Procedure related complications and how to prevent them

Transcription

1 Procedure related complications and how to prevent them Rama Jayanthi, M.D. Section of Urology Nationwide Children s Hospital The Ohio State University

2 Retroperitoneoscopic surgery Inadvertent peritoneal opening May place Veress needle into peritoneum to vent CO2 Enlarge opening and essentially convert to laparoscopy Place foley catheter percutaneously, pass through opening, inflate balloon and occlude opening

3 Laparoscopic nephrectomy Hl Hilar bleeding is biggest complication Mobilize kidney completely before dissecting i hilum If only hilar attachemts remain, there are more options to dealing with bleeding

4 Laparoscopic nephrectomy - hilar bleeding Fb Fibrin glue may be used df for minor bleeding Control bleeding point with Maryland graspers Extra port? Clips or vascular stapler proximal to bleeding point

5 Laparoscopic heminephrectomy Injury to ipsilateral l ureter Use of percutaneous holding suture Retracts ureter away from operative site Offers some traction to faciltate dissection of upper pole ureter Inadvertent injury to ipsilateral collecting system Preoperative stenting? Personal opinion - not needed

6 Laparoscopic heminephrectomy Injury to lower pole vessels Most critical time is when upper pole ureter is being dissected off of lower pole vessels Consider dividing vessels at kidney level and not hilum A heminephrectomy is not a partial nephrectomy renal cell carcinoma No real hilum to consider

7 Laparoscopic heminephrectomy Bleeding from divided d d upper pole Use of harmonic scalpel to divide upper pole Consider fibrin glue for small llbl bleeding points Better to leave a little dysplastic kidney with patient then a little normal lower pole with specimen

8 Laparoscopic pyeloplasty Wrong approach When should left sided repairs require colonic mobilization? Medially positioned sigmoid - colon overlies collecting system Small intrarenal pelvis - entire kidney may need to be mobilized to permit tension-free anastamosis Massive hydronephrosis - adequate exposure may not be possible through sigmoid window

9 Laparoscopic pyeloplasty Pl Pelvic fixation with hh hitch h stitch Ideally pelvis should be opened on medial border Use appropriately placed hitch suture to bring medial aspect of renal pelvis into view Hitch suture will also fix renal pelvis facilitating dissection of UPJ

10 Laparoscopic pyeloplasty Spatulation of ureter Avoid spiral Cannot treat, must avoid Use whichever hand allows direct access to ureter Make sure you make mini-snips Cut into healthy ureter Do scissors enter ureter easily?

11 Laparoscopic pyeloplasty Anastamotic probems - suturing Fixation suture of ureter to pelvis Consider interrupted extracorporeal tying if suturing is difficult or exposure suboptimal Obese patients Consider placing a few interrupted sutures at inferior apex of anastamosis

12 Laparoscopic pyeloplasty Extravasation Usually due to malpositioned stent Confirm stent postion intraop by instilling colored irrigant in bladder Consider immediate retrograde and restenting Perc neph tube placement

13 Ureteroureterostomy Creation of ureterotomy Preop stenting Hitch suture - fixs recipient ureter Fine, sharp scissors - make initial, small incision in ureter

14 Laparoscopic ureteral reimplantation Extravesical Mucosal tears May close with hf fine suture

15 Laparoscopic ureteral reimplantation It Intravesical Peritoneal leakage of gas - may prevent expansion of bladder reducing working space Place Veress needle Urinary extravasaion Importance of closure of fbl bladder ports Leakage along submucosal tunnels Proximal migration of feeding tubes Intraop ureteroscopy for retrieval