Specific Measures Taken To Avoid Complications

Many complications can be prevented with thoughtful, preoperative planning and attention to detail during surgery. As usual, this process begins with a thorough history and physical examination. Comorbidities should be assessed preoperatively with the physiologic changes unique to laparoscopic surgery kept in mind. For instance, an obese patient with obstructive pulmonary disease and CO2 retention may be difficult to ventilate with resultant hypercapnia during hand-assisted laparoscopic nephrectomy. Radiographic studies should be carefully examined for mass size and location, level of the renal hilum, renal vein, or caval involvement, duplicated renal vessels, retroaortic renal veins, etc. These factors will influence hand/port placement and allow the surgeon to anticipate minor anatomic anomalies. Occasionally, we will also perform preoperative renal artery embolization for tumors in which we feel that the ability to control and transect the renal vein before the artery will be beneficial. While intraoperative bowel complications are rare, we still conservatively have all our patients perform a bowel preparation with clear liquids and magnesium citrate the day before surgery (23).

While most anesthesiologists are comfortable with short laparoscopic procedures such as cholecystectomy, hernia repair, etc., they may be less versed in major, longer laparoscopic cases and inappropriately treat the patient as they would an open nephrec-tomy. Given the decreased blood loss, decreased insensible loss, and decreased urine output due to insufflation pressures, this can result in fluid overload. Avoid nitrous inhalants, as they can cause bowel distension with decreased exposure. Insufficient ventilation can result in hypercapnia with pulmonary arrest or fatal arrythmias. A multi-institutional review by Gill et al. (24) revealed that 35% of complications were due to the physiologic changes that occur during laparoscopy. Open communication before and during the surgery with the anesthesia team will avoid many of these complications.

When positioning the patient, be sure that all pressure points are well padded and the arms are positioned to avoid neurologic injuries. Initial access and trocar placement during laparoscopic surgery can be the cause of significant morbidity. As previously mentioned, we therefore make the hand incision first and place all subsequent trocars with hand guidance and/or direct visualization. Transilluminate the abdomen to avoid major vessels, particularly the epigastric. Having the patient secured to the table allows the surgeon to rotate the table for optimal exposure; exposure is obviously crucial in avoiding intraoperative injuries.

During right nephrectomy, incision of the triangular ligament with adequate liver mobilization will help avoid hepatic injuries. Similarly, the spleen and pancreas must be

Bleeding is not an uncommon complication of hand-assisted laparoscopic nephrectomy. Bleeding can be due to renal or adjacent organ injury as well as vascular injuries. These injuries can occur due to thermal injury, blunt trauma, or stapler/clip misadventure. Depending on the situation, pressure, endoclips or staplers, fibrin sealants, Surgicel, temporarily raising the insufflation pressure, or free suturing techniques can generally salvage the situation. However, one should not hesitate to obtain adequate assistance when necessary or to convert to an open procedure.

adequately mobilized during left nephrectomy. Care should be taken to avoid diaphragmatic injuries during splenic or hepatic mobilization as well as during the mobilization of large, upper pole tumors. In our experience, the most common indication of a diaphragm laceration is loss of space around the upper pole as the diaphragm is pushed inferiorly by the insufflation pressure. At times, this can be accompanied by hemodynamic or ventilatory changes. As long as there is no lung laceration and the patient is stable, the injury can be repaired and the CO2 will be rapidly reabsorbed. If the pneumothorax is preventing adequate exposure or the patient is hemodynamically unstable, a small Heimlich valve tube can be placed to evacuate the pneumothorax and complete the procedure.

Bleeding is not an uncommon complication of hand-assisted laparoscopic nephrectomy. Bleeding can be due to renal or adjacent organ injury as well as vascular injuries. These injuries can occur due to thermal injury, blunt trauma, or stapler/clip misadventure. Depending on the situation, pressure, endoclips or staplers, fibrin sealants, Surgicel, temporarily raising the insufflation pressure, or free suturing techniques can generally salvage the situation. However, one should not hesitate to obtain adequate assistance when necessary or to convert to an open procedure.

Large tumors should be placed in a retrieval bag to prevent tumor breakage, spillage, or port seeding. All trocars should be removed under laparoscopic visualization to assess for bleeding. Significant bleeding can be controlled with fulguration or endoscopic suturing with a Carter Thomason needle. Care should be taken to completely close all indicated port sites as well as the hand incision to prevent postoperative herniations.

At the end of the procedure, the patient should be examined for signs of significant subcutaneous emphysema. The presence of diffuse crepitus is associated with mucosal absorption and resultant laryngeal obstruction in a patient in whom hyperventilation may be required to expel excess CO2. Therefore, extubation in this setting must be controlled: Lack of cuff leak around endotracheal tube with a deflated balloon, chest X-ray evidence of pneumomediastinum, direct visualization of laryngeal coapta-tion, or baseline pulmonary insufficiency are all indications for delayed extubation.

In any surgery, diligent preoperative assessment and preparation, thoughtful operative planning and attention to detail during surgery, and open communication with the operative team will avoid most perioperative complications. The majority of complications during hand-assisted laparoscopic nephrectomy can be addressed laparoscopically, particularly with increased surgeon experience and skills. However, one should not hesitate to enlist the aid of a more experienced laparoscopic surgeon or convert to open surgery when the situation warrants.

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