V08-06: Bleeding Disaster Management During Robotic Renal Surgery
Intraoperative complications are reported in approximately 1.8% of robotic partial nephrectomy (RPN) cases. We demonstrate examples of published algorithms for management of bleeding during robotic kidney surgery using real-life scenarios in video format.
We present 8 robotic renal surgery cases (5 partial, 3 radical nephrectomy) demonstrating management of escalating vascular injuries, bleeding during renorraphy and excision of mass during RPN, management of a misfired endovasular stapler and bleeding during radical nephrectomy (missed upper pole vessel and torn parasitic vessel), one requiring open conversion.
Steps to manage vascular injuries included compression, cautery, increased pneumoperitoneum and utilization of a pre-prepared rescue suture. Techniques to avoid bleeding during excision and renorraphy included early unclamping to help visualize vessels, utilization of clips/sutures to visible vessels, additional tightening of renorraphy sutures and clamping maneuvers to avoid venous congestion while improving renal artery occlusion. Steps to manage bleeding during nephrectomy included removal of remaining attachments to control a missed vessel and a controlled conversion to open procedure. 7 cases were managed with EBL
Intraoperative bleeding during robotic renal surgery, although rare, can be disasterous if not managed appropriately. Familiarity of algorithms to manage intraoperative bleeding, and preparation for these scenarios, may help prevent unnecessary patient morbity.