Approaches to Anomalous Vasculature in Laparoscopic Renal Surgery

Abstract

Introduction: Recognition and safe management of vascular anomalies during laparoscopic renal surgery has become increasingly important as more challenging cases are undertaken via a laparoscopic approach. Recent studies have found comparable results in cases where vascular anomalies were found with low complication rates for laparoscopic donor nephrectomies1 and partial nephrectomies.2 The following video demonstrates the management of anatomic variations of the renal vein and artery, gonadal vein, lumbar vein, and accessory veins during laparoscopic radical nephrectomy, donor nephrectomy, and pyeloplasty. Methods: Digital video captures of laparoscopic renal surgeries were reviewed to find cases of anomalous renal vasculature. Cases were selected for their quality and content, with regard to demonstrating a distinct scenario in which a vascular anomaly is managed. During laparoscopic renal surgery, hilar vessels are managed either with clips or vascular staplers. The endo TA™ (Covidien, Mansfield, MD) is used for donor nephrectomies to increase vascular length, whereas the endo GIA™ (Covidien) or clips are used for radical nephrectomies. Vascular branches and small accessory vessels are managed with bipolar electrocautery. Results: A total of six cases are shown. The first case is a laparoscopic left radical nephrectomy complicated by a circumaortic renal vein. The anterior portion of the vein is taken with an endo GIA stapler to expose the renal artery, which is then controlled and divided. The posterior portion of the vein is divided last. The second case, a laparoscopic donor nephrectomy, demonstrates the use of the endo TA stapler, which adds length to the vessels by providing three rows of staples on the proximal side only, rather than the three rows of staples on both sides when using the endo GIA. The third case is a donor nephrectomy with two renal arteries. These are taken with the TA stapler, but some bleeding is noted in the staple line. This is corrected with clips. The fourth case demonstrates the management of large gonadal and lumbar veins with bipolar cautery during a laparoscopic donor nephrectomy. The fifth case, a laparoscopic pyeloplasty, shows an accessory renal vein and artery crossing the ureteropelvic junction. The vein is freed from the artery and divided using bipolar cautery. Division of the vein creates increased mobility, allowing one to move the artery away from the area of stricture. The last case, a laparoscopic donor nephrectomy, demonstrates a very proximal renal vein bifurcation, which is controlled with a stapler placed proximal to this bifurcation. Conclusion: Vascular anomalies are more frequently encountered in laparoscopic renal surgery. One must recognize these anomalies and often adjust to safely manage these. This requires familiarity with all forms of vascular control, including clips, staplers, and bipolar cautery. The authors of this video do not have any financial disclosures related to the production of this video. Runtime of video: 7 min 48 sec