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. Brisk ar- dissection before realizing the mistake. This will result terial bleeding must be dealt with in a surgical manner. 17.1 Management of Intraoperative Complications in Open Procedures 315

Fig. 17.1.1. Radical nephrectomy with tumor thrombectomy demonstrating proximal and distal vascular control

Topical agents are best used in areas of broad venous Tisseel is a versatile agent used for hemostasis and oozing or areas that are not easily accessible. wound healing. It also must be prepared for use and is Nu-Knit is a denser-weave version of Surgicel manu- delivered in liquid form via a double-barreled syringe. factured from regenerated cellulose that is oxidized It is essentially a fibrin glue formed by the mixture of a and woven into gauze-like strips. An advantage of Nu- highly concentrated fibrinogen aprotinin solution con- Knit over Surgicel is its tensile strength, allowing it to taining factor XIII with a solution of thrombin and cal- be sutured into position or wrapped around structures. cium chloride. Upon mixing and contact with blood It can also cover a broader area of brisk oozing and and tissue, a resilient coagulum is formed, providing does not disintegrate immediately during surgery. It is both rapid hemostasis as well as an adherent tissue fullyabsorbedbythebodywithin14days.Similarto bond. Preparation time is longer (10–15 min) and is Surgicel, Nu-Knit has bactericidal effects due to the low more labor-intensive, which can delay its availability. pH of its activated form. Both Nu-Knit and Surgicel are Some centers have used Tisseel during repair of collect- most effective when applied to a relatively dry field and ing system injuries or defects such as in partial ne- heldinplacewithadryspongefor5–10min.Neither phrectomies with some success (Pruthi et al. 2004). will induce a significant foreign body reaction when left in place. 17.1.2.2 FloSeal is a hemostatic agent in slurry form that Arterial Injuries must be prepared prior to use. It is a combination of specially engineered collagen-derived particles and In the event of a major arterial injury there should be topicalthrombin.Thecollagenparticlesserveasama- no hesitation on the part of the operating urologist to trix or lattice in which the thrombin can act to convert consult a vascular surgeon for assistance if necessary. fibrinogen into fibrin polymer. This in turn forms a lo- Injuries can be avoided by keeping in mind the fairly cal clot providing hemostasis. FloSeal’s advantage over constant branching and orientation of the arterial sys- Surgicel or Nu-Knit is its ability to effectively cover an tem and anticipating the take-off of distal arteries. Sim- irregular bleeding surface and to fill in defects. Prepa- pler injuries can often be adequately repaired using ration time, advertised as 2 min by the manufacturer, is standard techniques without intraoperative vascular a disadvantage (Richter et al. 2003). consultation. Basic principles of vascular repair include 316 17 Intraoperative Complications

maintenance of normal flow and direction with reapproximation and continuity of the intimal layer (Dono- hue1989).Throughthecourseofavascularrepair,re- duction in luminal surface area must be avoided as well as creation of turbulence from either irregular intimal surfaces or acute changes in direction of blood flow. These technical errors may result in vessel thrombosis. Local heparinized saline flushes in the distal segments ofinjuredvesselsmayberequiredifbloodflowre- mains interrupted for an extended period of time while a repair is completed. Injuries to the abdominal aorta may occur in retroperitoneal surgeries, including retroperitoneal lymph node dissection (RPLND) in the management of testic- Fig. 17.1.2. Example of retroaortic left renal vein in patient with ular germ cell tumors, radical nephrectomy, and resec- xanthogranulomatous pyelonephritis tion of primary retroperitoneal tumors. In the event of an aortic wall injury or laceration, the first step in management should focus on proximal and distal vascular nizant,however,ofpossiblevariationsinrenalveinand control, if possible. In most instances, this should al- vena caval anatomy (Hoeltl et al. 1990) (Fig. 17.1.2). ready be established as the operation is set up. Manual Furthermore, preoperative radiographic imaging with pressure or placement of an Allis clamp (for smaller in- specific attention to retroaortic renal veins is also help- juries) may be necessary to gain initial control and to fultoavoidSMAinjuryatthetimeofsurgery.Whenan assess the extent of injury. A 4-0 or 5-0 nonabsorbable injury to the superior mesenteric artery is recognized, suture should be utilized in repairing the wall injury ei- immediate revascularization should be performed by a ther in a simple figure-of-8 fashion if possible or a con- vascular surgeon. tinuous suture. Care must be taken to avoid narrowing Injury to the inferior mesenteric artery is easily the lumen. Occasionally, proper closure of the vessel in- avoidable given its location and ease of identification. It jury may require the use of Teflon pledgets, which will is, however, often involved with lymph node disease or add additional support to the repair. tumor infiltration, necessitating ligation and division. In certain cases, the primary tumor may be so inti- In younger patients, collateral circulation is typically mately attached to the aorta or directly involving the uncompromised and ligation may be performed with- aorta that it is more prudent to resect and replace the out untoward effects. In the older patient population, it damagedorinvolvedsegmentwithavascularDacron is prudent to palpate the vascular supply from marginal graft. Ideally, there should be a substantial infrarenal and rectal vessels when contemplating possible liga- aortic cuff to which a graft may be sewn. An anastomo- tion. Careful dissection and preservation of this vessel sis can be established using a continuous nonabsorb- may prove to be worthwhile in patients with compro- able suture. Depending on distal involvement, an aortic misedbloodsupply,preventingischemicinjurytothe interposition graft or a bifurcated aortoiliac graft may colonic mucosa. be utilized. Distal vessel heparinization should be used Injury to the iliac vessels may result from pelvic lym- until revascularization is established. In practice, re- phadenectomy but can be avoided when employing placement of a segment of the aorta with a synthetic careful and systematic techniques of dissection (Stein graft should be performed in conjunction with a vascu- and Skinner 2004). An injury to the iliac artery should lar surgery consultation. be primarily repaired in similar fashion to an aortic Injury to the superior mesenteric artery is potential- wall injury incorporating the principals of proximal ly a devastating and life-threatening complication if and distal control. Given the smaller caliber of the iliac unrecognized at surgery. This is especially the case dur- vessels, greater attention must be given to avoid reducing dissection of the renal arteries and left renal vein tion of vessel lumen and formation of turbulent flow. If while performing a nephrectomy. Anatomical aware- necessary, an autologous vein or Goretex patch may be ness of this vessel and avoidance of injury is para- utilized. Simple ligation should be avoided when possi- mount. As a point of reference when operating along ble, especially for injuries of the external iliac branches. the great vessels, identification of the left renal vein The internal iliac (hypogastric) branches may be ligat- provides a reliable anatomical landmark to identify ed if repair is not feasible. If possible, preservation of other important structures. Knowledge of the location the superior gluteal artery (branch of posterior divi- of the left renal vein allows consistent identification of sion of hypogastric artery) should be maintained to the superior mesenteric artery and both renal arteries prevent development of gluteal claudication (Killion and avoidance of injury. The surgeon must also be cog- 1989). 17.1 Management of Intraoperative Complications in Open Procedures 317

Lumbar arteries below the level of the renal pedicle massive hemorrhage, a balloon catheter may be used to can be systematically ligated during a unilateral tem- temporarily occlude blood flow. The catheter is placed plate or bilateral RPLND (Yoon et al. 2005). This facili- through the open ends of the vessel and inflated, allow- tates the lymph node dissection while also preventing ing surgical vision and planning. Serrated vascular accidental avulsion of the vessels. These branches can clamps as opposed to clamps with interdigitating teeth be safely ligated below the renal arteries without devas- should be used. A C-clamp may also be used to isolate cularizing the spinal cord. The feeding arteries to the the wall injury or defect without occluding total venous spinal cord are the longitudinal anterior and posterior flow. Likewise, an Allis clamp may be utilized on small- spinal arteries, which arise from the vertebral arteries. er injuries. Once control of bleeding is obtained, a 5-0 In the lower thoracic and lumbar regions, the arteria or 6-0 monofilament nonabsorbable suture (Prolene) radicularis magna (artery of Adamkiewicz) is the main or cardiovascular silk is used to oversew the area of vas- lower anterior radicular artery and provides collateral cular injury. blood supply to the anterior spinal artery and allows the lumbar arteries (below the renal arteries) to be ligated without consequence (Smith and Skinner 1976). Preemptive ligation and division of the posterior lumbar vessels can also provide needed mobilization of the great vessels when establishing proximal and distal vascular control. Isolation and pedicalization of the lumbar vessels can be performed using a relatively fine but blunt-tipped right angle clamp. In general, injury to the lumbar arteries can be easily controlled with an Allis clamp and suture ligated without significant detrimen- tal effect.

17.1.2.3 Venous Injuries Fig. 17.1.3. Exampleofleft-sidedvenacavawithabdominal In comparison to the arterial system, the venous sys- aorta identified by the presence of calcifications tem follows a less constant pattern of branching, especially in the distal vessels. The venous system is a low- pressure system and is palpably pulseless. In addition, the venous walls are much thinner, lacking the strong muscular fibers seen in arteries. These factors collec- tively contribute to the higher rate of venous injuries encountered in open surgical procedures. To its advantage, the venous system collateralizes to a greater extent and ligation of injured veins can be safely performed more often to control hemorrhage. In most situations, the urologist can repair an injury tothevenacavasafelyandproperly.Again,thebasic anatomyofvenousbranchesandtributariesalongthe vena cava must be kept in mind during dissection along its length. In rare cases, preoperative imaging may re- vealthepresenceofaleft-sidedvenacava,inwhich case the surgeon should anticipate altered anatomy (Figs. 17.1.3, 17.1.4). Laceration of the caval wall can be addressed in multiple manners. Proximal and distal control can be obtained by manual compression with theoperatororassistant’sfingers.Agauzespongeon the end of a long-handled clamp may be used for compression. Prior to anticipated vessel injury, proximal anddistalcontrolmaybeobtainedbyplacementofvas- cular clamps or Rummel tourniquets. In situations where conventional vascular control is unobtainable Fig. 17.1.4. Intraoperative photo of the same patient as in and there is an injury to a vein or the vena cava with Fig. 17.1.3 demonstrating a left-sided vena cava 318 17 Intraoperative Complications

On occasion, resection of the infrarenal vena cava maybenecessaryinthesettingofalargegermcelltu- mor in the retroperitoneum, especially following preoperative chemotherapy (Ahlering and Skinner 1989). Proximal and vascular control must first be established and preservation of both common iliac veins is important to avoid postoperative lower-extremity lymphede- ma. In patients with long-term obstruction of the vena cava, collateral circulation may be well developed; however, in situations where this is not apparent, the vena cava may be best replaced with an interposition polyte- trafluoroethylene vascular ring graft. Again, the importance of careful examination of all preoperative imaging studies cannot be over emphasized in order to anticipate such reconstruction needs. Lumbar veins can be a source of troublesome and significant bleeding if inadvertently avulsed or injured. Complete avulsion may result in retraction of a bleeding vessel into the foramina of the vertebral body. It is nearly impossible to identify and isolate the vessel’s edges to control bleeding. An Allis clamp may be used to occlude surrounding tissue so that a vascular suture may be placed. A 2-0 silk or Vicryl suture in a figure-of- Fig. 17.1.5. Clamp placed between dorsal venous complex and 8 fashion, which incorporates vertebral periosteum or urethra (© Hohenfellner 2007) the aponeurosis of the psoas muscle, should effectively control hemorrhage. Also, sterile bone tacks inserted directly into the periosteum in areas of troublesome bleeding can provide hemostasis. These tacks may be enforced with bone wax as well. To avoid this complication, we routinely ligate and divide the lumbar vessels inferior to the renal vessels when performing a retroperitoneal lymph node dissection. This maneuver allows mobility of the great vessels and facilitates removal of all lymphatic tissue overlying the vertebral col- umn. A right angle clamp with relatively fine tips is use- ful in pedicalizing the lumbar vessels for ligation. It should be noted that a left-sided posterior ascending lumbar vessel reliably drains into the left renal vein and should be prospectively identified to avoid accidental injury. Thedeepdorsalveincomplexcanbeatenacious source of hemorrhage while performing a radical retro- Fig. 17.1.6. Allis clamp used to gather dorsal venous complex pubic prostatectomy or radical cystoprostatectomy. Ef- (© Hohenfellner 2007) fective control of the dorsal vein complex can significantly limit blood loss and greatly improve surgical vi- clamp passed around the complex or with an Allis sion in the pelvis. Various techniques to prospectively clamp that is used to gather the complex (Figs. 17.1.5, control the complex are described and detailed else- 17.1.6). With the complex controlled, a suture ligature where (Quek et al. 2001). Effective control of the dorsal may then be secured. venous complex begins with proper and adequate ex- Occasionally, control of the dorsal venous complex posure of the apex of the prostate. We prospectively may be lost as a result of dislodgement of a suture. identify, ligate, and divide the superficial dorsal vein When persistent bleeding occurs from the complex, first. With firm tension on the prostate posteriorly, the vascular control may be obtained with suture ligation. puboprostatic ligaments are identified and sharply di- This requires proper assistance with constant suction vided lateral to the dorsal complex just enough to ex- of blood and retraction of pelvic organs posteriorly and pose the apex of the prostate. The dorsal venous com- cephalad. The leaflets of the complex are usually visible plex can then be controlled either with a right-angle for suture ligation in figure-of-8 fashion. If visualiza- 17.1 Management of Intraoperative Complications in Open Procedures 319 tion of the complex is difficult secondary to retraction sharpdebridementofnonviabletissuesisnecessary into the deep pelvis and if patient positioning permits, prior to repair. A two-layer closure with silk sutures in pressure applied on the perineal body with a sponges- a transverse fashion should be performed to avoid nar- tick may push the complex into view. When bleeding rowing of the lumen. An omental patch on the area of persists, a large-caliber urinary catheter with a large duodenal injury provides added security to reduce op- balloon may be inserted and inflated with 20–30 ml of portunities for leak. Postoperative gastric decompres- fluid and placed on temporary traction. sion with delayed enteral feeding is vital for proper healing. The authors prefer to place a gastrostomy tube when possible for patient comfort, which is detailed 17.1.3 elsewhere (Buscarini et al. 2000). Intestinal Complications Rectal injuries may occur in the setting of radical prostatectomy or cystoprostatectomy, with increased 17.1.3.1 incidences in those receiving previous definitive radia- Bowel Injury tion (Stephenson et al. 2004). The technique of radical Reoperative surgery and surgery in irradiated patients retropubic prostatectomy has been refined over the last can be technically challenging endeavors fraught with two decades based on important anatomical studies de- potential complications, intestinal injuries being the tailed by Walsh and Donker (1982). Today, this proce- most common. Extensive intraabdominal and intrapel- dure remains a standard therapeutic option in the vic adhesions often require tedious and meticulous ly- treatment of prostatic tumors, affording excellent can- sis of adhesions prior to initiation of the primary oper- cer control with maintenance of sexual function and ative procedure. This frequently results in a maze of in- urinary continence. Rectal injuries are an important testinal loops that must be completely sorted out. The potential complication, although they are extremely surgeon will find that by taking the necessary time ini- rare in nonoperated, nonirradiated patients with low- tially to release adhesions, the remainder of the opera- stage disease. An important consideration during a tion should proceed with greater ease and less opportu- nerve-sparing radical prostatectomy is the entrance in- nity for injuries. Often times, the surgeon will find that to a proper plane of dissection along the lateral prostat- tissue planes will present themselves with a combina- ic surface. Magnification loupes can aid in the visuali- tion of blunt and sharp dissection as the tissue is three- zation of this plane. Additionally, proper control of the dimensionalized. Again, we emphasize the principle of dorsal venous complex and its superficial branch prior actively preventing injuries and setting up the opera- to the delicate dissection of the neurovascular bundles tion for success. will help maintain a relatively bloodless operative field Enterotomies may be easily created but often poorly and optimize surgeon vision. Once the lateral pelvic recognized. When bowel injury is noted, immediate re- fascia is identified and incised, gentle blunt dissection pair is most prudent; however, a marking stitch may be alternating with sharp dissection will successfully iso- placed for later repair. With small rents, a simple in- late the bundle laterally and allow the posterior surface verting or figure-of-8 suture may be sufficient. For of the prostate to be freed up (Stein et al. 2001) more extensive injuries, a short segment of intestine (Fig. 17.1.7). may be discarded with primary anastomosis. The au- The posterior plane between the rectum with the pe- thors prefer a hand-sewn technique using interrupted rirectal fat and the posterior surface of the prostate silk sutures in two layers. with the leaflets of Denonvilliers fascia can be bluntly Injury to the second or third portion of the duode- dissected when there has been no previous radiation. If num may occur during a radical nephrectomy, espe- this dissection does not occur easily additional force ciallyontheright.Thiscanbepreventedbyadequate and traction should be avoided, as the correct plane and careful mobilization of the small bowel mesentery may not be identified and injury to the rectal wall is in a cephalad direction starting at the region of the possible. Following apical dissection of the prostate right lower quadrant with careful identification of the and transection of the urethra with placement of vesi- retroperitoneal portions of the duodenum. The Kocher courethral anastomosis sutures, the rectourethralis fi- maneuver can also be utilized to reflect the duodenum bers and lateral pillars of the prostate are encountered. medially and away from the operative field. On the left These attachments should be carefully incised sharply side, this maneuver will allow careful reflection of the as the apex of the prostate is gently retracted anteriorly pancreas, thus avoiding injury. Retracting instruments and cranially. This maneuver should allow entry into andmoistspongesshouldbeutilizedtoreflecttheduo- the perirectal fat space previously identified during the denum and other intestinal loops. Forceful retraction lateral dissection. should obviously be avoided to prevent bowel wall inju- In patients who have undergone definitive primary ry. In cases of duodenal injury with violation of the radiation therapy for the treatment of prostatic adeno- bowelwall,carefulinspectionofthewalledgeswith carcinoma or other pelvic malignancies, the normal 320 17 Intraoperative Complications

Fig. 17.1.8. Omental pedicle mobilized on left gastroepiploic artery with ligation and division of short gastric arteries

Fig. 17.1.7. Incision of lateral prostatic fascia with blunt dissection along prostatic surface with entry to correct plane posteriorly (Fig. 17.1.7 and 8 © Hohenfellner 2007)

planes of dissection are often obliterated and indiscern- ible. A preoperative mechanical bowel prep and enema is prudent in anticipation of possible rectal injury. The technique of radical prostatectomy is not significantly different but greater care must be observed in dissecting the periprostatic planes. Early ligation and division of the dorsal venous complex followed by division of the urethra allows the surgeon to reflect the prostate anteri- orlyandtovisualizetheprostate–rectalplane.This planeshouldbedissectedsharplymoresothanbluntly. In the event of a rectal injury, primary repair and closure (in multiple layers) should be undertaken immedi- atelyoncetheprostateglandisremoved.Carefulin- spection of the rectal wall edges should guide the need for debridement prior to closure. Closure should be per- formedinatransversefashion.Theclosureshouldbe performed in two layers with careful reapproximation of mucosal and seromuscular edges using interrupted 3-0silksutures.Alternatively,theclosuremaybeper- formed in a continuous fashion. If obvious fecal spillage is noted the area should be copiously irrigated and a di- Fig. 17.1.9. Omental pedicle based on left gastroepiploic artery verting colostomy should be seriously considered. A di- reaches deep pelvis with ease verting colostomy is imperative in patients previously irradiated for prostate cancer resulting from poor heal- Suction drains should be considered in cases of fecal ing of tissues. An omental flap interposition may also be spillage with additional postoperative antibiotics to necessary in cases of larger injuries or significant fecal cover Gram-negative and anaerobic organisms. Fol- contamination. It is our experience that an omental flap lowing completion of the operation, digital dilation of basedofftheleftgastroepiploicarteryhasgreatermo- the anal sphincter while the patient remains anesthe- bility and reach into the deep pelvis (Figs. 17.1.8, 17.1.9). tized may further serve to protect the repair. 17.1 Management of Intraoperative Complications in Open Procedures 321

Theauthors’preferredtechniqueofperformingadi- vertingileostomyistousetheTurnbullloopmethod. We utilize this routinely in the creation of ileal con- duits, as it provides superior fit for skin appliances and maintains better vascularity to the stoma to help prevent future stomal stenosis. Preoperative preparation for patients undergoing any stoma creation should focus on proper location. The stoma should be located away from bony prominences, skin creases, scars, and areas of chronic skin irritation. It should also be positioned so that an external appliance may be properly seated. After a suitable segment of bowel is identified and adequately mobilized for creation of the stoma, a circu- lar skin disk is excised by using the butt end of a 20-ml syringe plunger as a template. Underlying subcutaneous fat is incised and retracted using narrow retractors to expose the anterior rectus sheath. Excision of fat from the subcutaneous layer should be routinely avoided, as this may cause retraction of the stoma. The anterior rectus sheath is incised longitudinally over the bel- Fig. 17.1.10. Stoma rod used to support loop stoma ly of the rectus abdominus muscle approximately (Fig. 17.1.10–12 © Hohenfellner 2007) 2–3 cm in length. The muscle is split along the fibers using curved Mayo scissors and the underlying trans- versalis fascia and peritoneum are incised. A proper opening should accommodate two fingers and avoid injury to the inferior epigastric vessels. The anterior rectus sheath can also be opened transversely for a short distance to create a cruciate. Four 2-0 Vicryl sutures are preplaced in the fascial corners, which will later be placed in the seromuscular layer of the loop. A narrow Penrose drain is placed through the mesentery at the most mobile location of the ileal loop and theloopisdrawnthroughtheopening.Theknuckleof bowel should protrude 3–4 cm above the skin level and be secured in place with the preplaced fascial sutures. When properly oriented, the proximal aspect should be cephalad.Ifnecessary,astomarod,redRobinsoncath- eter, or Penrose drain may be used to support the loop while the stoma is everted and matured (Fig. 17.1.10). An incision is created along the seromuscular surface on the distal, defunctionalized aspect of the loop at the Fig. 17.1.11. Loop ileostomy with Allis clamp grasping inner mucosa skin layer approximately four-fifths of the way across. Three 3-0 Vicryl sutures are placed in the subdermal layer on the cephalad aspect of the stoma opening and then passed through the corresponding seromuscular layer and the enterostomy edge of the proximal loop (Fig. 17.1.11). One 3-0 Vicryl suture is placed in the subdermal layer on the caudal aspect and then passed throughtheenterostomyedgeofthedistalloop.AnAl- lis clamp is placed into the lumen of the bowel and the mucosa is grasped on the anterior luminal surface. A second clamp is placed on the edge of the enterostomy and the inner clamp is pulled out as the outer clamp is used to evert the bowel edge (Fig. 17.1.12). Once everted, the nipple stoma is matured using a series of inter- Fig. 17.1.12. Eversion of loop stoma using Allis clamp 322 17 Intraoperative Complications

rupted 3-0 Vicryl sutures. Care must be taken to avoid sutures in the mesentery (Fig. 17.1.13). The ileostomy is closed by excising the stoma and properly mobilizing the proximal and distal loops from thefascialedges.Themesenteryoftheloopiscentrally locatedandmustbeavoidedtomaintainvascularityto the ileal segment. The segment of bowel is excised and the two fresh ends of intestine anastomosed together. Theloopcolostomyisconstructedinasimilarfash- ion with slight modifications to accommodate the bulkier and occasionally more dilated nature of the colon. Alternatively, an end-loop stoma may be con- structed by creating an end stoma flush with the skin using the proximal loop. The distal loop can be brought to the skin as a mucus fistula (Figs. 17.1.14, 17.1.15). Thistechniquestillprovidestheadvantagesofaloop stoma. Given the more solid nature of output from a colostomy, a nipple stoma is less crucial for appliance fit and surrounding skin care. The closure of a loop or end-loop colostomy is, again, similar to the ileostomy. Resectionoftheshortsegmentofcolonisoftenunnec- essary, as the anterior defect or enterostomy can be closed in two layers. In the technique of radical cystectomy, the same principle of dissection in proper planes will prevent in- advertent rectal injury. This is particularly important in males, as the bladder, prostate, and seminal vesicles Fig. 17.1.13. Mature Turnbull loop stoma are directly apposed to the rectum. In women, the vagi- (Fig. 17.1.13 and 14 © Hohenfellner 2007) na provides a buffer against any rectal injury. We have previously described our technique of radical cystoprostatectomy and will emphasize key points of the posterior dissection (Fig. 17.1.16). (Stein and Skinner 2004) Following the division of the lateral vascular pedicles (anterior branches of the hypogastric artery), attention is directed toward entry of the pouch of Douglas. The surgeon elevates the bladder anteriorly with a gauze

Fig. 17.1.14. Creation of end-loop colostomy Fig. 17.1.15. End-loop colostomy with mucus fistula 17.1 Management of Intraoperative Complications in Open Procedures 323

17.1.4 Solid Organ Injury 17.1.4.1 Spleen Radicalsurgeryforaleft-sidedrenalcellcarcinoma and/or adrenal tumor may sometimes involve injury or removalofthespleen.Notuncommonly,malignanttu- morsmaylocallyinvadeorcloselyabutadjacentor- gans, including the spleen, pancreas, or duodenum. In- juries can be avoided with judicious use of retracting instruments with blunt edges and soft curves. Assis- tants should monitor the degree of force placed on retractors, which may frequently become excessive as attention is focused on the operation itself. Mobilization ofthespleenmaybenecessarytoexposeadrenaland large upper pole renal tumors. This is first accomplished mobilizing the colon and dividing the splenore- Fig. 17.1.16. Posterior plane of dissection should be carried out between Denonvilliers fascia and the perirectal fat nal and phrenocolic ligaments. When dividing the at- (© Hohenfellner 2007) tachments of the splenorenal ligament, care must be taken to avoid avulsion or transection of the splenic sponge in his left hand as the assistant retracts the peri- vessels that run with this ligament. Additionally, mobi- toneum and rectosigmoid colon cephalad. With the lizationofthespleencanalsocauseunduemobilization peritoneum on tension, it is sharply incised from lateral of the tail of the pancreas with subsequent injury. to medial from both sides. At this point, a clear under- When a splenic injury does occur, splenorrhaphy standing of fascial planes is critical in the remainder of should be primarily performed when feasible. Gentle the dissection. The anterior and posterior peritoneal manual compression of the splenic hilum will provide reflections converge at the pouch of Douglas to form temporary hemostasis for repair. Simple rents in the Denonvilliers fascia. Denonvilliers fascia itself is com- splenic capsule with concomitant bleeding can usually be posed of an anterior and posterior sheath with the pos- controlled with electrocautery followed by suturing of terior sheath adjacent to the perirectal fat. This is the the capsular defect using chromic catgut or silk sutures. correct plane of dissection that must be entered to suc- Large defects are best repaired with sutures and bolsters cessfully separate the bladder and prostate specimen of Gelfoam, NuKnit, or Surgicel placed in the defects. from the rectum. The anterior sheath of Denonvilliers Omental patches can also provide substance to both fill fascia is adjacent to the seminal vesicles, vasa, and and stop bleeding when repairing capsular defects. prostate and does not separate easily. In order to enter With larger injuries not amenable to repair, splenec- the proper plane of dissection, the peritoneum should tomyshouldbeandcanbesafelyperformed.Thepost- therefore be incised slightly on the rectal side, rather operative risk of sepsis is rare, especially in nonpedia- than on the bladder side. Once the plane between the tric patients; however, appropriate prophylactic immu- anterior rectal wall and the posterior sheath of Denon- nizationsshouldbeadministered.Tosafelyperforma villiers fascia is entered, a combination of blunt and splenectomy, the entire spleen should be mobilized an- sharp dissection should reliably carry the dissection teriorly and medially. This is best accomplished by ligat- down to the apex of the prostate. Again, sharp dissec- ing and dividing the short gastric vessels and by rotat- tion under direct vision is favored over blind blunt dis- ing the spleen and tail of the pancreas medially to ex- section. The assistant’s role is critical at this juncture, pose the major splenic vessels. The artery and veins astheworkingspaceislimitedandlightingmaybeless should be separately ligated and divided when possible, than ideal. Constant retraction on the rectosigmoid co- starting with the artery. This can be performed by uti- lonandsuctionofbloodandfluidswillmaintainthe lizing small clamps and free silk or Vicryl sutures. Note surgeon’s vision. The rectum will more likely be tented that the splenic vessels are best divided close to the hi- up to the prostate in the midline and therefore should lum of the spleen to prevent injury to the pancreatic tail. be sharply incised in this area. Blunt dissection in a sweeping motion from prostate to rectum is relatively 17.1.4.2 safe on either side of the midline. When the perirectal Pancreas space has been adequately developed, the posterior pedicles of the bladder will be easily identified for liga- As in the case of the duodenum and spleen, specific tion and division. measures should be taken through the course of an op- 324 17 Intraoperative Complications

eration to adequately mobilize the pancreatic tail or Occasionally,itmaybenecessarytoresectaportion head to optimize exposure as well as protect the pancre- of the pancreas in the surgical treatment of tumors in- as. This is especially important for large tumors of the volving the kidney, adrenal gland, and retroperitone- kidney and retroperitoneum. Careful mobilization of um (Fig. 17.1.17). For right-sided tumors that involve the tail or head of the pancreas and using padded re- the head of the pancreas as well as the duodenum, an en tractors with gentle force will minimize the opportunity bloc resection may be indicated. Preoperative planning for injury. Gross inspection of the pancreatic surface and imaging should alert the surgeon for probable con- should alert the surgeon for any signs of contusion, consultation with a hepatobiliary surgeon. In cases of left- gestion, or laceration. Postoperatively, a prolonged ileus sided tumors involving the tail of the pancreas, simple or intense abdominal pain, out of proportion to the site resection with repair can be safely performed. In cases and extent of the incision, should raise suspicion to the of injury to the tail of the pancreas, debridement of the possibility of pancreatitis and pancreatic injury. injured portion should be performed followed by visu-

Fig. 17.1.17. Involvement of the pancreatic tail by a large right renal mass

Fig. 17.1.18. Transection of the pancreatic tail using a gastrointestinal stapler 17.1 Management of Intraoperative Complications in Open Procedures 325 al identification of the pancreatic duct. The duct should CT, USA) or Proximate Linear Cutter (Johnson & John- be individually ligated or oversewn if visible and the son, Cincinnati, OH, USA) (Fig. 17.1.18). The transected edges of the gland can be reapproximated with inter- stump is reinforced with Teflon pledgets securely sewn in rupted silk sutures. Absorbable sutures should be place with number-0 silk sutures in a horizontal mattress avoided because of the enzymatic breakdown that may fashion (Figs. 17.1.19, 17.1.20). The pancreatic duct is ef- occur prior to complete healing. fectively ligated and divided with the stapling device. When formal resection of the pancreatic tail is neces- Whenever repair or resection of the pancreas is per- sary,wehavefoundsuccessinusingastaplingandcut- formed, a closed suction drain should be left in place ting device such as a GIA stapler (U.S. Surgical, Norwalk, with close monitoring of outputs postoperatively.

Fig. 17.1.19. Reinforcement of pancreatic tail utilizing Teflon pledgelets

Fig. 17.1.20. Complete repair of pancreatic tail 326 17 Intraoperative Complications

17.1.4.3 References Diaphragm Ahlering TE, Skinner DG (1989) Vena caval resection resection Resection of large retroperitoneal masses including re- in bulky metastatic germ cell tumors. J Urol 142:1497 nal masses may require partial removal of the adjacent Buscarini et al (2000) Tube gastrostomy following radical cystectomy with urinary diversion: surgical technique and ex- diaphragm. Typically, division of the diaphragm is nec- perience in 709 patients. Urology 56:150 essaryforadequateexposureinthethoracoabdominal Crawford ED, Skinner DG (1980) Salvage cystectomy after ra- incision and can be easily repaired. The diaphragm is diation failure. J Urol 123:32 reapproximated in two layers with nonabsorbable su- Donohue JP (1989) Postchemotherapy retroperitoneal lymphadenectomy for bulky tumor including extended suprahi- tures. Interrupted mattress sutures or an interlocking lar posterior mediastinal dissection and/or major vessel re- continuous suture may be used. When a large defect is section. In: McDougal WS (ed) Difficult problems in urolog- present because of resection, reconstruction is per- ic surgery. Year Book Medical Publishers formed by incorporation of synthetic mesh with non- Hoeltl W, Hruby W, Aharinejad S (1990) Renal vein anatomy absorbable suture to provide stability. We prefer to lay and its implications for retroperitoneal surgery. J Urol 143:1108 a greater omental apron to cover the mesh on the ab- Killion LT (1989) Management of intraoperative hemorrhage dominal side to protect the abdominal organs and facil- from open surgery of bladder and prostate. In: McDougal itate the diaphragm closure. Extended chest tube WS (ed) Difficult problems in urologic surgery. Year Book drainage may be required as intraperitoneal fluid shifts Medical Publishers into the ipsilateral thorax during the postoperative pe- Pruthi RS, Chun, Richman M (2004) The use of a fibrin tissue sealant during laparoscopic partial nephrectomy. BJU Int riod. 93:813 Quek ML, Stein JP, Skinner DG (2001) Surgical approaches to venous tumor thrombus. Sem Uro Onc 19:88 17.1.5 Richter F, Schnorr D, Deger S, Trk I, Roigas J, Wille A, Loening SA (2003) Improvement of hemostasis in open and laparo- Conclusion scopically performed partial nephrectomy using a gelatin matrix-thrombin tissue sealant (FloSeal). Urology 61:73 Surgical morbidity is significantly minimized with Skinner DG (1970) Complications of lymph node dissection. careful surgeon preparation and sound operative tech- In:SmithRB,SkinnerDG(eds)Complicationsofurologic niques. By adhering to basic principles of surgery and surgery: prevention and management. WB Saunders, Phila- delphia, p 422 patient care, the urologist will avoid many operative Stein JP et al (2001) Contemporary surgical techniques for con- misadventures. Thorough preoperative planning with tinent urinary diversion continence and potency preserva- appropriate radiographic imaging will elucidate any tion. Atlas Urol Clin of N Am 9:147 potential surprises (vascular or anatomical variances) Stein JP,Skinner DG (2004) Surgical atlas radical cystectomy. B J Urol 94:197 that may lead to vessel or organ injury. Complete Stephenson et al (2004) Morbidity and functional outcomes of knowledge of anatomical relationships is imperative, salvage radical prostatectomy for locally recurrent prostate especially in situations where normal anatomy is dis- cancer after radiation therapy. J Urol 172:2239 rupted because of large tumors, previous surgery, in- Touma NJ, Izawa JI, Chin JL (2005) Current status of loc l sal- fection, or irradiation. The appropriate incision must vage therapies following radiation failure for prostate cancer. J Urol 173:373 be employed when patient pathology requires it. Inade- Walsh PC, Donker PJ (1982) Impotence following radical pros- quateexposurewillnotonlyincreasethepotentialfor tatectomy: Insight into etiology and prevention. J Urol complications, but will also hamper the efforts to effec- 128:492 tively address them. Lastly, when an operation is per- Yoon GH, Stein JP, Skinner DG (2005) Retroperitoneal lymph node dissection in the treatment of low-stage nonsemino- formed the exact same way each time, the surgeon and matous mixed germ cell tumors of the testicle: An update. assistant will not only operate more efficiently but also Urol Oncol 23:168 prevent many complications.