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Abstract
A 58-year-old woman was admitted to the hospital with left hydronephrosis due to a 3 cm. obstructive calculus of the renal pelvis. She had undergone diskectomy 2 months earlier for symptomatic median disk herniation at L4/5. Postoperative followup revealed no residual neurological signs. A Double-J* catheter was inserted. Renal mercaptoacetyltriglycine-3 scintigraphy 14 days later demonstrated complete failure of the left kidney. Retroperitoneoscopic nephrectomy was scheduled. After preparation of the ureter and kidney, the hilus was removed laterally. Bleeding occurred and an endoscopic gastrointestinal anastomosis clip was positioned with limited visibility in the hilar region. Bleeding stopped and after cutting the ureter the left kidney was removed. Postoperatively the patient immediately complained of severe back and leg pain, partial loss of sensibility and weakness in both legs with paresis of the right foot levator muscle. Neurological and electromyographic examinations proposed an intraoperative pressure lesion of the right peroneal nerve. Computerized tomography of the abdomen and transbrachial aortography demonstrated a clip obstructing the aorta (figs. 1 and 2). The aorta was collapsed for 2 cm. and refilled by collaterals. Aortal clip closure was confirmed at reoperation. Preparation of the clipped aortic stump and right renal artery was not possible due to extensive scarring. A polytetrafluoroethylene tube graft was inserted with an end-to-side anastomosis from the supraoeliac aorta to the distal aortic stump maintaining perfusion to the right renal artery. Duplex sonography demonstrated normal perfusion of the renal and distal extremity arteries. The neurological disorders resolved completely. DISCUSSION Difficult dissection in retroperitoneoscopic nephrectomy due to bleeding or anatomy can cause severe complications. It is important to identify carefully the hilar vessels because the aorta and vena cava may be pulled into the operative field.
Published Version
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