Transperitoneal laparoscopic nephrectomy in acute Grade 4 renal trauma with literature review and a note on some unusual complications.

Most renal traumas are successfully managed conservatively. Grade 4 and 5 trauma, however, can require nephrectomy which is almost always by laparotomy and laparoscopic nephrectomy (LN) is still considered contraindicated in acute trauma setting. We report successful transperitoneal LN in an acute grade 4 renal trauma with retroperitoneal haematoma, extensive parenchymal devascularisation and urinary extravasation though retroperitoneoscopic nephrectomy in trauma has been reported recently. However, we believe transperitoneal approach is more logical and replicates all the principles of open renal trauma surgery more accurately. A review of LN in renal trauma and some unusual problems to be anticipated during laparoscopic procedures in acute trauma setting is presented.

INTRODUCTION

Most grade 1–3 American Association for Surgery of Trauma renal trauma cases are conservatively managed successfully. Grade 4 injury with extensive nonviable parenchyma and urinary extravasation experience higher complication rates and exploration can be required.[1] Open exploration is the rule, and laparoscopy is still considered contraindicated in acute renal trauma.[2] We herein report successful transperitoneal laparoscopic nephrectomy (LN) in acute grade 4 renal trauma with literature review and a note on some unusual complications to be anticipated in laparoscopy in acute trauma setting.

CASE REPORT

A 13-year-old boy presented with a history of collision of a two-wheeler with a wall 24 h previously with one episode of gross haematuria and persistent right hypochondriac pain. Examination showed pulse of 104/min and blood pressure of 110/70 mmHg. Abdominal examination revealed right hypochondriac tenderness and guarding. Investigations showed haemoglobin of 9.4 g/dL, elevated liver transaminases and normal urine examination. Computed tomography (CT) scan showed normal left kidney, devascularisation of lower two-third of right kidney with haematoma with perfusion of only upper polar parenchyma [Figure 1], urinary extravasation, non-visualisation of right ureter, liver laceration and perisplenic collection. Angiographic reconstruction [Figure 2] showed right single renal artery with only upper polar parenchymal branches being intact and anomalous low insertion of the left renal vein to inferior vena cava (IVC).

Figure 1

Computed tomography scan showing extensive right renal devasculrisation and hematoma

Figure 2

Angiographic reconstruction showing only right upper polar intact arterial supply and low insertion of left renal vein

Due to the abdominal guarding, extensive nonviable parenchyma and urinary extravasation, decision for exploration and right nephrectomy was taken. Initially, left flank semi-oblique position was given. First umbilical and left-sided abdominal ports were placed to allow spleen and visceral inspection. Later, position was changed to right flank semi-oblique to proceed with right nephrectomy. Laparoscopy (video at https://www.dropbox.com/s/kssufg0pav9ppla/Trauma.wmv?dl = 0) showed liver laceration that was not actively bleeding along with perisplenic collection, but no splenic injury. A large right perirenal non-expanding haematoma was seen haematoma after reflecting colon [Figure 3a]. Kocherization of duodenum allowed interaortocaval dissection and control of right renal artery at its origin before haematoma manipulation [Figure 3b]. Low insertion of left renal vein made this step easier [Figure 2]. Haematoma was then opened; right renal vein was clipped [Figure 3c] followed artery [Figure 3d]. Nephrectomy was subsequently completed with specimen removal by morcellation. Patient had uneventful recovery with a post-operative creatinine of 0.7 mg/dL.

Figure 3

(a) Right retroperitoneal haematoma after colonic mobilisation. (b) interaortocaval dissection for right renal artery control after Kocherization of duodenum. (c) Clipping of right renal vein after opening haematoma. (d) Clipping of right renal artery

DISCUSSION

Management of grade 4 renal injuries in a haemodynamically stable patient is controversial with advice from conservative approach to operative intervention.[3] With more than 25% devitalised parenchyma, complication rate is 80% (perinephric abscess, urinoma and delayed haemorrhage) and so is the long-term renal loss,[1] prompting us to proceed to nephrectomy.

Exploration in acute renal trauma is almost always by laparotomy, and this remains one of the last bastions for laparoscopic surgery to conquer. We could successfully complete LN in a case of grade 4 renal trauma.

We could find only three publications of LN following trauma in PubMed review. LN was delayed by 13 weeks in one case, and so this was not in an acute trauma setting.[4] Second case reported is in a case of grade 5 injury after 5 days of trauma. Due to complete arterial thrombosis, chance of bleeding was less, and kidney was mobilised first followed by vascular control.[5]

Wang et al. reported for the first time LN (retroperitoneoscopic) following acute renal trauma within 24 h of trauma after failed embolisation.[2]

However, transperitoneal approach is to be preferred in our opinion and replicates principles of open exploration in renal trauma more accurately. It allows inspection of all viscera. Assessment of retroperitoneal haematoma and early vascular control is possible in transperitoneal approach. In retroperitoneoscopic approach, haematoma manipulation is inevitable during retroperitoneal space creation. Wang et al themselves reported haematoma rupture before arterial control in one out of two cases.[2] Further, a large haematoma will not allow retroperitoneoscopic approach. Assessment of diaphragmatic injury will be easier in transperitoneal approach. Positioning for transperitoneal LN (semi-oblique) avoids 90° flank (for retroperitoneoscopic) position in a potentially unstable patient, makes cardiorespiratory management easier.

To plan LN in acute trauma, case selection is important. It should be attempted only in a stable patient without head injury and no thoracic trauma. Pre-operative CT scan gives information about other visceral/solid organ/thoracic injury, extent of retroperitoneal haematoma and angiographic anatomy to plan surgery. Timely availability of laparoscopic setup, laparoscopic urologic expertise and experience of trauma surgeon in laparoscopy is essential. Obvious contraindications are haemodynamic instability, shock, head injury, retinal detachment and coagulopathy.[6]

One should be aware of complications of laparoscopy in trauma. Gas insufflation can cause impaired venous return (causing hypotension in association with a volume depleted state and/or patient positioning), capnothorax, pneumomediastinum and venous gas embolism.

Gas embolism after establishment of pneumoperitoneum due to associated contained IVC/liver injury (due to opening of small hepatic veins) is possible. It is reported with laparoscopic liver surgeries but not in trauma.[7] It manifests with hypotension, decreased end-tidal carbon dioxide (CO2) levels and cardiac arrhythmia. If suspected, procedure is stopped, pneumoperitoneum is released and abdominal cavity irrigated with fluid. Patient is placed in left lateral position with head low. A central line can be placed to aspirate gas.[6]

CO2-related pneumothorax can occur due to diaphragmatic injury, tearing of diaphragm due to high insufflation pressures and diffusion of gas in retroperitonium that accumulates in pleura.[6] Chest imaging in diaphragm injuries can be normal.[6] It may manifest first intraoperatively with a sudden increase in end-tidal CO2, decrease in lung compliance and floppy diaphragm. Tension pneumothorax (TP) can occur after start of gas insufflation. In a model of diaphragmatic injury, TP was a threat with intra-abdominal pressures (IAPs) at 15 mmHg, whereas at 5 mmHg, IAP will lead to a simple pneumothorax.[8] Therefore, initial insufflation pressures should be low. Chest should be prepared, and chest drain should be ready.

Certain precautions should be observed during laparoscopy in trauma. Pre-operative case selection and imaging are important. At start of insufflation, one should watch for complications as discussed earlier. Sudden bleeding is always possible in such cases, so vascular control before opening disturbing haematoma is essential.[1] Time for conversion from laparoscopy to laparotomy should be taken into account, and one should be prepared for laparotomy at all times. A low threshold should be kept for conversion in an unexpected event, hypotension, suspected gas embolism, etc., and communication with anaesthetist and/or trauma surgeon is essential in such an event. Furthermore, if one cannot rule out visceral injury confidently, conversion to laparotomy may be wiser.[9] Chances of missed bowel injury are higher in laparoscopy in trauma.[6]

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Conflicts of interest

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