Bleeding

Bleeding during laparoscopic renal cyst ablation can occur during many steps of the operation including (i) mobilization and dissection of the kidney, (ii) cyst wall excision and fulguration, and (iii) dissection around the renal hilum.

Dissection of Gerota's fascia and perinephric fat and mobilization of the kidney, especially along the hilum and adrenal gland, can lead to bleeding. In cases of simple, solitary renal cyst, only limited dissection of Gerota's and perirenal fat should be performed, providing just enough exposure of the entire renal cyst and adjacent renal parenchyma. Extensive dissection of these tissues is unnecessary and can lead to unwanted bleeding. Only in cases of autosomal dominant polycystic kidney disease is complete, exposure of the renal surface generally required.

During cyst wall excision, only the exposed, extrarenal portion of the cyst wall should be excised, because attempts at complete enucleation often result in bleeding from the underlying renal parenchyma. Following cyst wall excision, only limited coagulation of the base should be performed because deep fulguration can initiate bleeding from larger parenchymal vessels.

Dissection of the renal hilum is generally not required except in cases of a peripelvic cyst or autosomal dominant polycystic kidney disease. Electrocautery and sharp dissection should be minimized during dissection around the renal hilum to avoid iatrogenic injury to the renal vessels. If bleeding from the renal vein occurs, temporary pressure applied to the point of bleeding often results in cessation of hemorrhage, if the site of injury is small. In the case of a large venous or arterial injury, pressure can be applied with prompt consideration for open conversion or nephrectomy if laparoscopic means (i.e., clips and sutures) fail to control the source.

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