Интраоперационные осложнения

Renal cancer. Contemporary management. Editor John A. Libertino. Springer New York, 2013

Intraoperative complications


Повреждение сосудов

Повреждения ворот почки могут иметь значительную летальность и морбидность при отсутствии быстрого лечения в контролируемой манере. В случаях небольшого венозного кровотечения прямое давление с Surgicel (Ethicon, Сомервилл, Нью-Джерси, США) может быть достаточным. Пневмоперитонеум должен быть уменьшен для достижения гемостаза. Повреждения крупных вен сшиваются 4-0 Prolene (Ethicon, Сомервилл, Нью-Джерси, США). Если наблюдается значительное повреждение воротных сосудов, может быть необходимо перейти к  радикальной нефрэктомии.

Таблица 14.1. Интраоперационные осложнения LPN и RAPN
Renal Cancer_ Contemporary Management-Springer New York (2013) T 14.1

Повреждение внутрибрюшных органов

Bowel injury etiologies include traumatic (e.g., during access) and sharp or thermal dissection. The method of repair of bowel injuries depends on the severity, original cause of the injury, and whether it is recognized at the time or in the postoperative period. In instances of an immediately identified minor thermal bowel injury, simple imbrication may be sufficient. Major thermal injuries should be managed with bowel resection and re-anastomosis or, rarely, diversion. In such a case, it would be prudent to obtain general surgery or colorectal surgery consultation depending on institution routine. If the bowel injury is identified in the postoperative period, depending on the clinical circumstances, this may require reoperation with bowel resection. Clinical signs and symptoms of bowel injury vary widely and include peritonitis, nausea, vomiting, tachycardia, fevers, and sepsis.

Pancreatic injuries during laparoscopic renal surgery most often occur at the pancreatic tail during left-sided procedures. Pancreatic injury identified in the postoperative period may present with increasing drain output, and confirmation is by fluid and serum amylase and lipase. If identified postoperatively, management includes total parenteral nutrition, nasogastric tube placement, somatostatin to suppress pancreatic exocrine function, and percutaneous drainage.

Injuries to the spleen can often be treated with argon coagulation and/or use of hemostatic agents. Rarely, in instances of significant splenic laceration, a splenectomy is performed.

In laparoscopic renal surgery, inadvertent diaphragm injury has a reported incidence of 0.4%. Billowing of the diaphragm is a noticeable sign of pleural entry. Repair can be performed laparoscopically in a technique similar to open repair.

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