Abstract
Open nephrectomy, either radical or simple, remains an important surgical approach for management of urologic pathology that cannot be addressed utilizing a minimally invasive technique. There are multiple surgical approaches; the best option is determined by the target anatomy, vascular access required, surgeon experience and preference, and the complications specific to each approach. Understanding these intricacies are important to tailoring the operation for each patient.
Complications due to nephrectomy, either open or laparoscopic, can be due to patient positioning, surgical approach utilized, visceral and vascular anatomy encountered, and postoperative management of the patient. Clear understanding of the normal and variant anatomy that may be encountered, as well as utilizing appropriately ordered preoperative imaging, is critical to the minimization of complications. In this chapter, we detail the common complications of open nephrectomy and appropriate management of those complications.
Keywords
Radical nephrectomy, Simple nephrectomy, Flank incision, Thoracoabdominal incision, Subcostal incision, Pneumothorax, Splenic injury, Liver injury, Tumor thrombus
Chapter Outline
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Key Points
- 1.
Advantages of anterior incisions, whether midline, subcostal, or chevron, include quick exposure to the renal pedicle and the great vessels.
- 2.
Up to 23% of patients will have a flank sag postoperatively as a result of injury to intercostal nerves that causes laxity of flank muscles at that level.
- 3.
In cases anticipated to have a difficult hilar dissection or anterior approach, in which anatomic access to the artery is more difficult, preoperative renal artery embolization may be helpful.
- 4.
The most common cause of splenic injury is excessive traction on the splenic attachments that rips the splenic capsule.
- 5.
In cases of pancreatic injury, if injury of the duct is noted, distal pancreatectomy is the preferred method of management.
- 6.
If bleeding makes repair of liver injury difficult, total obstruction of hepatic vascular inflow may be obtained by Pringle maneuver.
- 7.
Perioperative strategies to decrease complication rates in elderly patients include minimal operative time, earlier consideration of blood transfusions, and possible gastric tube placement to decrease pneumonia rates.
Surgical removal of the kidney was reported as early as 1861. However, the first planned nephrectomy was probably performed by Gustav Simon in 1869 for a ureterovaginal fistula. Because early nephrectomies were associated with high mortality rates as a result of peritonitis, the flank incision became the preferred approach until the 1950s, when effective antibiotic prophylaxis was developed. In 1969, Robson and colleagues published a seminal article describing their surgical management of renal tumors through the thoracoabdominal approach. Early control of the renal vessels, en bloc excision of kidney and adrenal with Gerota’s fascia remaining intact, and extended lymphadenectomy allowed improved survival compared with simple nephrectomy.
The principles outlined by Robson and associates still form the basis for treatment of similar tumors. Since that time, however, advances in imaging techniques have improved detection of smaller lesions and have caused a significant downward stage migration. This change may partially account for improvements in the morbidity and mortality of nephrectomy. Evolving surgical techniques, including laparoscopy and robotic surgery, anesthesia improvements, newer antibiotics, and effective intensive care contribute as well. Contemporary open nephrectomy is likely reserved for larger or more complex lesions thereby, possibly increasing complication risk.
Preoperative Considerations
Cardiopulmonary Considerations
Some possible life-threatening cardiopulmonary complications common to all surgical procedures include hypovolemic shock, myocardial infarction, pneumonia, pulmonary embolism, and pulmonary insufficiency. Renal surgery may cause severe stress to the cardiopulmonary system through many etiologies, including patient positioning effects and blood loss. The slow-growing nature of most renal neoplasms allows time for preoperative cardiopulmonary optimization, including the possibility of coronary or carotid artery revascularization. This must be balanced against the anticoagulation typically initiated after these interventions.
Patients undergoing nephrectomy frequently are placed in the flank position for surgical access. This position may severely stress the cardiopulmonary system, especially if the operating table is broken or a kidney rest is extended. First, pressure on the great vessels may decrease preload and increase afterload, thereby decreasing cardiac output. Second, ventilation is limited by the flank position. In addition to limiting the excursion of the dependent diaphragm, increased ventilation–perfusion mismatching may further decrease oxygen exchange and lead to hypoxia. These combined cardiopulmonary effects may make this position intolerable for some patients with limited reserve.
These issues necessitate careful preoperative screening of patients for pulmonary diseases and cardiac status. Cardiology and pulmonology consultation should be obtained if any doubt exists about the patient’s condition. Preventive measures instituted preoperatively and invasive monitoring intraoperatively may increase safety for some patients. The potential for blood loss and large hemodynamic shifts should prompt preoperative blood typing. In addition, autologous blood donation should be offered to patients.
Urologic Considerations
Preoperative workup of the urinary tract should include imaging of the operative site, with a specific focus on localized extent of tumor burden, effect on nearby visceral structures, presence or absence of tumor thrombus, and vascular anatomy. Physicians should include assessment of contralateral kidney function in addition to total kidney function. Urinalysis and, if indicated, urine culture and sensitivity should be performed to ensure urinary tract sterility before the planned operation. If urinary tract infection is found, antibiotics with adequate coverage should be given.
Patient Preparation
General intraoperative preventive measures are very important in avoiding complications common to any surgical procedure. Strict adherence to evidence-based recommendations ensures best possible outcomes. Antibiotic prophylaxis should be initiated ≥30 minutes before incision. Two large-bore intravenous access ports must be in place, and there should be consideration of arterial pressure monitoring and central venous access prior to the procedure. Per the 2008 AUA guidelines on the “Prevention of Deep Vein Thrombosis in Patients Undergoing Urologic Surgery,” subcutaneous heparin should be initiated preoperatively to decrease the risk of deep vein thrombosis. Alternatively, compression hose, or preferably sequential compression devices, should be placed on the lower extremities unless contraindications such as open ulcers exist. If this is the case, some evidence suggests that placement of these devices on the arms may still provide some antithrombotic effects. The patient must be positioned carefully with pressure points sufficiently padded. Factors pertaining to specific positions are discussed later.
General Medico-Renal Considerations
Nephrectomy represents the removal of an important component of the body’s mechanism for maintaining blood pressure homeostasis. The incidence of postoperative hypertension is <8%, usually mild, and it frequently resolves. In the long term, hypertension develops in some kidney donors, but it is not significantly different from hypertension in matched population controls or siblings.
Postoperative acute renal insufficiency may be multifactorial, relating to removal of a large percentage of the body’s functional nephrons, direct or indirect manipulation of the contralateral kidney that causes arterial spasm, and rhabdomyolysis related to patient positioning. Postoperative acute renal insufficiency is usually transient but may require dialysis in some cases.
In the long-term, radical nephrectomy has been shown to be associated with the development of renal insufficiency, and this should be considered in all patients undergoing nephrectomy, even in the presence of a normal contralateral kidney.
Surgical Approach
Many incisions have been described for nephrectomy. These may be classified into anterior, flank, and posterior approaches. Indications for specific incisions include patient body habitus, size and location of the renal lesion, other concurrently planned operations, indications for lymphadenectomy, and surgeon experience.
Site Verification
The Joint Commission (formerly the Joint Commission on Accreditation of Healthcare Organizations) reported statistics on wrong-site surgery and showed that the incidence was increasing, peaking in 2011 at 152 reported events. However, since that time, there has been a continued decrease in reported events; 67 events were reported in 2014. Approximately 10% of cases are reported to be urologic. A review of 7147 sentinel events reported to the AJCC between 2005 and 2010 revealed that 956 events, or 13.4%, were due to wrong-site surgery. In 2011, the World Health Organization published the surgical checklist which helps ensure the reduction of wrong-site surgery ( Table 37.1 ). Rigorous adherence to policies designed to prevent these occurrences is necessary to optimize patient care.
Anterior Incisions
A main advantage of anterior incisions, whether midline, subcostal, or chevron ( Fig. 37.1 ), is quick exposure to the renal pedicle and the great vessels. This feature may not be as important for prevention of tumor seeding as was first thought, but ease of exposure and familiarity with anatomy is still advantageous. Other situations that would favor the anterior approach include procedures in trauma patients, patients who cannot tolerate flank approach positioning, planned bilateral nephrectomy in patients with polycystic kidney disease, large or upper pole tumors, bilateral renal neoplasms, left nephrectomy with significant thrombus extension into the vena cava, and other preoperative indications for bilateral dissection. Although rarely indicated because of the accuracy of modern imaging techniques, the anterior approach also allows exploration of the abdomen for metastatic disease. Some investigators advocate extended lymphadenectomy with nephrectomy, and this procedure is easiest through an anterior approach.
The disadvantages of anterior approaches include transection of multiple muscle groups for subcostal or chevron incisions. If the operation is performed transperitoneally, any spillage of tumor or infectious material may have greater consequences than if the material is confined to the retroperitoneum. If the operation is intended to be retroperitoneal, anterior approaches may not be best because entry into the peritoneal cavity may accidentally occur. Transperitoneal operations are associated with formation of adhesions and possible future small bowel obstruction. This complication was estimated to occur in 2% of patients in some series. Obese patients may not be suitable candidates for anterior approaches because of difficulties associated with excessive extraperitoneal and intraperitoneal fat.
Flank Incisions
Flank approaches may be preferable for uncomplicated nephrectomies. This approach allows access to the retroperitoneum while avoiding entry into the peritoneum or chest. Careful attention must be given to positioning and padding of the patient. Taping the hips too tightly to the operating table can result in gluteal necrosis. The incision may be accomplished in the 10th or 11th interspaces, or the 10th, 11th, or 12th ribs may be resected. If an intercostal incision is performed, the incision should be made immediately superior to the rib to avoid damage to the neurovascular bundle that runs immediately below each rib and is between the internal oblique and transversalis muscle layers. Up to 23% of patients have a flank sag postoperatively as a result of injury to intercostal nerves that causes laxity of flank muscles at that level ( Fig. 37.2 ). This condition may be difficult to distinguish from a true hernia, which is a rarer complication requiring surgical treatment to prevent incarceration. Poor nutritional status, diabetes, and other risk factors for poor wound healing predispose to the risk of hernia formation. Computed tomography (CT) imaging aids in establishing the diagnosis of an incisional hernia. Postoperative pain from flank incisions may be significant, especially during deep inspiration. Pain may become a long-term problem as a result of neuritis or entrapment of an intercostal nerve in the sutures or surrounding scar tissue. This complication may be prevented by careful reapproximation of the muscle layers. Fortunately, these issues usually resolve with time. Reassurance may be all that is required, but some patients require local steroid injections for analgesia.
Thoracoabdominal Incisions
The thoracoabdominal incision is a large incision now usually reserved for large or complicated radical nephrectomies. The extensive incision allows exploration of the peritoneal, retroperitoneal, and thoracic compartments with biopsy or wedge resection of any suspicious lesions. The exposure to the upper pole of the kidney is excellent, and therefore this incision may be used when an extensive upper pole lesion is anticipated. Vena cava thrombi with known extension above the diaphragm or into the right atrium may require entry into the thoracic cavity, and a right thoracoabdominal incision provides good visualization of the thoracic vena cava and right atrium. The disadvantage of this incision is the considerable morbidity associated with it. The size of the incision predisposes it to infection and significant postoperative discomfort. Spillage of tumor or infectious particles may be problematic given that both the peritoneum and the thoracic cavity are affected. Caution must be exercised when the left thoracoabdominal incision is used, to avoid injury to the spleen during incision of the diaphragm. The division of the costal cartilages anteriorly may lead to significant postoperative pain if these cartilages are not fixed securely with nonabsorbable suture. Rare complications include postoperative hemidiaphragmatic paralysis from division of the phrenic nerve and an annoying clicking sensation from nonunion of the costal cartilages.
Lumbodorsal Incisions
A distinct advantage of lumbodorsal incisions is decreased postoperative pain. This incision allows entry into the retroperitoneal space without division of any muscle groups and thereby minimizes the surgical trauma, which is one cause of postoperative discomfort of patients. Wound breakdown is uncommon with lumbodorsal incisions because the only layer to be divided, the lumbodorsal fascia, is very strong. The disadvantages of this incision center on the limited exposure it provides. Because extensive dissection of the vascular pedicle is very difficult, this incision is inadequate for renovascular surgery and radical nephrectomies with large tumors, upper pole disease, or suspected tumor extension or tumor thrombus. Division of the costovertebral ligament of the 12th rib may improve upper pole exposure. However, this maneuver risks damage to the costal neurovascular bundle. Because of the limited exposure provided by lumbodorsal incisions, they are less commonly used than are anterior or flank approaches. At present, laparoscopic surgery has widely replaced the lumbodorsal approach to minimize incision size and postoperative pain.
Intraoperative Complications
Hemorrhage
Angiography is not routinely performed before nephrectomy. Thus, prevention of significant intraoperative hemorrhage requires accurate knowledge of renal anatomy and blood supply as well as the variations commonly encountered.
Arterial Anatomy
In the majority of patients, a single renal artery branches laterally off the aorta and enters the renal hilum. On the right, the renal artery usually courses posterior to the vena cava. Multiple renal arteries are not uncommon, seen in >25% of patients in some series. These arteries, if present on the right, generally pass anterior to the vena cava. The renal arteries are end circulation. If the artery or any of its branches is occluded, ischemic infarction of the kidney or the respective segment will occur.
Because the gonadal artery, adrenal artery, and inferior phrenic artery also lie in close proximity to the areas of dissection, these vessels are vulnerable to injury. The inferior phrenic arteries are the first abdominal branches of the aorta and generally have branches coursing inferior to supply a portion of the adrenal circulation. The adrenal arteries branch from the aorta at the level of the celiac trunk anteriorly and course laterally to the adrenals. Additional adrenal arterial branches frequently originate from the renal artery. The gonadal arteries branch laterally off the aorta below the renal arteries. Alternatively, they may occasionally branch off the renal artery. The right gonadal artery most often passes anterior to the vena cava.
Venous Anatomy
Venous drainage of the kidney, in contrast to the arterial circulation, has many collateral vessels. The right renal vein drains directly into the vena cava, usually without major branches. The left renal vein is usually joined by the left gonadal vein, left adrenal, and a lumbar vein before it passes anterior to the aorta to join the vena cava. Both renal veins generally lie anterior to the corresponding renal artery. Multiple renal veins are less common than are multiple arteries but they do occur in approximately 1% of patients, generally on the left. The renal vein may divide, with one limb anterior and one posterior to the aorta. Alternatively, only the posterior branch may remain. The extensive collateral vessels of the renal venous system prevent slowly occurring occlusive processes such as tumor thrombus formation from causing kidney damage, renal failure, or other symptoms. Because of the greater collateral circulation on the left, the left renal vein may be ligated acutely with probable survival of the renal unit. The right lacks such extensive collateral vessels.
Statistics of Hemorrhage
Radical nephrectomy has classically been considered a bloody surgical procedure. Neovascularization and additional collateral circulation to renal tumors can be extensive. In historical series, most patients required transfusions with the average amount reaching 2 L. More modern series report an average blood loss of 300 mL and a transfusion rate of only 15%. Hemorrhage during nephrectomy for neoplastic conditions is more likely compared with benign conditions. Close attention to surgical technique may minimize complications associated with hypotension, anemia, and blood transfusion. Adequate venous access must be ensured preoperatively to allow rapid resuscitation and possible blood transfusion.
Preoperative Embolization
Preoperative embolization is an attractive option when tumor extent makes extensive vascularity probable ( Fig. 37.3 ). Infarction of the entire kidney should theoretically reduce blood loss, although most studies have not found this to be the case. Some surgeons believe that embolization may allow easier dissection of the kidney because it forms an edematous plane immediately surrounding the infarcted tissue. Arterial embolization also allows earlier ligation of the renal vein. In cases anticipated to have a difficult hilar dissection or anterior approaches, in which the anatomic access to the artery is more difficult, angioinfarction may be helpful. Examples include patients with large hilar tumors overlying the artery, bulky nodal disease encasing the artery, or bulky venous thrombus. Early ligation of the vein or mobilization of the kidney itself may allow better-visualized division of the renal artery.
In patients with tumor thrombus (discussed later), embolization may cause some regression in the extent of the thrombus. More importantly, in the case of an occluded renal vein, it may allow early division of the collateral venous drainage that encircles the kidney in the perinephric fat. This technique may allow much easier surgical approach and dissection. Although it is not routinely necessary, preoperative embolization may assist in management of large, hypervascular tumors.
Common complications of embolization include the embolization syndrome consisting of nausea, vomiting, fever, and flank pain. Nephrectomy should be carried out ≤48 hours after embolization to minimize these symptoms. Another alternative is placement of a thoracic epidural catheter before embolization, a strategy we routinely employ. Embolization contributes to postoperative ileus. Thus, some degree of bowel preparation or a clear liquid diet preoperatively may by useful. More serious complications include acute renal failure, which may be exacerbated by accidental embolization of the contralateral kidney through reflux of the embolizing agent. Accidental embolization of other organs also occasionally occurs and causes serious complications such as heart failure and spinal cord injury. Occasionally, an associated tumor thrombus may embolize and may possibly cause sudden death. The mortality rate for embolization with a variety of techniques has been reported to be ≤3.3% when embolization is used for palliation in inoperable cases. However, the actual complication rate for preoperative embolization is probably lower.
It should be noted, however, that the use of embolization has never been demonstrated to provide benefit in a randomized controlled trial. Subramanian and colleagues, in a retrospective review of 255 patients, actually found patients undergoing radical nephrectomy and inferior vena cava (IVC) thrombectomy who received preoperative angioembolization had a greater transfusion rate, longer operative time, more postoperative complications, longer intensive care unit stay, and increased perioperative mortality; no differences were found in intraoperative complications or length of hospitalization. However, as noted, this was a retrospective study and, to date, no prospective study has been completed.
Vessel Dissection
Among the principles of radical nephrectomy, as originally described by Robson and colleagues, are early control and ligation of the renal vasculature to prevent hematogenous tumor spread. Regardless of the incision used, the renal artery should be ligated first to prevent renal congestion. Careful dissection is necessary to confirm the identity of the renal artery. Depending on the approach, the celiac artery, superior mesenteric artery, contralateral renal artery, and lumber vessels may all be mistaken for the renal artery. If an injury occurs to one of these vessels, immediate recognition and primary repair will minimize subsequent complications. Consultation with a vascular surgeon, if available, is suggested. When approaching the renal artery, care should be taken to prevent avulsion of any branches listed earlier. Adrenal arterial branches are particularly prone to such injury. Although they are small, they may bleed profusely.
The renal artery may be clamped but left undivided if the anatomic features dictate it. Once the renal vein is ligated and divided, exposure to the renal artery may be improved. If the renal vein does not decrease in size after ligation of the renal artery, multiple renal arteries may be present.
The renal vein must be handled with care because a lumbar vein may drain posteriorly into it, especially on the left. The thinner walls of the vein make avulsion of these small veins a real possibility. The distal segment may retract into the paraspinous muscles and render hemostasis difficult. Prevention of this complicating factor begins with recognition. Preoperative imaging may be helpful in some cases. If lumbar veins are visualized, some incisional approaches with more limited visibility should be avoided. If avulsion of these veins occurs, compression of the bleeding site while completing removal of the kidney will improve exposure and thereby facilitate hemostasis. Figure-of-eight sutures in the paraspinous muscle to oversew the bleeding site are usually effective. A bolster of Surgicel (an oxidized cellulose hemostatic agent; Johnson & Johnson Wound Management, Somerville, NJ) placed under the figure-of-eight suture will assist in tamponade of the retracted vein.
Hematoma
Hematoma formation following radical nephrectomy may complicate the patient’s postoperative course. In addition to the ability of the retroperitoneum to hold large amounts of fluid, the potential space left behind from bulky tumors allows significant bleeding without causing symptoms. The patient’s hematocrit and blood pressure should be carefully followed, and one should realize that healthy individuals may lose up to 25% of their intravascular volume before significant symptoms occur. Even small hematomas may become infected and form abscesses. Verification of a dry surgical bed is an absolute necessity.
Drains are not routinely needed for nephrectomy. When significant intraoperative hypotension has occurred, some vessels may be in spasm, which may cause delayed postoperative bleeding. Placement of a closed drain for 24 to 48 hours postoperatively will permit early identification of bleeding.
Injury to Nearby Organs
Spleen
Splenic injury is a well-known complication of intraabdominal surgery, and left nephrectomy is the third leading cause of iatrogenic splenic injury. Wide ranges of statistics are given (from 2% to 26%), but most modern series report splenic injury in approximately 1–5% of cases.
Risk factors for splenic injury include prior abdominal surgical procedures, obesity, increasing age, large left kidney (i.e., polycystic kidney disease), and upper pole lesions. Most case series show very different rates in donor nephrectomy–associated splenectomy and in splenectomy complicating radical left nephrectomy for neoplastic disease. Cooper and colleagues speculated that this discrepancy reflects the different goals of surgery. Donor nephrectomies carry a risk of splenectomy of only 1–2%. In addition, retroperitoneal approaches carry a much smaller risk of splenic injury.
Prevention of splenic injury begins with careful planning of the surgical approach and recognition of the importance of adequate exposure to the upper pole of the left kidney. Splenic injuries occur in different ways. The most common cause is excessive traction on the splenic attachments that rips the splenic capsule. In addition, direct injury during dissection of large tumors may lacerate the splenic capsule, and retractors may damage the spleen if excessive force is placed on them or if countertraction is too great. In addition, direct injury during division of the diaphragm is a rare cause of injury from thoracoabdominal incisions.
Avoidance of splenic injury requires an understanding of the splenic attachments. The spleen is attached to all surrounding structures including the diaphragm, colon, stomach, and kidney (the lienophrenic, lienocolic, lienogastric, and lienorenal ligaments, respectively). The most superficial attachment, a lieno-omental band, was described by Lord and Gourevitch. Early division of the inferior lienocolic and lienorenal attachments allows safe retraction of the spleen, although care should be taken to pad all retractors well and to avoid excessive pulling. Some investigators advocate coloepiploic mobilization or separation of the greater omentum off the colon from the midpoint of the transverse colon to the splenic flexure. Mejean and associates retrospectively demonstrated decreased rates of splenic complications ostensibly from increased splenic mobility as a result of early and more complete division of the colic attachments. These investigators further suggested that the subcostal incision is superior to the midline incision for avoiding excessive traction on the splenic ligaments.
Splenic injury is easily recognized by immediate bleeding from this highly vascular organ. Traditional treatment proceeded to immediate splenectomy. Increasing experience with splenorrhaphy from trauma surgery shows that significant numbers of spleens may be salvaged. Superficial lacerations may be treated with argon beam coagulation or hemostatic products such as Avitene (Davon, Cranston, RI) or Surgicel. Packing with laparotomy sponges to promote hemostasis followed by repeat examination is recommended. Deeper lacerations may require bolsters or splenic wrapping with mesh to tamponade the bleeding. Excessive intraoperative bleeding may be controlled by manual compression of the splenic vessels as they course near the tail of the pancreas until splenorrhaphy or splenectomy is completed.
Postoperative management of splenectomy includes vaccination for pneumococcal, Haemophilus, and meningococcal infections. Some investigators advocate preoperative vaccine administration to patients who are undergoing left nephrectomy and who have risk factors for splenectomy because the morbidity is minimal compared with the risk of postoperative vaccine administration. Sepsis in splenectomized patients is much more serious than in immunocompetent persons, and the incidence is probably ≥10 times greater. Drains in splenectomized patients, if used, should be removed as quickly as possible to decrease the risk of overwhelming infection.
Pancreas
Pancreatic injuries are rare compared with injuries of other nearby organs. Historical series in open kidney donor nephrectomies gave an incidence of <1%. Pancreatic injuries may occur with right nephrectomy during performance of Kocher’s maneuver to mobilize the second portion of the duodenum. However, most injuries occur secondary to the close proximity of the tail of the pancreas to the hilum of the left kidney. Retraction, avulsion of surrounding structures, and direct laceration may all injure the organ. Intraoperative bruising may also cause postoperative pancreatitis or asymptomatic elevation of amylase and lipase concentrations. Risk factors probably include prior operations, inflammation surrounding the kidney, larger lesions, or any other cause of difficult dissection.
Prevention of pancreatic injury includes development of the plane between Gerota’s fascia and the visceral peritoneum during dissection of the superomedial pole of the left kidney. Identification, complete mobilization, and careful retraction of the pancreas will help to avoid any avulsion injuries.
Recognition of pancreatic lacerations requires immediate repair. It is important to inspect for injury to the pancreatic duct. If no injury is noted, simple repair of the pancreatic capsule with nonabsorbable suture and an omental bolster is all that is necessary. If the duct is involved, distal resection of the pancreas is probably preferable. General surgical consultation should be obtained if available. The distal pancreas is resected and the duct is closed. The capsule of the pancreas is then closed over the stump. In these cases, placement of a surgical drain is indicated.
Postoperative management of the patient who has undergone significant pancreatic manipulation includes monitoring of amylase and lipase levels, especially as the patient begins to eat. Any patients with significant injury to the pancreas require placement of a nasogastric tube. Parenteral alimentation should be considered early in the postoperative course. If clinical signs or symptoms of pancreatitis do not resolve, a CT scan should be performed. Fluid collections possibly representing a pancreatic leak, if found, require aspiration by interventional radiologic means. The fluid should be sent for measurement of amylase, lipase, pH, Gram stain, and culture. Infected liquid suggests the presence of necrotizing pancreatitis and requires emergency laparotomy for debridement and drainage. If the fluid is not infected, a percutaneous drain should be left and total bowel rest instituted. The addition of octreotide decreases pancreatic output and may be helpful in some cases. The starting dose is 50 µg subcutaneously three times daily, with titration up to 200 µg three times daily based on fistula output.
Duodenum
Duodenal injuries most commonly occur during dissection anteromedial to the right kidney. The second part of the duodenum is most commonly involved. Far more uncommon is injury to the distal duodenum immediately adjacent to the ligament of Treitz. Such injuries occur on reflection of the left mesocolon medial to the inferior mesenteric vein where the mesocolon can be quite thin, or due to thermal injury or direct laceration.
Duodenal injuries are rather rare; in one series only a single injury to the duodenum occurred in 344 right nephrectomies. Risk factors may include prior operations, inflammation surrounding the kidney, larger lesions, or any other cause of difficult dissection and adherence of the duodenum.
Prevention of duodenal injury includes careful dissection and the use of padded retractors. When necessary, Kocher’s maneuver mobilizes the duodenum away from the operative field.
Careful inspection of the duodenum for lacerations and hematomas should be performed. Duodenal laceration should be closed with a two-layer technique and possibly reinforced with omentum or jejunum. If a duodenal hematoma is found, it should be opened and drained to prevent transient small bowel obstruction. The duodenum can then be repaired and covered with an omental bolster or jejunal tissue. If more extensive injury occurs, general surgical consultation should be considered. With standard preoperative prophylactic antibiotic coverage only for skin organisms, consideration should be given to adding gram-negative and anaerobic coverage, especially if no bowel preparation was used. Postoperatively, nasogastric suction should be maintained until intestinal peristalsis resumes.
Liver
Liver injury during nephrectomy in general is relatively rare. Many large case series list no liver lacerations. Causes of liver injury generally include forceful retraction during right nephrectomy. Preventive measures include adequate padding of retractors and division of the triangular and coronary ligaments if necessary to achieve adequate mobilization.
On recognition of a liver injury, or during intentional resection of liver extensions of the primary tumor, the liver laceration may be managed with Bovie or argon beam coagulation. For larger defects, Surgicel bolsters with horizontal mattress sutures of 2-0 silk or 1 chromic gut on a blunt-point needle may be more appropriate. If bleeding makes repair difficult, total obstruction of hepatic vascular inflow may be obtained by Pringle maneuver ( Fig. 37.4 ). The hepatic artery and portal vein are isolated at the porta hepatis and are cross-clamped. Studies in liver donors indicated that significant ischemic injury does not take place with intermittent total occlusion from 10 minutes progressing to 30 minutes alternating with 5-minute reperfusion intervals. If the extent of liver injury is judged to present a risk of postoperative bile leakage, drain placement is indicated.
