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Kidney Surgery

Discussion in 'Ask Jack' started by John Nicholas, Nov 27, 2018.

  1. John Nicholas

    John Nicholas New Member

    Hi Doc,

    Again, thank you for meeting with me in Cancun. I enjoyed my time with you.

    I had my kidney surgery the day before Thanksgiving. Thus far, it appears to be successful although the pain was pretty terrible for at least a day I have to admit. I was getting spams in my stomach area and it took many hours to get it under control. I had to go back into ICU.

    I won't know the results until Friday. They did do a follow up CT with contact to see if I had a bleed or something was wrong while I was having so much pain. They said it came back perfectly and there was no evidence of any issues or remaining areas of the mass.

    I'm still managing the pain and being mindful of the severe fatty liver issue I have a taking too much Tylenol, Advil and/or Oxy. I don't like taking Oxy at all and stopped. I'm going to try the CBD / medical marijuana route given I own a license. Is there anything you would specifically recommend to help with pain that will not impact my fatty liver?

    Here's another big question: When I left the hospital I was specifically told by my surgeon to avoid ANY submersion of my torso (there are a total of six incisions mainly on my abdomen in hot or cold water (any water) for 4 to 6 weeks due to the surgery and the sutures. This sucks because I'm not doing CT to manage pain and inflammation. I'm spending a ton of time in the sun.

    Any suggestions?

    Thank you.

    John


    See below if needed.

    OPERATIVE FINDINGS:

    There was a single renal artery and vein. The tumor was very difficult to identify even with extensive

    ultrasonography. The most likely area of the tumor located was removed. There did not appear to be outright

    evidence of malignancy in this area, but no other areas were suspicious. A renal repair was excellent with total

    ischemia time of 25 minutes. Estimated blood loss was 90 mL.

    PROCEDURE IN DETAIL:

    The patient was brought to the operating room and placed in supine position. After adequate general anesthesia

    had been administered and IV antibiotics administered, Foley catheter was placed sterilely and left to gravity

    drainage. The patient was then positioned in the right flank up position and all pressure points appropriately

    padded. He was prepped and draped in the usual sterile fashion.

    The Veress technique was utilized to enter the abdominal cavity. Towel clips were placed on either side of the

    Veress needle, which was advanced into the abdominal cavity. The aspiration and drop test were excellent.

    Insufflation was then began at high flow with low pressure. The abdomen was insufflated to 15 cm of water. I

    then placed an 8 mm port in the midclavicular line, approximately 8 cm inferior to the costal margin on the right

    side. When the obturator was removed, there was excellent efflux of gas, confirming proper positioning. The 0

    degree camera was then inserted and the abdomen inspected. There was very slight ooze from the liver as the

    Veress needle may have grazed that. There were some adhesions in the right lower quadrant. The abdomen

    was otherwise without adhesions.

    Under direct vision, another 8 mm port was placed in the midclavicular line approximately 6 cm inferior to the

    first place port and then another one in the midclavicular line, 6 cm inferior to that port. The final 8 mm port

    was placed just about 2 cm in the midclavicular line, 2 cm inferior to the costal margin. All ports were placed

    under direct vision. I then placed a 5 mm port towards just lateral to the midline subcostally and then a 12 mm

    port lateral and slightly superior to the umbilicus. Next, the da Vinci robot was brought to the table and lined

    up appropriately to the initially placed camera port. I then docked to the robot to the camera and targeted the

    kidney and the remaining arms were automatically adjusted. Next, all the remaining robotic arms were docked

    to the robot and the arms adjusted appropriately.

    I then scrubbed out of surgery and manned the console. I began dissection using my monopolar scissors in the

    right lower quadrant, taking down the adhesions with care to avoid any bowel. These adhesions were from his

    prior appendectomy. I then examined the liver and the graze was cauterized and there was excellent

    hemostasis. Next, I incised the ascending colon along the white line of Toldt and reflected it medially. The

    duodenum became apparent was sharply dissected and kocherized medially. The inferior vena cava then

    became apparent. With a combination of blunt and sharp dissection, I was able to prospectively identify the

    right renal vein. This was carefully dissected out of the surrounding tissues circumferentially. With further

    dissection, I was able to identify the right renal artery, which was just inferior and posterior to the right renal

    vein. Careful dissection was done around the right renal artery. There was an early branch of the renal artery,

    but I was able to dissect proximally just adjacent to the lateral border of the IVC for the main branch.

    I then dissected inferiorly along the cava, identified the gonadal vein and more inferiorly the ureter. The ureter

    was reflected laterally and underneath it and excellent hemostasis during the procedure was maintained.

    Next, I dissected fat off of the kidney. I defatted the kidney with care to avoid the ureter.

    The drop-in ultrasound was then utilized to try to identify the tumor. On CT scan, the appearance of the tumor

    was not typical for renal cell carcinoma, although it did enhance. The borders of the mass were not readily

    apparent on most of the views and indeed I defatted basically the entire kidney and there was no obvious tumor

    noted unlike the vast majority of renal mass surgeries. I carefully assay the entire kidney with the Doppler

    ultrasound. There was just a subtle abnormality in the location just inferior to the mid pole and slightly

    posterior identified. This is in the same location as on the CT scan. While this was a subtle abnormality, I did

    not note any other significant abnormalities in this region or really throughout the kidney and hence I felt the

    best approach was to perform a partial nephrectomy in this area. I did entertain performing a complete

    nephrectomy, but because I could not find any other significant areas, this area was in the same anatomic

    location as the defect on CT scan and I felt like there was a reasonable possibility that the mass may not

    represent a renal cell carcinoma. I felt performing a partial nephrectomy would better serve the patient. If

    pathology demonstrated that the tumor was not resected and on followup imaging is still present, biopsy and

    cryoablation of the area could be performed or completion nephrectomy. Hence, I decided to proceed with a

    partial nephrectomy. I carefully marked out the area where the lesion was noted with monopolar cautery

    circumferentially. Next, I placed two bulldogs on the renal artery and then waited a little bit and then placed a

    bulldog on the renal vein. Using cold scissors dissection, I circumferentially resected the marked out area.

    Again, there was no obvious tumor in the area, although the tissue did appear more friable in this area than

    normal healthy renal tissue. I completely resected the area and then even took a separate area of dissection

    more inferiorly. All this tissue was placed in the EndoCatch bag. Using the monopolar cautery, I then

    cauterized the border and base of the defect. I then ran a 2-0 Vicryl suture with Lapra-Ty on the end of it in a

    baseball stitch, closing the medullary part of the kidney. Next, interrupted 0 Vicryl sutures with a Weck clip

    and Lapra-Ty at the tail end of it were placed spanning the defect. A total of 4 sutures were placed. On the

    other end Weck clips were placed and cinched down closing the defect. I then placed Lapra-Tys on each of the

    proximal end of the Weck clips to secure the closure. The bulldog was then taken off of the renal vein and the

    kidney was seen to pink up nicely. The bulldogs were taken off the renal artery and the kidney pinked up very

    well. There was excellent hemostasis. All needles were removed. Total ischemia time was 25 minutes. I then

    examined the hilum under low pressure as well as the defect in the abdomen and there was excellent hemostasis

    in all areas. The insufflation pressure was increased back to 15 cm. FloSeal was placed over the defect.

    I then scrubbed back into surgery. All ports were removed under direct vision and there was excellent

    hemostasis. The EndoCatch bag was emerging from the camera port. This skin incision was slightly extended

    and I was able to remove the tumor in the EndoCatch bag, which was sent for permanent pathologic analysis.

    The wounds were irrigated. The fascia of the camera port was closed using a single 0 Vicryl suture. All skin

    incisions were closed using 4-0 Monocryl subcuticular sutures, followed by Dermabond.
    The patient was then

    returned to supine position. Estimated blood loss was 90 mL. Anesthesia was reversed and he was brought to

    recovery room having tolerated the procedure well.
     
    JanSz likes this.
  2. Jack Kruse

    Jack Kruse Administrator

    I bet the pain was due to CO2 insufflation or the inadvertent cutting of the sensory nerves. I have some other thoughts but I don't want to air them here. Wrong place based upon the op note.
     

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