Splenectomy Complicating Left Nephrectomy

[Nephrectomy: complication management]

BACKGROUND

Nephrectomy is a standard procedure that is associated with a low complication rate.

OBJECTIVES

Based on an analysis of the literature, expert recommendations, and our own experience, the management of complications during and after nephrectomy is described.

RESULTS

Complications during and after nephrectomy can be avoided by careful surgical planning, optimal approach and exposure, and precise knowledge of the principles of anatomy. The treatment of bleeding complications and injuries to neighboring structures are essential elements in the management of complications. Hernia and relaxation of the lumbar muscles should be avoided.

CONCLUSION

Morbidity associated with nephrectomy can be reduced by careful surgical planning and paying attention to the basic anatomical and surgical principles.

Anatomic mechanisms for splenic injury during colorectal surgery

Intraoperative iatrogenic splenic injury during colorectal surgery is rare but may cause significant morbidity. We aimed to describe the anatomic mechanisms of iatrogenic injury to the spleen during colonic surgery. All adult surgical patients who sustained a splenic injury during colectomy at our institution from 1992 to 2007 were retrospectively identified. The operative and pathologic reports were reviewed, and anatomic details of the injuries were collected. Results are reported as a proportion or median, with range reported in brackets. Of 13,897 colectomies, 71 splenic injuries among 58 patients were identified. Splenic flexure colonic mobilization occurred in 53 (91%) of these patients. The median number of tears was 1 (1-3). The average length of tear was 4.59 cm. The distribution of injury location on the spleen was 24 (34%) inferior, 14 (20%) hilar, 3 (4%) posterior, 2 (3%) lateral, and 1 (1%) superior. Three (4%) patients suffered from splenic rupture. The location of 24 (34%) injuries was not described. Capsular tears were the cause of splenic injury in 55 (95%) patients. Intraoperative splenic injury ultimately resulted in splenectomy in 44 (76%) patients. Splenic injury was a delayed finding requiring reoperation in 4 (7%) patients. The primary mechanism of intraoperative splenic injury during colectomy is capsular tears and lacerations secondary to misplaced traction and tension on the spleen during colonic mobilization. Techniques to lessen these forces may decrease the number of injuries and subsequent splenectomy.

Iatrogenic splenectomy during left nephrectomy: a single-institution experience of eight years

INTRODUCTION

Iatrogenic injury to the spleen is not an uncommon complication. Left nephrectomy has been reported as the second commonest cause of iatrogenic splenectomy with a reported incidence between 1.3 and 24%. Iatrogenic splenectomy is associated with significant morbidity and mortality.

AIMS

We reviewed the occurrence of iatrogenic splenectomy during left nephrectomy at our centre. Our aims were to determine the incidence of iatrogenic splenectomy within the Mid Yorkshire Hospitals NHS Trust in order to understand the nature of the splenic injury and the morbidity and mortality associated with it.

METHODS

All splenectomy and nephrectomy histology reports from January 2000 to December 2007 were reviewed retrospectively. Indications for splenectomy and nephrectomy were identified. Patients' demographic data, tumour characteristics, operative details, length of hospital stay and any reported morbidity or mortality were collected.

RESULTS

A total of 447 nephrectomies were identified which included 234 left nephrectomies. Within the same period 136 cases of splenectomy were performed. Thirty-four cases were iatrogenic splenectomies and 12 were caused by left nephrectomy. The incidence was 5.13%. The male to female ratio was 1:1 with an average age of 66 years. Grade 2 and stage pT2 renal cancer were the commonest tumour characteristics. All iatrogenic injuries occurred during mobilisation of the colon or division of adhesion. The average operative time was 4.7 h. Average length of hospital stay was 14 days. Five patients had postoperative complications and 1 died of respiratory failure and sepsis.

CONCLUSION

Splenic injury during left nephrectomy is a morbid complication. A good understanding of anatomy and surgical approach may reduce the incidence, morbidity and mortality of iatrogenic splenectomy during left nephrectomy.

Management of intraoperative splenic injury during laparoscopic urological surgery

Study Type - Therapy (case series).

LEVEL OF EVIDENCE

4. What's known on the subject? and What does the study add? The exact incidence of splenic injury during laparoscopic urologic procedures is not known; however, it is an uncommon occurrence. Also, the optimal treatment algorithm is not well delineated and the efficacy of successfully treating minor injuries to the spleen without resorting to splenectomy is not well described in the urologic literature. This study outlines the rate of splenic injury during a variety of laparoscopic urologic procedures and we outline a treatment algorithm that has been successfully employed in the management of these patients, which in all cases, did not lead to splenectomy. An important point is also that multiple adjunctive hemostatic measures should be used when a splenic injury is recognized and that a thorough search should ensue when suspicion of an occult splenic injury exists, as an unrecognized splenic injury may lead to severe post operative haemorrhagic complications.

OBJECTIVE

• To evaluate incidence, risk factors for, and management of intraoperative splenic injury in our laparoscopic patient cohort.

PATIENTS AND METHODS

• All patients undergoing laparoscopic urological upper tract procedures at two institutions between January 2001 and April 2006 and January 2000 and December 2008, respectively, were retrospectively examined for complications. • From these patients, those with intraoperative splenic injuries were selected and examined. • Possible factors predisposing patients to splenic injury were evaluated and the management plan for each patient was analysed to identify optimal treatment efficacy.

RESULTS

• Of 2620 patients undergoing upper tract urological laparoscopic surgery, 14 patients (0.5%) sustained splenic injury and underwent left-sided surgery, 13 via a transperitoneal approach. • In 12 of the 14 patients, the splenic injury was recognized intraoperatively and all were effectively managed laparoscopically with a combination of argon beam coagulation, biological haemostatic agent FloSeal(TM) (Baxter, Deerfield, IL, USA), and bio-absorbable Surgicel® (Johnson and Johnson, Somerville, NJ, USA); none of these patients required splenectomy or developed any postoperative complications. • In two patients, the splenic injury was not recognized intraoperatively; both patients presented with delayed haemorrhage necessitating open splenectomy in each instance.

CONCLUSIONS

• Splenic injuries are uncommon during laparoscopic urological surgery, but when a significant splenic injury occurs, it can be effectively managed laparoscopically, using conservative measures, without need for splenectomy. • If the splenic injury is not recognized intraoperatively, delayed haemorrhage is likely to occur necessitating emergent re-exploration and splenectomy. • Prompt and accurate intraoperative diagnosis of splenic injury is critical for achieving a good outcome.

Complications of laparoscopic surgery for renal masses: prevention, management, and comparison with the open experience

CONTEXT

The initial excitement about the laparoscopic treatment of renal masses has been tempered by concerns related to increased operative time, technical complexity, and the suitability of laparoscopic approaches to oncologic surgery.

OBJECTIVE

To provide a comprehensive review of intraoperative and postoperative complications and their prevention and management during laparoscopic surgery of renal tumors.

EVIDENCE ACQUISITION

A literature review of the Medline and Google Scholar databases was performed, searching for renal cell carcinoma, renal mass, laparoscopy, laparoscopic radical nephrectomy, open radical nephrectomy, laparoscopic partial nephrectomy, open partial nephrectomy, laparoscopic cryoablation, laparoscopic radiofrequency ablation, complications, intra-operative, and post-operative. English-language articles published between 1990 and 2008 were reviewed.

EVIDENCE SYNTHESIS

Laparoscopic radical nephrectomy (LRN), whether transperitoneal or retroperitoneal, can be performed safely. The overall complication rate is low and does not significantly differ from that of the open experience. Laparoscopic partial nephrectomy (LPN), in contrast, is a technically challenging procedure. Although the intermediate oncologic outcomes are comparable to those of the open experience, there are concerns related to warm ischemia time, and there is a risk of major complications such as urinary leakage and hemorrhage requiring transfusion. Laparoscopic-assisted ablative therapies (cryotherapy and radiofrequency) are being performed more commonly for the treatment of small exophytic renal lesions with a low complication rate and intermediate oncologic outcomes similar to LRN and LPN.

CONCLUSIONS

Complications associated with the laparoscopic management of renal masses vary among the different procedures and with surgeon experience. The rate of complication appears to be similar to that of open surgery.

Iatrogenic splenic injury in postoperative patients: a series of case reports

The purpose of this study was to report case studies of iatrogenic splenic injuries on computed tomography (CT) in symptomatic postsurgical patients. The medical records and CT studies of all patients with injury to the spleen after abdominal surgery were reviewed. CT was performed in the postoperative period, urgently in all patients. Unsuspected splenic injuries were found on CT performed in the early postoperative period in seven symptomatic patients (five women and two men, age range 21-81 years) after various abdominal surgical procedures. Injuries as detected on CT included splenic infarct in five, subcapsular hematoma in two, and laceration of the spleen in one. These findings were the only abnormal abdominal findings in four of the patients and were probably the source of the postoperative abdominal pain and fever. Splenic injury is a rare complication of abdominal surgery. It is often the radiologist who diagnoses the injury, and awareness of this possible complication can obviate further investigations.

Iatrogenic Injury to the Spleen—CT Appearance

Splenic injury is a well-known but rare complication of various abdominal surgical and invasive procedures, and even of cardiac surgery. The true incidence of iatrogenic splenic trauma is, however, difficult to assess and is probably underestimated. Overt injuries diagnosed during surgery are usually immediately treated by splenectomy without imaging. This review focuses on missed splenic injuries that are diagnosed on imaging following surgery or an invasive procedure.

Management of patients undergoing splenectomy in an Irish teaching hospital: impact of guidelines

INTRODUCTION

Overwhelming post-splenectomy infection (OPSI) has a 50-70% mortality rate and carries a lifetime risk for the asplenic patient. Specific British guidelines have been developed to reduce its incidence.

AIMS

To determine whether British guidelines were being followed in our own institution and what impact they had on overwhelming post-splenectomy infection.

METHODS

Retrospective chart review of 100 splenectomies performed by Department of Surgery, Beaumont Hospital from January 1990 to January 2000.

RESULTS

Twenty per cent of patients were discharged without any recommended vaccinations. Prophylactic antibiotics were not prescribed in 53% of patients. Just 12% of charts document a verbal explanation of the complications and management of asplenia to the patient. Overall septic mortality was 12%, of whom 8% died in hospital and 4% after discharge.

CONCLUSION

Management of the asplenic patient has improved but is far from complete. A central register of asplenic patients and national asplenic guidelines should be established in Ireland to ensure optimum patient care.

Coloepiploic mobilization during left radical nephrectomy for renal cell carcinoma is indicated to reduce the risk of iatrogenic splenectomy

OBJECTIVES

To determine whether coloepiploic mobilization (CEM) is indicated to reduce the incidence of iatrogenic splenectomy during left radical nephrectomy for renal cell carcinoma. The incidence of iatrogenic splenectomy during a left nephrectomy is estimated to be between 1.4% and 24%. In a recent study, we reported that the incidence of iatrogenic splenectomy was 8% during a left nephrectomy performed for renal cell carcinoma through a transperitoneal anterior subcostal incision.

METHODS

A left radical nephrectomy was performed in 233 consecutive patients for renal cell carcinoma through a transperitoneal anterior subcostal incision with a CEM procedure in which the left colonic flexure was completely detached from the epiploa. Perioperative and postoperative complications, including splenic injury, were noted in a database. The mean patient age was 51.3 years (range 21.3 to 90.2). The mean tumor size was 58 mm (range 15 to 230).

RESULTS

An iatrogenic splenectomy was required in 3 patients, and in 1 patient, a splenic injury was treated conservatively. The incidence of iatrogenic splenectomy accompanying left radical nephrectomy was 1.3%. The mean operative time was 120 minutes (range 80 to 240). The mean time to normal gut motility was 3.4 days (range 2 to 11) and to discharge from the hospital it was 9.3 days (range 6 to 19). Regarding CEM, we did not observe any significant abdominal complications.

CONCLUSIONS

The incidence of iatrogenic splenectomy during a left radical nephrectomy through a transperitoneal anterior subcostal incision may be reduced by performing the technique of CEM.

Impact of splenectomy on the early outcome after oesophagectomy for squamous cell carcinoma of the oesophagus

AIM

Operative procedures for oesophageal malignancies are becoming more extensive and may result in fatal complications. Splenectomy compromises the immune system and can lead to increased susceptibility to infections. The aim of the present study was to report the early outcome of patients who underwent oesophagectomy and simultaneous splenectomy due to oesophageal squamous cell carcinoma (SCC).

METHODS

Pre-operative risks and post-operative morbidity and mortality in 135 patients who had undergone extensive oesophagectomy without simultaneous splenectomy for SCC of the thoracic oesophagus were compared with those of 14 patients who had undergone oesophagectomy associated with splenectomy.

RESULTS

Post-operative pneumonia, intra-abdominal abscess, post-operative sepsis and anastonotic leakage were significantly increased when splenectomy was added to the original operation. The incidence of in-hospital death was significantly higher among splenectomized than non-splenectomized patients (35.7% vs 8.1%, P<0.01). Pulmonary complications and leakage were the main causes of death. Multivariate analysis recognized splenectomy as an independent prognostic factor for in-hospital death following transthoracic oesophagectomy for SCC.

CONCLUSION

The addition of splenectomy to transthoracic oesophagectomy for oesophageal carcinoma can be a fatal combination. Preservation of the spleen should be the primary intention. In circumstances that necessitate splenectomy precautions should be taken to prevent post-operative infectious complications.

Incidental splenic injury during abdominal vascular surgery: a case-controlled analysis

BACKGROUND

The small but finite risk of postsplenectomy sepsis is generally regarded as a firm indication for splenic preservation after iatrogenic injury, especially in the young. But splenectomy may be preferable in patients who sustain splenic injuries during vascular operations because of the potential for continued bleeding associated with anticoagulation. The purpose of this study was to determine the perioperative morbidity of incidental splenectomy among patients undergoing abdominal vascular operations.

STUDY DESIGN

We studied 17 patients who underwent incidental splenectomy at the time of abdominal vascular operations. Complete data collected on each subject included preoperative and postoperative blood counts, operative indications and details, transfusion requirements, length of hospital stay, and outcomes. Using age- and gender-matched case controls undergoing identical vascular operations from the same period, we evaluated the complication rate and outcomes of patients who underwent splenectomy for iatrogenic injuries of the spleen, versus those who did not sustain splenic injuries.

RESULTS

The estimated prevalence of iatrogenic splenic injury during the study period was 0.5%. Mean operative time, estimated blood loss, and duration of mechanical ventilation tended to be greater in the splenectomy patients, but the differences did not achieve statistical significance. Splenorrhaphy was attempted in seven patients, but continued bleeding mandated spleen removal in all cases. Splenectomy patients had a higher transfusion requirement (p = 0.03) and a longer mean length of stay (p = 0.03) than controls. Compared with controls, there was a higher prevalence of infectious complications in the splenectomy patients (p = 0.015), but there was no difference in the prevalence of thromboembolic complications between groups. Two of the splenectomy patients died in the postoperative period from multisystem organ failure, and one died of a missed splenic injury.

CONCLUSIONS

These data suggest that incidental splenectomy during abdominal vascular operations is associated with increased postoperative infectious complications and prolonged hospitalization.