17.1 Management of Intraoperative Complications in Open Procedures 315

17 Intraoperative Complications Management of Intraoperative Complications 17.1 in Open Procedures G.H.Yoon,J.Stein,D.G.Skinner complicationsthattheauthorshaveencountereddur- 17.1.1 Introduction 313 ing open urologic procedures. It is emphasized that the 17.1.2 Vascular Complications 314 best surgical offense starts with good defense. 17.1.2.1 General Principles 314 17.1.2.2 Arterial Injuries 315 Prior to entering the operating room, the urologic 17.1.2.3 Venous Injuries 317 surgeon must prepare by mentally reviewing four gen- 17.1.3 Intestinal Complications 319 eral principles. Firstly, all necessary imaging studies 17.1.3.1 Bowel Injury 319 should be obtained preoperatively to completely delin- 17.1.4 Solid Organ Injury 323 eate the disease process, its extent, and its relation to 17.1.4.1 Spleen 323 adjacent organs and structures. This provides a work- 17.1.4.2 Pancreas 323 ing knowledge of the lay of the land, so to speak, such 17.1.4.3 Diaphragm 326 that few or no surprises are encountered. Radiographic 17.1.5 Conclusion 326 imaging techniques have clearly improved over the past References 326 decadesandprovidethesurgeonaroadmapfroman anatomical perspective. Proper imaging preoperatively will reduce the potential for surgical misadventures, 17.1.1 identify the anatomy and anomalous structures, as well Introduction as help identify the so-called pathology of interest. Pre- operative imaging studies may also direct the need for Attention to surgical details and a commitment to sur- consultations with other surgical specialties as deemed gical excellence are two fundamental principles that necessary. will help provide the best clinical and functional results Secondly, based on the region of the body involved, following open surgical procedures. Most postopera- total familiarity with and understanding of the basic tive complications can be clinically related or traced anatomy and the relations between organs, vessels, back to technical errors made in the operating room. bones, and tissue planes are an absolute requirement. Thus, the importance of avoiding or reducing intraope- This becomes exceedingly important in reoperative rative surgical complications cannot be overempha- surgery and even more so in the irradiated patient sized. where complication rates escalate due to the disruption Effective management of intraoperative complica- of normal anatomy. This includes intraabdominal, ret- tionsinopensurgicalproceduresbeginswiththe roperitoneal, and pelvic anatomy (Touma et al. 2005; avoidance and prevention of dreaded surgical misad- Crawford and Skinner 1980). ventures. A surgical plan must be devised even before Thirdly, the most appropriate surgical approach and an incision is made. The urologic surgeon must be pre- incisions must be determined in order to provide the pared for any potential changes in plan or alternatives necessary operative exposure. In cases of large retro- that he may encounter during the course of operating. peritoneal masses arising from renal, adrenal, or germ This preparation often times is derived from personal cell tumors, the great vessels and their many branches as well as collective experiences in previous clinical as well as intestinal segments such as the duodenum practice where lessons are sometimes best learned may be intimately apposed or involved. Proper expo- frommistakes.Inthisdayandage,whenmodernurol- sure is mandatory as normal anatomical relationships ogy is shifting toward minimally invasive techniques, may become unrecognizably distorted. Surgeons there remains a need and requirement for maximally should utilize a proper incision from a repertoire that is invasive surgery to address specific urologic diseases, familiar and comfortable. An incision may be extended especially in urologic oncology and reconstructive sur- insituationswherepoorexposuremaylimitanappro- gery. This chapter will describe a philosophical ap- priate dissection or inhibit the surgeon’s ability to oper- proach and management of specific intraoperative ate. Thus, the patient should be properly positioned, 314 17 Intraoperative Complications prepped, and draped at the start. A general surgical in a large surface area of the aortic wall becoming sig- rule is that big cases require big incisions. In addition, nificantly compromised and eventually rupturing. thesurgicalapproachandincisionprovidetheopera- Theseconsequencesunderscoretheimportantprinci- tive exposure, which is fundamental in performing the ple of proximal and distal vascular control. safest surgical procedure. As may be the case in elderly patients with bladder Lastly, many operative complications can be avoided or renal tumors, associated co-morbidities such as pe- by simply performing the operation exactly the same ripheral vascular disease and atherosclerosis may re- way every single time. A routine that is employed each sult in arteries that are calcified and brittle with intimal time an operation is performed minimizes the oppor- plaques. Overhandling these vessels both manually and tunity for mistakes to be made. This approach also in- with instruments may result in plaque embolization or creases surgical efficiency as assistants and scrub tech- even rupture. Vessels should be palpated for firmness nicians can anticipate the next operative maneuver. or brittleness prior to placement of vascular clamps. Severe tortuosity of vessels often indicates significant vascular disease. 17.1.2 In anticipation of extensive vascular dissection, the Vascular Complications proper instruments, including sutures, forceps, needle holders, and vascular clamps, should be readily avail- 17.1.2.1 able on the sterile field. Nonabsorbable suture such as General Principles cardiovascular silk or monofilament polypropylene No other operative mishap is more stressful or feared (Prolene) on a fine vascular needle should be utilized than a major vascular injury. The surgical management onvesselwalls.Thechoiceinsuturematerialismostly of a number of urologic diseases requires close dissec- determined by surgeon preference; however, distinct tion along major arterial and venous vessels, branches, advantages between silk and Prolene exist. Silk is gen- and networks. In the event of a vascular injury, it is es- erally easier to handle and tie. Prolene is thought to in- sential that the surgeon remain calm and direct the sur- duce less of an inflammatory response and be less likely gical staff in preparation for control of the injury. Con- to harbor infection. Vascular forceps with fine serra- stant communication with the anesthesiology staff tions or interdigitating teeth allow delicate handling of should be maintained. A momentary pause may be re- vessel walls. Fine vascular needle holders with dia- quired of the surgeon as the anesthesiologist prepares mond jaws allow for precise handling of suture without for possible rapid and large-volume blood loss. In an- damaging or distorting the needle. ticipation of possible rapid volume resuscitation, ade- A variety of different vascular clamps are a vital set quatevenousaccess,withlarge-boreperipheralvenous of instruments that the urologist must be familiar with. catheters or central venous catheters, should be ob- Application of these clamps is best performed in a con- tained by the anesthesiologist prior to surgery. Addi- trolled setting with proximal and distal control of the tional suction tubing and surgical assistants may be vessels, a fundamental principle of vascular surgery. necessary to provide a clean working field and addi- Often times dissection of difficult tissue planes or ad- tional hands for retraction. Large masses may obstruct herent tumors may involve major vessels. Obtaining vision within the operative field and/or may have large proximalanddistalcontrolofvesselspriortoinadver- parasitizing vessels themselves that are susceptible to tent injury allows for rapid control of hemorrhage as injury. It is prudent and maybe necessary to proceed the operative field is cleared and the injury is ad- with first extirpating large tumors while temporarily dressed. Vascular control may also be obtained using controlling hemorrhage with manual pressure. After Rummel tourniquets fashioned from red Robinson removing the mass and surgical vision is improved, the catheters and moist umbilical tape (Fig. 17.1.1). vascular injury may be more safely and efficiently re- Topical hemostatic agents such as oxidized regener- paired. ative cellulose (Surgicel), absorbable gelatin sponge Lymphadenectomy in the treatment of testicular, re- (Gelfoam), and microfibrillar collagen (Avitene) are nal, bladder, and prostatic cancers often requires close adjunctive agents of hemostasis used in all specialties dissection along major vessels. It is imperative that sub- of surgery, including urology. Newer agents such as Nu- adventitial dissecting planes be avoided, as this weak- Knit (Ethicon, Johnson & Johnson, Cincinnati, OH, ens the integrity of vessel walls and may lead to rup- USA),FloSeal(Baxter,Deerfield,IL,USA),andTisseel ture.Thisisespeciallythecasewhenperforminga (Baxter) are variations of the original theme with dif- postchemotherapy retroperitoneal lymph node dissec- ferent delivery mechanisms. It should be noted that tion. A thick and adherent layer of tissue encases the theseagentsaresupplementaltoolsofhemostasisand great vessels. In the case of the aorta, the surgeon may do not substitute for traditional surgical techniques of inadvertently enter a subadventitial plane and continue vessel ligation or suturing to control bleeding.

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