NARUS 2018: Complications and Management During Robotic Surgery
The first case involved bleeding during the renal hilar dissection of a partial nephrectomy. During this procedure, a small accessory artery was identified coming off of the aorta which was inadvertently transected resulting in rapid blood loss. Dr. Eun notes that important points at this stage are to (i) have aggressive suction evacuation of accumulated blood via the bed-side assistant to improve visualization, (ii) introduce an e-tape or sponge via the assistant port for compression, and (iii) switch the right arm for a needle driver to prepare for suture reconstruction. Additionally, one may use a surgical bolster for focused compression of the vascular injury. Dr. Eun favors a 4 inch 4-O prolene suture on an RB-1 needle for repairing the aorta, starting with a figure of 8 suture to control bleeding.
A second case presented by Dr. Stifelman was a lower pole robotic partial nephrectomy for a large renal mass in which the proximal ureter was in very close proximity to the renal mass. During dissection of the renal mass, the proximal ureter was inadvertently partially transected. At the point of recognition, Dr. Stifelman notes that one must complete the partial nephrectomy and then come back and repair the ureteral injury rather than vice versa, which the panel agreed. Of note, a tension free ureteral repair may require further mobilization of the kidney and/or ureter, with subsequent nephropexy to ensure kidney stability. Dr. Stifelman notes that in these situations it is important to perform an omental wrap to protect the anastomosis from the fresh renorrhaphy in close proximity.
The third case presented by Dr. Eun was an upper pole large renal mass that was adherent to the diaphragm. During mobilization of the mass and secondary to adhesions, an intraoperative pneumothorax was noted. To repair this in an intracorporeal fashion, Dr. Eun utilized tubing from a 15Fr blake drain placing this through the defect in the diaphragm, with a prior vicryl purse string suture encompassing the injury. With the end of the blake drain outside the body, the bed-assistant is able to insert the suction tip into the tubing to help evacuate the pneumothorax. Subsequently, the blake drain is pulled out of the chest while simultaneously cinching down the purse string suture.
Dr. Sotelo then presented several cases of complications during robotic cystectomy with intracorporeal urinary diversion. First, during the entero-entero anastomosis, he presented a case of the jaws of the robotic stapler not completely within the lumen of the bowel prior to firing the stapler. This resulted in the need for further bowel resection and re-anastamosis. Dr. Sotelo notes that this can be avoided by checking both sides of the bowel to ensure the jaws are completely within the lumen prior to firing the robotic stapler. A second similar case also during an entero-entero anastomosis demonstrated inclusion of a separate loop of small bowel within the robotic stapler secondary to once again failing to check both sides of the bowel prior to firing the robotic stapler. This resulted in resecting this segment of bowel and redoing the entero-entero anastomosis.
Presented by: Daniel Eun, Temple University, Philadelphia, PA; Ash Hemal, Wake Forest Baptist Medical Center, Winston-Salem, NC; Rene Sotelo, University of Southern California, Los Angeles, CA; Michael Stifelman, Hackensack University, Hackensack, NJ
Written By: Zachary Klaassen, MD, Urologic Oncology Fellow, University of Toronto, Princess Margaret Cancer Centre @zklaassen_md at 2018 North American Robotic Urology Symposium, February 16-17, 2018 - Las Vegas, NV