Thoracoabdominal Radical Nephrectomy: 1 Splenic and Liver Injury

THORACOABDOMINAL RADICAL NEPHRECTOMY: 1 SPLENIC AND LIVER INJURY

LATERAL POSITION AND FLANK nal vein and the renal artery lies INCISION posterior and inferior to the renal FIG. 1-1. The lateral positioning vein, there have been reports of of the flank incision provides the experienced surgeons ligating and easiest access to the kidney in the dividing the superior mesenteric retroperitoneum. However, if a artery, mistaking it for the left re- large left hilar or upper pole renal nal artery, during a left radical mass exists, the surgeon may find nephrectomy.1,2 that the orientation of the midline In addition to the confusion of vasculature is obscured when the vascular orientation in large renal patient is in the lateral position. tumors, dissection of the renal Although the superior mesen- hilum for good vascular control is teric artery lies superior to the re- difficult.

Flank Position

Orientation of Vasculature in Flank Position Easy access Left Left from flank incision renal renal artery vein Superior mesenteric artery

Aorta

Vena Kidney cava

Right Right renal renal artery vein

1-1 Peritoneum

1 2 Critical Operative Maneuvers in Urologic Surgery

Supine Position SUPINE POSITION AND MIDLINE Specifically, for large left-sided INCISION tumors, a more exaggerated me- FIG. 1-2. The supine position with dial reflection of the left colon and a midline incision provides good transverse colon helps the sur- exposure and orientation of the geon to identify the superior mes- midline great vessels and major enteric artery from the renal branches. However, if the incision pedicle. The surgeon frees the pos- is not carried up to the xiphoid terior parietal peritoneum along process or higher, resection of the line of Toldt from the sigmoid Orientation of Vasculature large medial or superior pole re- colon all the way around the in Supine Position nal masses may be difficult. splenocolic ligament and part of With the patient in a supine po- the transverse colon. Superior mesenteric sition, the superior pole of the artery Left renal Right renal kidney is angled posteriorly, and vein vein therefore resection of a large su- CHEVRON INCISION AND Vena perior renal mass is difficult. cava FIG. 1-3. The best compromise is SUBCOSTAL WITH EXTENDED-T INCISION Aorta to have the chest and upper abdomen positioned at a 45-degree an- FIGS. 1-4 AND 1-5. Whether using a Left Right gle from the operating table and thoracoabdominal, chevron, or renal artery renal artery the lower abdomen placed as flat subcostal with an extended-T in- as possible in a supine position— cision, the surgeon attains good 1-2 a torque configuration. A long access to the high retroperi- sandbag behind the back main- toneum by the following maneu- tains this position. The best posi- ver. The principal objectives of pa- tioning is achieved when the tient positioning involve the break of the table is in line with following: the anterior superior iliac spine. 1 45-degree angle of the chest The 45-degree–angled position and upper abdomen provides easy access to the upper 2 As much supine position as pole of the kidney and retroperito- possible in the lower abdomen neum, yet the near-supine position 3 Flexion of the table at the an- of the lower abdomen affords good atomic landmark of the ante- orientation and allows optimal rior superior iliac spine control of the midline vasculature.

Incised peritoneum and medial bowel mobilization Orientation of Vasculature in 45-Degree Position

Easy access Left Superior 45-Degree Position to kidney renal mesenteric vein artery

Left Right renal Vena Aorta renal artery cava vein

45° 45° Kidney Right renal artery 1-3 Chapter 1 Thoracoabdominal Radical Nephrectomy: Splenic and Liver Injury 3

Anterior superior Airplane iliac spine in line arm with table flexion support Extension of leg

Sandbag support Flexion of leg

Flexion of leg

Anterior superior iliac spine in line with table flexion 1-4

Chest at 45-degree angle Tape over in Trendelenburg position anterior superior iliac spine

Flexion of table Abdomen as flat as possible 1-5 4 Critical Operative Maneuvers in Urologic Surgery

Chevron Incision FIGS. 1-6 AND 1-7. If a chevron or subcostal with an extended-T incision is chosen,3 the surgeon should ensure that the incision ex- Possible extension tends laterally past both rectus ab- into chest 2 dominis muscles and superiorly to the xiphoid process. Especially in patients with sharply angled Incision for sharp costal margins, this extension su- 1 infrasternal angle periorly allows good exposure of the vena cava and of the aorta and its major branches. The surgeon should be prepared to extend these incisions into the pleural cavity if needed (2). Possible extension into chest 2 THORACOABDOMINAL INCISION The thoracoabdominal incision 1 provides the best exposure for Incision for wide high retroperitoneal dissections. infrasternal angle This incision is especially suited for right-sided hilar or upper renal tumors associated with a large 1-6 liver. FIGS. 1-8 AND 1-9. Beginning at the eighth or ninth rib interspace, the surgeon makes an incision from the posterior axillary line all the way across the cartilage and past both rectus abdominis muscles in a straight diagonal line. This incision not only provides excellent exposure but also contains the bowel mobilized medially. We

Subcostal with Extended-T Incision

Olivier bar Subcostal incision with T-extension

Ioban catch drape From Marsh CL: Contemp Urol 6:15, 1994.

1-7 Chapter 1 Thoracoabdominal Radical Nephrectomy: Splenic and Liver Injury 5 have not found the combination opened through the eighth or of a diagonal incision and a verti- ninth intercostal space and the cal extension to be helpful. surgeon resects a segment of the FIG. 1-10. After the peritoneum costal cartilage arch to connect the is opened, the pleural cavity is peritoneum and pleural cavity.

Second 3 interspace Palpate sternal angle to find second interspace leading to 9th interspace

7 8 8 9 9 Ninth Ninth interspace 10 interspace 11 10 12 Diagonal 11 incision 1-8 12

Vertical extension

1-9

Rectus abdominis muscle 8

Lung 9

Diaphragm

10 Intercostal muscles Wedge excision of cartilage of Intestines costal arch within peritoneum 1-10 6 Critical Operative Maneuvers in Urologic Surgery

Division of diaphragm

Lung

10 Intercostal muscles Diaphragm

1-11

Optimal direction of diaphragmatic incision Shorter incision on left side

Diaphragm muscle

Incomplete use of diaphragmatic incision

Liver Spleen

1-12

View From Below Diaphragm Muscle View From Above Diaphragm Muscle

Right-sided Right-sided incision incision

Aortic hiatus

1-13 Chapter 1 Thoracoabdominal Radical Nephrectomy: Splenic and Liver Injury 7

FIGS. 1-11, 1-12, AND 1-13. The most common error in dividing the diaphragm is to cut too laterally. The surgeon’s goal is to split the diaphragm such that the liver and spleen can be mobilized partially or entirely into the pleural cavity when the patient is in the Trendel- enburg position. The diaphragmatic incision should be a semicircle aiming toward the great vessels and the crus of the diaphragm. FIGS. 1-14 AND 1-15. Using Babcock clamps for traction, the surgeon should divide only one third of Diaphragm on traction for division the total incision ﬁrst and then ﬁn- ish the division after the Fino- 1-14 chetto retractor is positioned between the ribs to provide a better exposure.

Line of incision Lung

Split diaphragmatic muscle

Liver Stomach From Zollinger RM Jr, Zollinger RM: Atlas of surgical operations, ed 6, New York, 1989, Macmillan.

1-15 8 Critical Operative Maneuvers in Urologic Surgery

Direction of incision into RIGHT RENAL CANCER the transverse colon and behind foramen of Winslow FIG. 1-16. Immediately after com- the porta hepatis at the foramen of pleting one third of the diaphrag- Winslow. This parietal peritoneal matic incision, the surgeon divides incision allows maximal bowel the parietal peritoneum along the mobilization and reﬂection.4,5 avascular line of Toldt lateral to the FIGS. 1-17 AND 1-18. In cases of acci- ascending colon. dental liver hemorrhage from lac- The incision should be carried erations, the Pringle maneuver is from around the cecum to the useful to reduce bleeding.6-8 The foramen of Winslow. The incision surgeon places the left index fin- Ascending from the hepatic flexure to the ger into the foramen of Winslow colon foramen should be made only af- and compresses the tissues ante- ter the Finochetto retractor has rior to it with the thumb, essen- been positioned. tially obstructing the bile duct, If the surgeon places two dry portal vein, and hepatic artery laparotomy pads against the ribs, (portal triad). This same maneu- the Finochetto retractor will not ver can be done with vascular slip when the wound is further clamps. opened. FIG. 1-19. Before reflecting the The Finochetto retractor is ﬁrst colon medially, the surgeon should partially opened. first take down the three liga- The surgeon completes the di- ments of the liver: the falciform 1-16 aphragmatic incision, aiming to- ligaments in the midline (1), the ward the great vessels and avoid- right triangular ligament off the ing major branches of the phrenic back muscles and diaphragm (2), nerve within the central tendon. and part of the left triangular liga- The incision from the hepatic ment (3). In rare situations a part flexure along the lateral colonic of the right coronary ligament (4) wall should be continued above also needs to be divided.

Pringle Maneuver: Compression of Porta Hepatis

1-17 Chapter 1 Thoracoabdominal Radical Nephrectomy: Splenic and Liver Injury 9

Cross-Clamping of Porta Hepatis

Gallbladder Round ligament

Lesser omentum

Portal vein Common hepatic duct Cystic duct Hepatic artery

Duodenum Renal cell carcinoma of right kidney Pancreas

From Crawford ED, Borden TA, editors: Genitourinary cancer surgery, Philadelphia, 1982, Lea & Febiger.

1-18

Coronary ligament 4

Right triangular 2 ligament 3 Left triangular ligament Liver 1 Falciform ligament

1-19 10 Critical Operative Maneuvers in Urologic Surgery

FIG. 1-20. The division of the right triangular ligament with its two leaves may need to extend toward the coronary ligament if the right lobe of the liver is large. FIG. 1-21. Once these three liver ligaments are free and with the Finochetto retractor completely opened, the patient is placed in the Trendelenburg position. The liver can now be delivered and mobilized into the pleural cavity. FIGS. 1-22 AND 1-23. Depending on the liver configuration, the surgeon should be able to mobilize Right lobe part if not most of the liver into of liver the chest. This maneuver provides Two leaves of the best exposure of the high ret- right triangular ligament roperitoneal region on the right side. 1-20

Liver Body in Liver Right-sided delivered into Trendelenburg incision of pleural position diaphragm cavity

Vena cava Abdominal cavity Divided diaphragm Divided Divided diaphragm diaphragm

Vena Liver cava

Liver Pleural cavity

1-21 Chapter 1 Thoracoabdominal Radical Nephrectomy: Splenic and Liver Injury 11

Liver Mobilized into Pleural Cavity with Patient in Trendelenburg Position

Liver Left leaf of Gallbladder split diaphragm

Kocher maneuver of duodenum Right leaf of split diaphragm

Renal cancer Vena cava

1-22

Liver within pleural cavity

Split leaf of diaphragm

1-23 12 Critical Operative Maneuvers in Urologic Surgery

FIGS. 1-24, 1-25, AND 1-26. The surgeon should perform a standard Stomach Kocher maneuver of the duodenum, reflecting the duodenum medially, thus exposing the renal Ligament Right kidney of Treitz pedicle and part of the vena cava. FIG. 1-27. The vena cava at the renal pedicle has three important Left kidney branches: 1 Renal vein 2 Gonadal vein inferiorly 3 Adrenal vein superiorly Duodenum Of the three, the most troublesome for potential bleeding is the 1-24 adrenal vein. A torn adrenal vein is the most common bleeding site Kocher Maneuver in right radical nephrectomy. FIG. 1-28. The adrenal vein can be Ligament of Treitz of a large caliber (A), can have a short segment to the vena cava Pancreas (B), can be in the retrocaval position (C), or can be in a high position relative to the renal vein (D). Even if there is easy access for isolation of the renal artery and Duodenum vein, the surgeon should take ev-

Vena cava Aorta

1-25 Frontal View

Superior mesenteric artery

Right adrenal vein Right renal vein

Left renal vein Duodenum Line of incision for Gonadal Inferior Kocher maneuver vein mesenteric From Crawford ED, Borden TA, editors: Genitourinary cancer surgery, Vena cava artery Philadelphia, 1982, Lea & Febiger.

1-26 1-27 Chapter 1 Thoracoabdominal Radical Nephrectomy: Splenic and Liver Injury 13

ery opportunity to control and di- vena cava involvement (greater Variations of Adrenal Vein vide the adrenal vein as soon as than 60%) are at the renal and in- and Adrenal Gland possible. frahepatic levels (levels I and II). If the renal artery is identified This discussion is limited to these and isolated, the surgeon should more common situations and rec- ligate it (using 0 silk) as soon as ommends the current best opera- possible to decrease the size of the tive references for intrahepatic, renal mass immediately. suprahepatic, and atrial tumor in- Even though the venous sys- volvement; with venovenous by- tem is exposed more easily than pass without heparinization; and A B the arterial system, the surgeon with cardiopulmonary bypass should never ligate the renal vein with hypothermia.6, 10-12 first. The kidney can literally ex- pand and rupture its precarious Extraction of Tumor Thrombus from neovasculature. The order of liga- Renal Vein and Vena Cava tion should be (1) renal artery, (2) Most thrombi of renal carci- renal vein, and then (3) ureter. noma do not invade the wall of the renal vein or the vena cava and therefore can be removed TUMOR THROMBUS without resection of the vascular FIG. 1-29. Montie9 has classified walls. tumor thrombus based on the ex- Controlling the vena cava prox- C tent of intracaval involvement: imally and distally to the renal Level I: tumor thrombus ex- veins with Rummel vascular tends less than 2 cm from the re- tourniquets or vessel loops with- nal ostia out occluding the vessel is an in- D Level II: tumor thrombus ex- valuable safety measure in case of tends greater than 2 cm from the sudden hemorrhage. 1-28 renal ostia yet remains below the FIG. 1-30. The Satinsky clamp or hepatic veins its equivalent is placed around the Level III: tumor thrombus in- junction of the vena cava and the volves the hepatic veins but does renal vein. not extend to the diaphragm The renal vein incision should Level IV: tumor thrombus is leave a proximal cuff intact with supradiaphragmatic or atrial the vena cava. The tumor throm- The majority of cases of tumor bus is gently teased out. Right Renal Vein thrombus with renal vein and with Tumor Thrombus

Vessel loop Renal Infrahepatic Intrahepatic Atrial

Left renal vein Tumor thrombus Vena I II III IV cava 20 (28%) 23 (33%) 14 (20%) 13 (19%) Vessel From Montie JE: Inferior vena cava tumor thrombectomy. In Montie JE, Pontes JE, Bukowski RM, editors: loop Clinical management of renal cell carcinoma, Chicago, 1990, Mosby.

1-29 1-30 14 Critical Operative Maneuvers in Urologic Surgery

Renal Cancer with Large Tumor Thrombus Invading Renal Vein

Second vascular clamp

Ligated right adrenal vein

Left renal Left vein renal vein

Vena cava Satinsky clamp

1-31 1-32

FIG. 1-31. The surgeon can close forced with an additional Prolene the venotomy with a double-arm stitch. stitch (4-0 Prolene), making two rows of a running stitch. Complete Occlusion of Vena Cava Rarely, the tumor thrombus has for Tumors Below Hepatic Veins invaded the vascular walls. In situations in which complete FIG. 1-32. At times, a Satinsky occlusion of the vena cava is an- clamp may be insufficient to go ticipated, the surgeon should ﬁrst around a large, irregular conﬁgu- isolate the vena cava and ligate Left ration of a tumor thrombus, so an the lumbar veins in the region renal additional clamp is needed for concerned. vein complete occlusion. FIG. 1-34. The usual collateral ve- To the extent possible, the sur- nous channels back to the heart geon should leave a part of the are the azygos and hemiazygos Two rows vena cava in continuity for ve- veins. When these veins are ob- of stitches nous flow return from the con- structed by tumor involvement or tralateral renal vein and lower scarring, then the inferior mesen- vena cava. teric vein becomes a main collat- The surgeon should wait after eral channel and will be enlarged the clamps are placed and then and dilated. Vena FIG. 1-35. cava check for hemodynamic changes If the tumor thrombus 1 by the blood pressure changes. is higher than expected, it is im- FIG. 1-33. Partial excision of the portant to first ligate and divide vena cava may be necessary with the small four to six veins to the tumor invasion, and a double row caudate lobe of the liver. This ma- of stitches for closure of the ve- neuver gives the surgeon an extra 2 notomy (4-0 Prolene double-arm 2 to 3 cm for more maneuverabil- sutures) should be performed. ity during the vascular occlusion 1-33 Small bleeding sites may be rein- of the vena cava. Chapter 1 Thoracoabdominal Radical Nephrectomy: Splenic and Liver Injury 15

Posterior View of Retroperitoneal Anatomy

From Crawford ED, Das S: Current genitourinary cancer surgery, Philadelphia, 1990, Lea & Febiger.

1-34

Superior vena cava Azygos vein Inferior vena cava

Diaphragm

Left triangular Right hepatic vein ligament

Suprarenal vein Caudate lobe and gland of liver Suprarenal gland

Left kidney Lower layer of coronary ligament

Right triangular ligament

Renal cell carcinoma of Hemiazygos vein right kidney Azygos vein Inferior vena cava

Caudate lobe of liver

Stomach Liver Accessory hepatic veins Right hepatic vein

Duodenum Inferior Adrenal vein Diaphragm vena cava From Edwards EA, Malone PD, MacArthur JD: Operative anatomy of abdomen and pelvis, Right kidney Philadelphia, 1975, Lea & Febiger. 1-35 16 Critical Operative Maneuvers in Urologic Surgery

Caudate Right and left lobe hepatic veins Accessory Tying accessory hepatic veins veins of liver divided

Vena Renal cava artery

Aorta Incising vena cava Lumbar to resect veins intravena caval tumor Kidney Renal veins

From Marshall FF et al: J Urol 139:1166, 1988.

1-36

FIGS. 1-36 AND 1-37. The renal artery should be ligated as early as pos- Accessory veins to sible because the ligation will caudate lobe of liver cause the renal tumor as well as the tumor thrombus to shrink. We prefer to use Rummel vascular tourniquets rather than vascular clamps whenever possible because they are more maneuver- able and less traumatic to the vasculature. The order of vascular occlusion should be as follows: 1 Ligation of veins to the hepatic veins. 2 Ligation of the renal artery. 3 Temporary occlusion of the vena cava proximally (cranial) and distally (caudad) and contralateral renal vein. Closure of Cavotomy FIG. 1-38. After the cavotomy and

From Blute ML, Zincke H: Surgical management of renal cell carcinoma with intracaval involvement, extraction of the tumor thrombus, AUA Update Series, lesson 17, vol XIII, 1994. the cavotomy can be reapproximated with a double-arm stitch 1-37 (4-0 Prolene). When the cavotomy Chapter 1 Thoracoabdominal Radical Nephrectomy: Splenic and Liver Injury 17 is longer than the length of the FIG. 1-39. As in a retroperitoneal Closure of Venotomy Satinsky clamp, the surgeon may lymph node dissection, the sur- After Tumor Extraction need to ﬁrst reapproximate part of geon performs a split-and-roll the venotomy and then apply the maneuver over the vena cava and Satinsky clamp for closure of the the aorta (see p. 58) and works Tumor remaining venotomy with the laterally to expose the right renal thrombus “venting” procedure. Reapproxi- artery, renal vein, and adrenal mation should be performed from vein. cephalad to caudad. The surgeon should always tie the renal artery ﬁrst and then the Restoration of Vascular Continuity vein. The arterial occlusion often The sequence of vascular res- will decrease the volume of the re- toration is important in the evac- nal mass. Double proximal ties (0 uation of trapped air and tumor silk) and one distal tie are placed Vena and/or tissue debris before the for both the artery and vein. cava systemic circulation is restored. The adrenal vein should not be Rummel The “venting” procedure is as fol- clipped but tied (3-0 or 4-0 silk). tourniquet lows: Clips should not be used on the 1 Patient in 20-degree Trendel- tumor side because they often slip enburg position and lead to back-bleeding. 2 Contralateral renal vein restoration 3 Aorta restoration if occluded 4 Distal (caudad) vena cava Venotomy approximated with two rows of stitches restoration with “venting” by temporary unclamping of the Satinsky clamp 1-38 5 Proximal (cranial) vena cava restoration with “venting” Venotomy The residual venotomy is then for venting closed with two rows of double- Satinsky arm stitches (4-0 Prolene). clamp Split-and-roll maneuver over vena cava

LARGE RIGHT-SIDED RENAL Right CANCER adrenal In situations in which safely vein identifying and isolating the renal pedicle and the adrenal vein are impossible, the surgeon should first mobilize the bowel as if to perform retroperitoneal lymph node dissection. The surgeon should continue the right incision lateral to the ascending colon, come around the cecum, and up the mesentery to Right the ligament of Treitz. Renal renal artery The inferior mesenteric vein cancer should be ligated and divided and the ligament of Treitz divided if Aorta necessary (see pp. 53-54). The bowel is placed in a bowel bag and re- Vena Right cava ﬂected cephalad on the chest. This renal vein maneuver allows the surgeon to work right over the great vessels. 1-39 18 Critical Operative Maneuvers in Urologic Surgery

LEFT-SIDED RENAL CANCER FIG. 1-40. The patient is posi- The surgeon incises the parietal tioned in the Trendelenburg posi- peritoneum along the line of Toldt tion, and the spleen is delivered lateral to the descending colon into the pleural cavity. from the sigmoid colon all the FIG. 1-41. We prefer ﬁrst to dissect way up and around most of the a plane between the kidney and splenocolic ligament. the psoas muscle (1), then isolate Before the surgeon divides the ureter for later ligation and di- the splenocolic ligament, the vision, and then dissect a plane Finochetto retractor is placed be- between the parietal peritoneum tween two dry laparotomy pads and the renal pedicle (2). against the ribs and opened. This FIG. 1-42. An alternative to plac- maneuver provides excellent ex- ing the spleen into the pleural posure for the proximal diaphrag- cavity is performing a medial matic division and the splenocolic splenopancreatic roll. This tech- ligament division. nique is especially useful in the Because the spleen is smaller case of large, upper pole tumors. than the liver, the diaphragmatic The left gastric vessels and the in- incision does not need to be as ex- ferior mesenteric vein are ligated, tensive as on the right side. and circumferential dissection around the splenopancreatic segment is performed. This incision extends around the splenic pedicle and continues around the fun- dus of the stomach to a point near the esophageal hiatus (A). Using the spleen as a handle, the sur- Spleen Left geon mobilizes the splenopancre- lung atic segment, freeing its posterior Pericardium attachments (B). FIG. 1-43. This maneuver dis- places the spleen and pancreas into a medial position, thus de- fining the plane between the Gerota’s fascia and the peritoneum and exposing the renal pedicle and the entire retroperitoneum for surgery.3

Division of Left leaf splenocolic of split ligament diaphragm

Division of parietal peritoneum

Kidney

1-40 Chapter 1 Thoracoabdominal Radical Nephrectomy: Splenic and Liver Injury 19

Reflected peritoneum Left renal Left cancer gastric pedicle 1 Ligated left gastric vessels

Adrenal vein Superior Circumferential mesenteric artery dissection A Lumbar vein Vena cava Ligated inferior Gonadal mesenteric vein vein Aorta Ureter

1-41

Tumor

Spleen B

From Marsh CL: Contemp Urol 6(8):15-20, 1994.

1-42

Left kidney

Left renal vein From Crawford ED, Borden TA, editors: Genitourinary cancer surgery, Philadelphia, 1982, Lea & Febiger.

1-43 20 Critical Operative Maneuvers in Urologic Surgery

Left Lateral View of Renal Vasculature

Left adrenal vein Superior mesenteric artery Renal vein

Vena cava Lumbar vein

Gonadal vein

Aorta Inferior mesenteric artery

1-44

Vena cava Adrenal vein

Lumbar Left renal vein Gonadal cancer with vein tumor thrombus 1-45 Chapter 1 Thoracoabdominal Radical Nephrectomy: Splenic and Liver Injury 21

FIGS. 1-44 AND 1-45. On the left side, FIG. 1-46. Of the three, the lumbar the venous tributaries from the re- vein is the most troublesome be- nal vein are the following: cause it drains from the posterior 1 Gonadal vein aspect, often is not visualized, and 2 Adrenal vein can have anomalous anatomic 3 Lumbar vein variations. If all three tributaries from the It is wise ﬁrst to ligate the adrenal renal vein have been divided, the vein, gonadal vein, and lumbar surgeon’s best option is to ligate vein before performing the neph- and divide the renal vein more rectomy. proximally or distally, especially Again, the renal artery should in cases with a small tumor always be ligated ﬁrst to decrease thrombus. the volume of renal mass.

Variations in Anatomy of Lumbar Vein

Renal vein

Gonadal Anomalous vein A lumbar vein

Lumbar vein

From Crawford ED, Borden TA, editors: Genitourinary cancer surgery, Philadelphia, 1982, Lea & Febiger.

1-46 22 Critical Operative Maneuvers in Urologic Surgery

MEDIAL LARGE LEFT RENAL mesenteric artery and part of the CANCER pancreas, the surgeon should di- If the surgeon has difficulty vide the inferior mesenteric vein even approaching the renal pedi- to gain the maximal exposure of cle because of a large, medially the vasculature and the adjacent placed cancer, an alternative ma- organs. This approach differs from neuver should be used. the mesenteric incision, which is As on the right side, exposure made medial to the inferior mes- should be gained by an incision enteric artery and is used in cases carried from the foramen of of trauma.13 The inferior mesen- Winslow around the ascending teric vein varies in its communica- colon and cecum, and toward the tion with the portal venous ligament of Treitz. drainage and may act as a barrier FIGS. 1-47 THROUGH 1-50. With large for a full exposure of the great left-sided renal tumors or retro- vessels and their major branches peritoneal masses for which it is (more commonly conﬁguration 1 necessary to mobilize the superior than 2 in Fig. 1-49).

From McAninich JW, Carroll PR: J Trauma 22:285, 1982.

1-47 Chapter 1 Thoracoabdominal Radical Nephrectomy: Splenic and Liver Injury 23

Variations in Anatomy of Portal Vena Aorta Inferior Mesenteric Vein vein cava Portal vein Celiac trunk Splenic vein Splenic vein A

Renal artery Inferior 1 and vein mesenteric Foramen Superior 2 vein of Winslow mesenteric (epiploic vein Inferior foramen) mesenteric vein

Portal vein Superior mesenteric vein Division of the inferior Splenic mesenteric vein Superior vein B mesenteric artery Incision for high transmesenteric access Division of ligament of Treitz

1, most common configuration of inferior Superior Inferior mesenteric vein mesenteric mesenteric 2, possible configuration of inferior vein vein 1-49 mesenteric vein

Portal vein

Splenic vein C

Inferior Superior Portal mesenteric mesenteric Vena vein Aorta Splenic vein vein cava vein 1-48 Left Adrenal renal gland cancer

Superior mesenteric vein

Inferior mesenteric vein Transmesenteric access with division of the inferior mesenteric vein and ligament of Treitz in large, medially placed left 1-50 renal cancer 24 Critical Operative Maneuvers in Urologic Surgery

Anterior View

Aorta Superior Portal mesenteric artery Splenic Incision vein vein Superior Peritoneum mesenteric artery Superior mesenteric Descending vein colon Diaphragm

Inferior Pancreas mesenteric vein Lung Spleen Left renal vein

Left renal Inferior mesenteric mass Vena cava vein From Skinner DG: Urol Clin North Am 5:253, 1978.

1-51 1-52 FIGS. 1-51 AND 1-52. By following the inferior mesenteric vein up to its junction with the splenic vein, the surgeon can identify the region of the superior mesenteric artery,14 an important landmark Crus of for both right- and left-sided dis- diaphragm sections. Once the inferior mesen- Celiac trunk teric vein and the ligament of Tre- itz are divided (there are small vessels within the ligament), the bowel is reﬂected cephalad. 1.25 cm FIG. 1-53. The left renal artery is Superior only 1 cm below the superior mes- mesenteric enteric artery. artery 1cm SUPERIOR DISSECTION OF ADRENAL GLAND For both left and right adrenal gland resection, the first maneuver is to ligate and divide the Renal arteries adrenal vein(s). The surgeon must slide the left ﬁngers on either side 1-53 of the adrenal gland and apply a downward traction while the right hand applies clips above the gland. The residual lymphatics and the ureter are divided to complete the excision of the renal mass. Chapter 1 Thoracoabdominal Radical Nephrectomy: Splenic and Liver Injury 25

CLOSURE OF DIAPHRAGM AND RIB tor blade, the following maneu- REAPPROXIMATION vers are useful to stop liver hem- FIG. 1-54. The reapproximation of orrhages: the diaphragm is best performed 1 The Pringle maneuver with by a Teflon felt pledget “sand- finger compression anterior wiching” technique, whereby a to the foramen of Winslow mattress stitch (0 silk) and two felt will occlude the hepatic pledgets sandwich the two leaves artery6 (see pp. 8-9). of the diaphragm. These pledgets 2 The surgeon can manually are placed on the abdominal side compress the lacerated area. rather than on the pleural side. 3 Avitene placed between a The ribs are reapproximated Surgicel sandwich can be using two interrupted stitches (1-0 packed into the laceration Prolene). with compression. FIG. 1-55. One or two chest tubes 4 Fibrin glue (Hemaedics, Inc., are placed, and the more depen- Malibu, Calif.) can be used to dent tube suctions ﬂuid and blood occlude the wound. if the patient is placed in a semi- 5 The argon beam coagulator is upright position (head up 30 de- a useful adjunct (Birtcher/So- grees) postoperatively. los Medical Systems, Irvine, Calif.). 6 ATeflon felt pledget sand- LIVER INJURIES wiching technique applied When inadvertent blunt trauma to either side of the lacera- to the liver occurs secondary to tion usually occludes the excessive pressure from a retrac- bleeding edges.

Lung

Reapproximation of split diaphragm Pleural side

Diaphragm reapproximated

Abdominal side Chest tubes Teflon felt sandwich technique 1-54 1-55 26 Critical Operative Maneuvers in Urologic Surgery

KEY The ureter and gonadal vessels are divided. POINTS Large tumor thrombus in the THORACOABDOMINAL INCISION vena cava below the hepatic An eighth or a ninth interspace veins may require ligation of incision is made from the poste- lumbar veins, veins to the cau- rior axillary line all the way date lobe of the liver, and com- across the contralateral rectus ab- plete occlusion of the vena cava. dominis muscle. The order of restoration of ve- A straight diagonal incision is nous continuity after vena cavot- preferable to the combination of omy is important to avoid air a diagonal incision with a verti- and debris embolus. cal extension below. For large tumors in which expos- The diaphragm is split toward ing the renal pedicle is difficult, the great vessels, ﬁrst without the the incision must be continued retractor and then with the Fino- around the cecum up the liga- chetto retractor opened. ment of Treitz to gain medial ac- The peritoneum is opened and cess to the great vessels and their nasal gastric tube is positioned. branches. A split-and-roll maneuver should RIGHT RENAL CANCER be carried out over the vena cava Incision and mobilization are to expose the renal vein and the performed along the line of Toldt adrenal vein and over the aorta up to the foramen of Winslow. to expose the renal pedicle. The Finochetto retractor should Arterial ligation, performed be- be placed with a dry laparotomy fore venous occlusion, decreases pad on each side of the ribs to the volume of the renal mass. prevent slippage. The tissues holding the adrenal Once the Finochetto retractor has gland from above are clipped been opened halfway, the dia- and divided from lateral to me- phragm should be incised all the dial. way to the central tendon, avoiding any major phrenic branches. LEFT-SIDED RENAL CANCER The incision along the line of Incision and mobilization are Toldt lateral to the colon is now performed along the line of Toldt extended medially into the fora- lateral to the descending colon men of Winslow. up the splenocolic ligament. The three ligaments of the liver Before division of the splenocolic are divided. ligament, the Finochetto retractor The patient is placed in the is put in place with two dry lap- Trendelenburg position and the arotomy pads. liver is mobilized into the pleu- Diaphragmatic division is com- ral cavity. pleted but it does not extend to The surgeon first reflects the the central tendon. colon medially and then per- Division of the splenocolic liga- forms a Kocher maneuver of the ment is performed. duodenum. The patient is placed in the Tren- The vena cava and renal pedicle delenburg position and the spleen are exposed. is delivered into the pleural cavity. It is important to divide the The left colon is reflected medi- adrenal vein early. ally. The renal artery is divided before The gonadal vein, adrenal vein, the renal vein. and lumbar vein are ligated and Chapter 1 Thoracoabdominal Radical Nephrectomy: Splenic and Liver Injury 27

divided before nephrectomy is SPLENIC HEMORRHAGE AND performed. SPLENECTOMY The renal artery and renal vein Vigorous retractor compression are isolated. especially by the Harrington re- With a large medial tumor, the tractor can lead to contusions and incision is made on the line of lacerations of the liver, pancreas, Toldt lateral to the right colon and spleen. In most cases manual and is carried from the ascending compression alone is sufficient to colon, around the cecum, and arrest small injuries. When splenic along the route of the mesentery. laceration results in more persis- tent bleeding, other maneuvers The aorta and the vena cava are must be considered. exposed by a split-and-roll maneuver of the overlying tissue Minor Splenic Hemorrhage and the renal vein and artery are If there is a small wedge of isolated from a medial approach. macerated spleen with a slow Closure of the diaphragm is per- hemorrhage, the surgeon should formed with a pledget sandwich- first try manual compression. ing technique. An alternative is to insert a Sur- Chest tubes are placed and the gicel sandwich with Avitene in be- ribs are reapproximated. tween using manual compression. FIG. 1-56. If the bleeding continues, the surgeon can apply syn- POTENTIAL thetic hemostatic gauze or omen- PROBLEMS tum over the defect and place mattress sutures (0 chromic) to se- Liver laceration: Six options: per- cure it. Bolsters of hemostatic form Pringle maneuver, apply gauze can be inserted under the manual compression, apply com- suture loops, or a compressive pression with Surgicel, seal Teflon felt sandwich technique us- wound with fibrin glue, use ar- ing a mattress stitch (0 chromic) gon beam coagulator, perform can be performed. The hemostatic Teflon felt sandwich technique, gauze or Teflon felt provides sup- or call for surgical consultation port on both sides of the organ for possible partial liver resection and prevents the suture from tear- Splenic laceration: Proceed as for ing through the organ while liver laceration → if hemorrhage providing compression. We use is severe, perform splenectomy the sandwiching technique for Inferior mesenteric artery injury: splenic, liver, kidney, and dia- Ligate and proceed with surgery phragmatic closures (see Fig. 1-54). Adrenal vein and vena cava laceration: Apply three-finger compression of proximal vena cava → clamp vena cava → close with running stitch (4-0 Prolene) Difficult exposure of left renal pedicle because of large tumor: Divide root of mesentery → divide inferior mesenteric vein → isolate great vessels → perform split- and-roll maneuver → identify superior mesenteric artery and pancreas → isolate and divide left renal artery and then renal vein From Hinman F Jr: Atlas of urologic surgery, Diaphragm muscle torn in reap- Philadelphia, 1989, WB Saunders. proximation: Use Teflon felt pledget sandwich technique 1-56 28 Critical Operative Maneuvers in Urologic Surgery

Massive Hemorrhage from Splenic ligate it. This ligation will slow Pancreatic Laceration tail down the bleeding immediately Spleen reflected medially Posterior Approach as well as decrease the size of the Splenic FIGS. 1-57 AND 1-58. When sudden spleen. The surgeon can then con- pedicle splenic hemorrhage obliterates tinue the posterior approach, di- the operative field, the surgeon’s vide the splenic vein, and com- first maneuver is to place the left plete the splenectomy. palm over the spleen with the fin- gers as close to the pedicle as pos- Anterior Approach sible. The surgeon should rotate If the posterior approach is dif- the spleen medially while com- ficult, the assistant’s dominant pressing the organ. hand can be placed over the re- Instead of using suctioning, the gion of the splenic pedicle and surgeon and assistant should lit- compression applied while the erally “scoop” the blood out with surgeon focuses on an anterior dry laparotomy pads. This tech- approach. nique is the easiest and fastest Even after ligation of the splenic Parietal peritoneum way to clear the operative field of artery from behind, in some situa- incised large amounts of blood that may tions access for the splenectomy is 1-57 be partially coagulated. Suction- better using the anterior than the ing is useful only after the bulk of posterior approach. blood has been evacuated. FIGS. 1-58 AND 1-59. The gastro- With the right hand, the surgeon splenic ligament, containing the can now divide the parietal peri- left gastroepiploic artery and the toneal attachments inferiorly, later- short gastric arteries, is ligated and ally, and then superiorly and occa- divided. This maneuver separates sionally on the diaphragm. The the stomach from the omentum. lower pole is freed, if adherent. The exposure should be such As the spleen is rotated medi- that the greater curvature of the ally, the surgeon must be careful stomach can be reflected cepha- to expose the splenic pedicle lad, providing a window to the while avoiding injury to the pan- pancreas and the splenic pedicle. Spleen and Its Relations creatic tail. Avoiding any injury to the pan- As Seen From Below The critical maneuver is to find creas, the surgeon then ligates and not the branches but the more divides both the splenic artery Gastrosplenic proximal main splenic artery and and vein. ligament Liver

Stomach

Spleen Spleen

Splenic Stomach vessels Pancreas

Short Kidney gastric arteries Splenic Lienorenal artery ligament From Bowers WF, Hewlett TH, Thomas GJ: Manual of surgical technique, Springﬁeld, Ill, 1963, Charles C Thomas.

1-58 1-59 Transverse colon Chapter 1 Thoracoabdominal Radical Nephrectomy: Splenic and Liver Injury 29

KEY REFERENCES POINTS 11 Ikard R, Merendino KA: Accidental excision of the superior mesenteric POSTERIOR APPROACH artery, Surg Clin North Am 50:1075, Using the left hand, the surgeon 1970. 12 medially rotates the spleen while Moul JW et al: Celiac axis and superior mesenteric artery injury associ- compressing the organ. ated with left radical nephrectomy Evacuation of blood is per- for locally advanced renal cell carci- formed using laparotomy pads. noma, J Urol 141:1104-1108, 1991. Via the posterior approach, the 13 Marsh CL: Enhancing exposure of peritoneal attachments are di- the left upper retroperitoneum, Con- temp Urol 6(8):15-20, 1994. vided and the splenic pedicle 14 Wise HA III: Anterior transabdomi- and pancreatic tail are identiﬁed. nal approach for radical retroperito- Division of the peritoneal attach- neum lymphadenectomy. In Craw- ments and short gastric arteries is ford ED, Borden TA, editors: Genito- performed. urinary cancer surgery, Philadelphia, 1982, Lea & Febiger, p 298. The arterial system of the splenic 15 Donohue JP: Testis tumors. In Lib- artery is ligated. ertino JA, editor: International per- The splenic vein is ligated. spectives in urology, Baltimore, 1983, Williams & Wilkins, pp 181-193. ANTERIOR APPROACH 16 Cummings K: Surgical management The gastroepiploic and short of renal cell carcinoma with exten- gastric arteries are divided, sep- sion into the vena cava. In Crawford arating the omentum from the ED, Borden TA, editors: Genitouri- nary cancer surgery, Philadelphia, stomach. 1982, Lea & Febiger, pp 70-79. The stomach is reflected superi- 17 Pringle JH: Notes on the arrest of he- orly, and ligation and division of patic hemorrhage due to trauma, the splenic artery and then the Ann Surg 48:541-549, 1908. splenic vein are performed. 18 Edwards EA et al: The duodenum, pancreas, and spleen. In Edwards EA, Malone PD, MacArthur JD, editors: Operative anatomy of the abdomen and pelvis, ed 9, Philadelphia, 1975, Lea & Febiger, pp 37-44. POTENTIAL 19 Montie JE: Inferior vena cava tumor PROBLEMS thrombectomy. In Montie JE, Pontes JE, Bukowski RM, editors: Clinical Massive hemorrhage: Apply com- management of renal cell carcinoma, pression to the spleen → evacu- Chicago, 1990, Mosby. 10 ate blood with dry sponge (do Blute ML, Zincke H: Surgical management of renal cell carcinoma with not use suction device because it intracaval involvement, AUA Update is not quick enough) Series, lesson 17, vol XIII, 1994. Posterior dissection with injury of 11 Clayman RV, Gonzalez R, Fraley EE: tail of pancreas: Continue proce- Renal cell cancer invading the infe- dure and consider a surgical rior vena cava: clinical review and consultation for inspection and anatomical approach, J Urol 123:157- drain placement 162, 1980. 12 Marshall FF et al: Surgical manage- Spleen is too large to use posterior ment of renal cell carcinoma with in- approach: Use the anterior ap- tracaval neoplastic extension above proach to ligate the splenic artery the hepatic veins, J Urol 139:1166, ﬁrst 1988. 30 Critical Operative Maneuvers in Urologic Surgery

13 McAninich JW, Carroll PR: Renal Hoeltl W, Hruby W, Aharinejad S: Renal trauma: kidney preservation through vein anatomy and its implications for improved vascular control—a re- retroperitoneal surgery, J Urol 143: fined approach, J Trauma 22(4):285- 1108-1114, 1990. 289, 1982. Matsumata T et al: Modiﬁed technique 14 Skinner DG: Considerations for of Pringle’s maneuver in resection of management of large retroperitoneal the liver, Surg Gynecol Obstet 172:245- tumors: use of the modified thora- 256, 1991. coabdominal approach, J Urol Skinner DG: Technique of nephroure- 117:605-609, 1977. terectomy with regional lymph node dissection, Urol Clin North Am 5(1):253-255, 1978. SUGGESTED READINGS Zollinger RM Jr, Zollinger RM: Right Bowers WF, Hewlett TH, Thomas GJ: hepatic lobectomy. In Atlas of surgical Manual of surgical technique, Spring- operations, ed 6, New York, 1989, ﬁeld, Ill, 1963, Charles C Thomas, pp Macmillan, pp 209-210. 215-217.