From initial abdominal entry until fascial closure, the possibility of inadvertent injury to the bowel is a potential risk for the surgeon undertaking robotic nephrectomy. Bowel injury is a relatively rare complication, occurring in 0.1–0.75% of cases in several large, retrospective series of minimally invasive urologic operations [32–35]. However, when missed intraoperatively by the surgeon, the consequences are grievous. A history of prior abdominal surgery, with intra-abdominal adhesions, increases the risk for bowel injury in minimally invasive surgery [36, 37]. Injuries occur via one of two general mechanisms: direct traumatic injury or inadvertent transmission of electrocautery. A high degree of suspicion for bowel injury must be maintained by the surgeon, especially for cautery injuries, as they are especially likely to be missed intraoperatively. Extreme care should be taken when activating an electrocautery instrument in the vicinity of a metal instrument or trocar, as there is a high risk of conduction and inadvertent tissue injury. If colonic and/or small bowel adhesions are present in the planned operating field, they should be taken down sharply with minimal, if any, use of cautery.

In transperitoneal robotic nephrectomy, access to the contents of Gerota’s fascia and the renal hilar structures requires negotiating the ascending or descending colon, depending on whether a right or left nephrectomy, respectively, is being attempted. Most commonly, the white line of Toldt is incised, allowing medial mobilization of the colon along an avascular plane between the mesocolon and Gerota’s fascia. During this maneuver, the colon is at risk for inadvertent injury as from excessive medial traction placed on the colon and/or mesocolon as well as from the indiscriminate use of electrocautery. Development of this surgical plane can frequently be done primarily in a blunt manner, especially in a patient without prior ipsilateral retroperitoneal or colonic surgery, thus avoiding the need for significant amounts of electrocautery. Additionally, the use of the fourth robotic arm for posterolateral renal retraction decreases the risk of a colonic traction injury. A transperitoneal, transmesenteric approach to the kidney has also been described, which decreases the need for colonic mobilization [38]. However, the utility of this approach is often limited in the adult, Western population due to poor visualization of the underlying retroperitoneal structures due to abundant mesenteric fat.

Any suspected colonic or small bowel injury should be promptly repaired. Depending on the degree of injury and the causative agent, this can encompass a range of repairs from simple tissue approximation to major bowel resection and fecal diversion. Early involvement of a general or colorectal surgeon is prudent. The decision to perform intestinal repairs robotically, laparoscopically, or with an open conversion is dependent on the injury incurred and the comfort level of the involved surgeons with minimally invasive techniques. Sharp, seromuscular injuries not breaching the intestinal lumen can be approximated, whereas full-thickness, sharp colonic, or small bowel injury requires two-layer repair [37]. Bowel repairs should be completed using absorbable 3-0 suture material. Small thermal injuries can often be reinforced using imbricating, absorbable suture. However, extensive thermal injuries generally require segmental bowel resection and primary anastomosis [39, 40]. Hematomas should be opened and drained, with inspection of the underlying tissue for injury. Postoperatively, a high index of suspicion should be maintained for a missed bowel injury, as these patients present with myriad symptoms. Classic signs and symptoms such as fevers, leukocytosis, and abdominal pain with peritoneal findings on examination are not always present [41]. Concern for occult bowel injury should trigger urgent evaluation, with a low threshold for obtaining CT with oral contrast material and general or colorectal surgical consultation. Confirmation of an injury, or signs of overwhelming peritonitis , should prompt urgent surgical intervention.

The duodenum is primarily encountered during robotic right nephrectomy, when it is frequently necessary to medially mobilize its second portion off of the anteromedial surface of Gerota’s fascia and the inferior vena cava to access the right renal hilar structures. Performance of the so-called Kocher maneuver (see Fig. 16.3) should be done using a combination of blunt and sharp dissection as well as minimal electrocautery. Less commonly, the fourth portion of the duodenum, just proximal the ligament of Treitz, is occasionally seen when the colon and small bowel are medially mobilized during left nephrectomy. This is particularly true when the medial bowel mobilization is extensive, as is needed with large left-sided tumors and left nephrectomies requiring concomitant retroperitoneal lymph node dissection.

Injuries to the duodenum during renal surgery are rare, with few published reports in the urologic literature. Meraney et al. [42] reported a single, minor duodenal injury requiring serosal repair in a series of 404 retroperitoneal laparoscopic renal and adrenal surgeries. Ono et al. [43] and Joshi et al. [44] each reported single instances of duodenal injury with laparoscopic nephrectomy. In both cases, the injury was extensive, requiring laparotomy and duodenojejunostomy.

Repair of duodenal injuries should be approached in a manner similar to that described above for other small bowel or colonic injuries. Small cautery injuries, or those limited to the serosa, may be oversewn with absorbable suture. Full-thickness injuries are repaired in two layers. Omental patches may be used to buttress duodenal repairs. Extensive injuries, especially if cautery was involved, may require resection and duodenojejunostomy and should involve a general surgical team.

Under normal physiologic conditions, the kidneys receive 20% of total body cardiac output, equating to approximately 982 ml/min and 1209 ml/min in the average woman and man, respectively [45]. Such abundant vascularity makes catastrophic hemorrhage a distinct possibility. Each kidney typically is fed by a single renal artery and drained by single renal vein. However, supernumerary renal arteries are found in approximately 25% of patients, more commonly on the left side. These arteries may insert into the renal hilum or directly into the renal parenchyma. Accessory renal arteries are end arteries, and transecting these vessels will result in ischemia to a portion of the kidney [46]. Accessory renal veins are less common, seen in approximately 1% of patients. While the right renal vein is not typically fed by smaller branches, the left adrenal, gonadal, and a posterior lumbar vein all drain into the left renal vein. All of these vessels can be sources of troublesome bleeding during nephrectomy.

Since the advent and widespread use of laparoscopy, blood loss associated with nephrectomy is decreased. In a large, retrospective series involving 549 laparoscopic radical and 186 laparoscopic simple nephrectomies, vascular injury was noted in 2.2% and 1.6% of cases, respectively [10]. Within this patient population, bleeding requiring transfusion was required in 1.3% of laparoscopic radical nephrectomies and 0.54% of laparoscopic simple nephrectomies and open conversion for bleeding in 0.36% and 1.08%, respectively. By comparison, a contemporary series of 668 open radical nephrectomies yielded a transfusion rate of 15% [47].

Careful dissection of the renal hilum is critical to avoiding vessel injury during radical nephrectomy. We prefer to put the hilum on stretch prior to dissecting the renal artery and vein. This involves defining a plane between the ureter and psoas muscle and placing the robotic fourth arm with a grasping retractor under the lower renal pole and ureter. The kidney can then be lifted in an anteromedial direction. In a right nephrectomy, the gonadal vein is mobilized medially prior to retracting the kidney, whereas in a left nephrectomy, the gonadal vein is elevated with the kidney. Dissection through perihilar adipose and lymphatic tissue can then proceed toward the hilum. Lumbar veins and arteries, if encountered, should be controlled with Hem-o-lok clips (Weck Closure Systems, Research Triangle Park, NC), as they can be the source of significant bleeding. The renal artery and vein should be circumferentially dissected. Care should be taken to fully cauterize the well-vascularized investing connective tissue of the renal artery. The renal artery may be ligated using Hem-o-lok clips (Weck Closure Systems, Research Triangle Park, NC), a surgical stapler or nonabsorbable sutures. If access to the renal artery is difficult, it may be ligated, and transection may be delayed until after the renal vein is divided. En bloc ligation of the renal artery and vein is an option in emergency situations. In a retrospective study of 90 patients who underwent en bloc ligation of the renal artery and vein for nephrectomy or nephroureterectomy, no clinical evidence of arteriovenous fistula was seen after an average of 34 months postoperatively [48].

One distinct advantage of the robotic platform is the ability to repair both minor and major vascular injuries in an expedient manner using wristed instruments. This allows for more rapid, precise suturing and easier placement of vascular clips as compared to traditional laparoscopy. For any surgical procedure involving dissection in or near the renal hilum, we routinely have a dedicated set of instruments, vascular sutures and clips, and hemostatic agents open and available in the event of a vascular injury.

Rapid recognition and localization of bleeding by the operative team, including the console surgeon and bedside assistant, are imperative first steps in managing vascular injuries. If a distinct source of bleeding from an injured blood vessel is recognized, it can be grasped by the console surgeon using robotic Maryland forceps. Venous bleeding can often be fully or at least partially controlled, by increasing pneumoperitoneum. Intra-abdominal pressures up to 25 mm Hg are acceptable for short periods of time until major bleeding is controlled [41]. Direct application of pressure to the area of bleeding, with or without the aid of absorbent sponges and/or hemostatic materials such as Surgicel sheets (Ethicon, Somerville, NJ), can often effectively tamponade bleeding. Once temporized, the source of bleeding can be addressed with a permanent repair. Completely or partially transected branches of the renal vein (segmental, adrenal, gonadal, lumbar) or small-caliber arteries can often be controlled with Hem-o-lok clips (Weck Closure Systems, Research Triangle Park, NC). Lacerations of the main renal vein or artery, IVC, or aorta require sutured repair using 4-0 Prolene (Ethicon, Somerville, NJ). Depending on the size of the injury, this can be completed using figure-of-eight or running repairs (see Fig. 16.4). We also always keep a single, short length of 4-0 Prolene (Ethicon, Somerville, NJ) suture readily available with a tapered, vascular needle on one end and a closed Hem-o-lok clips (Weck Closure Systems, Research Triangle Park, NC) on the other. The clip is held in place with a knot at the end of the suture. In the event of a major vascular emergency, the suture can be passed through the bleeding vessel, and tension applied to the clip can be used to tamponade bleeding. Regardless of the source, if major hemorrhaging cannot be quickly managed, open conversion is warranted , and open instrument trays should be readily available in the operating room at all times during robotic nephrectomy.

Injuries to the liver primarily occur at two points during robotic nephrectomy: during passage of Veress needles and laparoscopic trocars and during hepatic mobilization for right-sided nephrectomy. Regardless, liver lacerations in minimally invasive nephrectomy are rare and are not mentioned individually in several large series of minimally invasive urologic procedures [10, 32, 49]. In one large retrospective study of 894 patients undergoing laparoscopic urologic procedures, including 313 live donor nephrectomies, 142 radical nephrectomies, and 87 simple nephrectomies, there was 1 liver injury [50]. It is possible, however, that small intraoperative liver injuries requiring minimal intervention are underreported. Patients especially at risk for hepatobiliary injury are those with a prior history of cholecystitis and/or cholecystectomy due to the presence of inflammatory adhesions in the vicinity of the right hepatic lobe, common bile duct, and, if present, the gallbladder. All adhesions should be taken down sharply before the liver is retracted away from the retroperitoneum to avoid liver lacerations.

Small liver lacerations can often be managed with focused application of electrocautery and, if needed, argon beam coagulation. Deeper parenchymal lacerations often require packing with hemostatic material, such as Surgicel (Ethicon, Somerville, NJ), which can be formed into a bolster and placed into the wound. If direct application of pressure to the bolster does not staunch bleeding, the liver parenchyma and capsule can be approximated over the bolster using 2-0 silk or 1 chromic mattress sutures [51]. Deep parenchymal lacerations with heavy bleeding or bile leakage should prompt consultation with a hepatobiliary surgeon.

Like hepatic injury, damage to the bile ducts and gallbladder are rare, with a similar risk factor profile, specifically prior hepatobiliary inflammatory processes and/or surgery. Canes et al. [52] reported on two cases of common bile duct injury during urologic laparoscopy, one of which occurred during a laparoscopic right partial nephrectomy. In this procedure, a 63-year-old male with prior cholecystectomy required lysis of adhesions on the undersurface of the liver for exposure of the right kidney. Metal clips were placed to control bleeding on the anterior duodenum, after which leakage of bilious fluid was noted, and a pinhole injury to the common bile duct was discovered. After a general surgery consultation was obtained, the defect was oversewn laparoscopically with 5-0 absorbable suture and a drain was left in place near the bile duct. Postoperatively, an attempt at retrograde cannulation of the common bile duct via endoscopic retrograde cholangiopancreatography was unsuccessful. The patient subsequently underwent percutaneous transhepatic cholangiography, which demonstrated no leakage from the bile duct repair and narrowing of the distal common bile duct, presumably from prior ERCP instrumentation. Antegrade stenting of the bile duct was performed, and the patient was discharged thereafter.

The spleen, pancreatic tail and upper pole of the left kidney are intimately associated in the left upper abdominal quadrant, and dissection of these structures away from the upper pole of the left kidney and adrenal gland is an essential step in robotic left nephrectomy. For this reason, the spleen, pancreatic tail, and the large-caliber splenic vein running underneath the pancreas are all at risk for injury, and careful dissection is critical.

While rare in large series of laparoscopic urologic procedures, pancreatic injury is a known complication of left renal and adrenal procedures. Varkarakis et al. [53] reported four pancreatic injuries from a series of 890 laparoscopic urologic operations taking place between 1999 and 2004, corresponding to an overall rate of pancreatic injury of 0.4%. All four injuries were during left-sided retroperitoneal procedures, two during laparoscopic left radical nephrectomy, and two during laparoscopic left adrenalectomy. One patient had an intraoperative parenchymal tear of the pancreatic tail with no evident pancreatic duct injury. A drain was left in place postoperatively, and serum levels of amylase, lipase, and white blood cell (WBC) count were monitored postoperatively, while the patient was maintained on nasogastric tube drainage with intravenous somatostatin. The patient was fed orally when serum WBC and pancreatic enzyme levels normalized and drain output was <40 ml/24 h. The three other patients were all diagnosed postoperatively with pancreatic injuries. Two developed clinical signs of pancreatitis, with elevated WBC and pancreatic enzyme levels. Of these two, one resolved spontaneously. However, the other was diagnosed with a fluid collection at the surgical site which was drained and ultimately became a pancreatic fistula. A final patient was found to have pancreatic tissue on pathologic specimen analysis but showed no clinical signs of pancreatic injury.

Prevention of pancreatic injury with left robotic nephrectomy primarily involves careful tissue handling and dissection within the proper surgical planes. In the absence of prior surgery or inflammation, a plane can usually be developed between the tail of the pancreas and Gerota’s fascia using primarily blunt dissection, with judicious use of cautery and scissors. Forceful retraction on the pancreas and splenic vein with the surgeon’s left robotic arm should be avoided, and the pancreas and splenic vein should not be directly grasped with forceps. The use of the fourth robotic arm to place countertraction on the kidney can aid in dissecting the contents of Gerota’s fascia away from the pancreas and splenic vein.

Management of pancreatic injury, if noted intraoperatively, depends on injury severity. Small parenchymal injuries may be oversewn and buttressed with omentum. Involvement of the pancreatic ductal apparatus should prompt consultation with a general or hepatobiliary surgeon. A severe injury involving the pancreatic duct may require distal pancreatectomy, which may be performed in a minimally invasive or open fashion depending on the preference and comfort level of the general surgeon. Postoperatively, serum levels of amylase, lipase, and the WBC count should be monitored. Enteric feeding should be resumed slowly, with a low threshold to begin parenteral nutrition. Clinical signs and/or symptoms of pancreatitis such as fevers, nausea, emesis, and abdominal pain should prompt imaging with a CT scan to look for fluid collections caused by pancreatic leak. Fluid collections should be drained percutaneously, with fluid examination for levels of pancreatic enzymes and triglycerides, as well as bacterial cultures. If not done previously, involvement of consulting services such as general surgery, hepatobiliary surgery, and gastroenterology is advisable.