexico
b
Urology Service Management, Hospital Central Militar, Mexico City, Mexico
c
Urology Service, Hospital Central Militar, Mexico City, Mexico
KEYWORDS
Nephrectomy;
Laparoscopy; Lesion
in vena cava;
Laparoscopic repair;
Mexico.
Abstract The first reports on laparoscopic nephrectomy appeared more than 2 decades ago
and the great benefits of this surgical technique have been demonstrated in relation to open or
conventional surgery. As is the case with open surgery, laparoscopic surgery is not exempt from
complications, which can range from slight undetected lesions to severe or catastrophic ones.
We present herein the case of a patient that, while undergoing laparoscopic nephrectomy, had
the complication of a lesion in the vena cava, which was resolved during the same procedure
with no need to convert to open surgery. It is our opinion that the experience of the laparoscopic surgeon is important for resolving this type of problem.
Laparoscopic surgery generally is converted to open surgery in the face of severe lesions. Depending on the case and the experience of the surgeon, such events can be repaired without the
need for conversion.
Palabras clave
Nefrectomía;
Laparoscopía; Lesión
en vena cava;
Reparación
laparoscópica;
Reparación laparoscópica de una lesión de vena cava producida por una engrapadora
durante una nefrectomía laparoscópica
Resumen La nefrectomía laparoscópica tiene más de 2 décadas, en las que empezaron los
primeros reportes. Se han demostrado los grandes beneficios de esta técnica quirúrgica en relación a la cirugía abierta o tradicional. Al igual que la cirugía abierta, la cirugía laparoscópica no
* Corresponding author at: Blvd. Manuel Ávila Camacho s/n, Lomas de Sotelo, Av. Industria Militar y General Cabral, Delegación Miguel
Hidalgo, C.P. 11200, México D.F., México. Telephone: (01) 5557 3100, ext. 1704. Email: briv_edca@hotmail.com (E. I. Bravo-Castro).
Laparoscopic repair of the inferior vena cava in laparoscopic nephrectomy México.
191
está exenta de complicaciones, las cuales pueden ir de lesiones inadvertidas leves, hasta lesiones graves o catastróficas.
Se presenta el caso de un paciente sometido a nefrectomía laparoscópica, donde se manifiesta
como complicación una lesión en vena cava, haciéndose la reparación por esta misma vía sin
necesidad de convertirla a cirugía abierta.
Creemos que la experiencia del cirujano laparoscopista es importante para resolver este tipo de
problemas.
Las lesiones graves en cirugía laparoscópica generalmente la convierten en cirugía abierta; dependiendo del caso y la experiencia del cirujano, éstas pueden ser reparadas por la misma vía.
85-4542 © 2014. Revista Mexicana de Urología. Publicado por Elsevier México. Todos los derechos
reservados.
Introduction
Since the first laparoscopic nephrectomy performed in 1991
by Clayman et al.1 for benign kidney disease, laparoscopy for
malignant kidney diseases and healthy donor nephrectomy
has rapidly increased. More extensive and complicated
laparoscopic renal surgeries have been carried out in
numerous urologic centers worldwide. Laparoscopic renal
surgery has clear advantages over open surgery that include
reduced postoperative pain, shorter hospital stay, a faster
return to normal daily activities, and better cosmetic results.2
Nevertheless, laparoscopic renal surgery is associated with
unique changes and complications, compared with open
surgery. A complication range of 5% to 13.3% has been
reported in various laparoscopic renal surgery case series,
with a rate of conversion to open surgery of 4% to 7.5%.3-6
Vascular complications are common. In a meta-analysis of
laparoscopic renal surgery complications in which different
techniques were reviewed, venous trauma was found to be
the most frequent vascular complication. It most often
presented with a very high rate of conversion to open surgery,
except in cases of laparoscopic partial nephrectomy.7
Vena cava injury can have a traumatic or iatrogenic
origin. During nephrectomy, such lesions usually occur on
the lateral wall. Customary management is primary repair
with individual nonabsorbent sutures when the size of the
lesion is less than 50% of the circumference; when lesions
are greater than 50% of the circumference, they require a
venous or peritoneal patch. Repair of posterior wall injury is
more complex when there is massive destruction of the
infrarenal inferior vena cava; its complete ligation is
adequately tolerated.8
The aim of this report was to describe our experience
with the laparoscopic management of injury detected in the
inferior vena cava.
the operation. The procedure began with the application of
general anesthesia. A 16 Fr urethral catheter was placed,
after which the patient was put in the right lateral decubitus
position, supported by the articulated arms of the surgical
table. Once the operating field was installed, a 1 cm incision
lateral to the umbilicus was made to introduce the blunt-tip
port. When adequate pneumoperitoneum (15 mmHg) was
reached, the camera with a 30° lens was inserted.
Diagnostic laparoscopy was carried out and 3 ports (one 10
mm and two 5 mm) were installed under direct vision: at
the midpoint of the subcostal arch, midway between the
anterior superior iliac spine and the camera, and another
over the iliac crest. A bipolar electrosurgical scalpel and
radiofrequency electrocoagulation (Ligasure®) were used.
First, the ipsilateral colon was separated in order to expose
the retroperitoneum. En bloc dissection and freeing of the
kidney initially located the ureter; it was sectioned and
sealed with 10 mm clips. A more proximal dissection then
reached the renal hilum, after which careful dissection and
identification of the renal vein and artery were done. The
renal artery was ligated using Hem-o-lok® and the renal
vein was stapled using an Ethicon Endosurgery ENDO-GIATM
ATW 45 mm stapler with a white reload for vascular use with
6 rows of staples. However, when the stapler was removed,
it was found that the row of staples had not been adequately
performed and there was an approximately 1 cm lesion in
the lateral wall of the vena cava. Aspiration was
immediately carried out, along with primary repair with 5-0
Prolene® double-armed sutures (fig.1). Adequate repair was
verified. The procedure continued with the dissection of the
upper pole, removing the surgical specimen. Hemostasis
was verified, the ports were removed and a 1/8 drain was
placed under direct vision. The port wounds were closed,
ending the procedure.
Case presentation
Results
A man in the sixth decade of life with no past medical
history of chronic diseases was diagnosed with a right nonfunctioning kidney secondary to lithiasis. The proposed
management was laparoscopic right simple nephrectomy.
Surgery duration was 280 minutes and the repair time was
40 minutes. Quantified blood loss was 600 cc. Hospital stay
was 5 days, postoperative pain was managed in the
conventional manner, and the patient was ambulatory at 24
hours. Postoperative hemoglobin value was 9 g/dL. During
the procedure one erythrocyte concentrate was applied.
The drain was removed on the 4th day and the patient was
released on day 6. His current follow-up at our service
shows adequate control.
Procedure description
After receiving the diagnosis and having the procedure
explained to him, the patient gave his informed consent for
192
E. I. Bravo-Castro et al
highly experienced in laparoscopic procedures and always
open to the possible necessity of procedure conversion in
order to have successful repair; another determining factor
is the hemodynamic condition of the patient, never letting
the laparoscopic approach compromise the stability of the
patient and always being aware of the possibility of
conversion; other important factors are having an adequate
hospital infrastructure in relation to laparoscopic and
surgical material and having the support of a blood bank, if
needed; and an essential factor is adequate surgical team
coordination, completely synchronized with the surgeon, so
that there is active collaboration during the procedure.
Figure 1 Intraoperative image during primary repair.
Discussion
Over the past 20 years, laparoscopy has had a great impact
on the management of patients presenting with
genitourinary problems thanks to its many advantages, such
as reduced blood loss, less postoperative pain, shorter
hospital stay, and rapid return to normal daily activities.
However, it requires a learning curve, as well as a command
of the complications derived from the procedure, such as
problems related to trocar insertion and carbon dioxide
pressure.3
The learning curve varies, depending on the procedure to
be performed. In the case of nephrectomy, at least 50 are
considered necessary; as a minimum, one procedure a week
for the first year of training. It is well known that the
number of complications decrease as experience increases.3
In a study reporting on the first 100 cases of laparoscopic
nephrectomy, the complication rate was approximately
13.3%; it decreased to 3.6% as the procedures continued to
be performed. 3 In a meta-analysis published on the
experience of different laparoscopic procedures, the most
frequent intraoperative complication was blood loss at
1.4%; intestinal trauma was found in fewer than 0.5% of the
cases, and trauma to a solid organ in less than 0.5%.7
A case series on complications related to nephrectomy
stated that one of the complications produced by bleeding
was due to poor technique in closing the stapler over the
renal vein and required conversion to open surgery in order
to be controlled.7
Finally, we can conclude that despite the fact that
laparoscopic nephrectomy is an ideal method for the
surgical management of renal pathology in selected cases,
it is not exempt from complications; the most common one
is intraoperative bleeding due to vascular injury. There are
various factors that determine the possibility of laparoscopic
repair: initially the laparoscopic urologic surgeon should be
Conclusions
In our experience with this patient there were various
factors that determined the success of the primary repair,
the most significant of which was the experience of the
laparoscopic surgeon in the management of such lesions.
Conflict of interest
The authors declare that there is no conflict of interest.
Financial disclosure
No financial support was received in relation to this article.
References
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