V13-02: Intraoperative Recognition & Management of an Iatrogenic Clipping of the Superior Mesenteric Artery During Robotic Left Cytoreductive Nephrectomy

Brijesh Patel*, Daniel Roadman, Chicago, IL, Mark Biebel, St. Louis, MO, Alexander Chow, Chicago, IL, Robert Figenshau, St. Loius, MO

Introduction: Ligation of the superior mesenteric artery (SMA) is a very rare, and often fatal complication of minimally invasive left nephrectomy (MILN). Despite its rare occurrence, urologists must be cautious when dissecting the left renal artery (RA) and vein (RV) in cases where surgical planes and vascular anatomy are distorted.  We present a case of a 77 year old male with metastatic renal cell carcinoma who underwent a robotic left nephrectomy following immunotherapy.

Methods: The patient was placed in standard right decubitus position with the left flank flexed.  Pneumoperitoneum was achieved with a Veress needle, and 4 robotic 8 mm ports were placed in a straight line along the lateral edge of the rectus with a 12 mm assistant port in the midline. After the colon was medialized, hilar dissection started with identifying the RV.  A pulsation was seen cephalad and parallel to the RV. This vessel was dissected and presumed to be the RA. After the RA was ligated with one clip, the distal part of the vessel continued to pulsate.  The left kidney and hilar region behind this clipped vessel continued pulsating, raising suspicion that we clipped the SMA. Adding to this suspicion was the anterior location of the artery, in contrast to the normal posterior location relative to the RV. Immediately, two needle drivers were inserted and the clip prongs were pulled in opposite directions to dislodge the locking mechanism. Total ischemia time was less than ten minutes, and the rest of the case was completed without incident.

Results: Procedure time was 4 hours and 2 minutes. Pathology revealed clear cell RCC, Furhman grade 4 with rhabdoid features and negative surgical margins. On the evening of POD#0, the patient’s pain was well controlled, vital signs were stable, and abdominal exam was reassuring.  On POD#1, the patient remained stable with no clinical deterioration. He was monitored and discharged on POD#2.

Conclusions: Ligation of the SMA during MILN is exceedingly rare, but can occur in several scenarios: post-systemic therapy operative fields, cytoreductive settings, and large tumors distorting anatomy via mass effect.  In such cases, the path of the SMA can be distorted and appear to head laterally towards the kidney. We favor clip placement over stapling to permit removal of the clips should such a complication arise.  Urologists must know techniques to remove clips, including using the laparoscopic clip remover, cutting the locking mechanism off the clip, and pulling the prongs of the clip in opposite directions to dislodge the locking mechanism.

Source of Funding: None