V13-01: Superior Mesenteric Artery Injury During Robotic Left Radical Nephrectomy: Prevention and Management

Aref S. Sayegh*, Anibal La Riva, Laura C. Perez, Luis G. Medina, Edward Forsyth, Ryan Powers, Los Angeles, CA, Ben Challacombe, London, United Kingdom, Michael Stifelman, Hackensack, NJ, Inderbir S. Gill, Rene Sotelo, Los Angeles, CA

Introduction: Injury to the Superior Mesenteric Artery (SMA) during renal surgery is a rare but potentially devastating complication. It can rarely occur in patients with large left renal tumors and bulky lymphadenopathy, or in the setting of re-do surgery with significant retroperitoneal and intraabdominal scarring, which may distort the vascular anatomy. In most cases, the inadvertent injury occurs due to misidentification of the SMA as the renal artery. Failure to recognize and repair an SMA injury may result in ischemic bowel and/or mortality. Herein, we present three different scenarios of injury to the SMA when misidentified as the left renal artery during left robotic radical nephrectomy. We also describe how to avoid and manage SMA injury.

Methods: A compilation of three video clips were collected anonymously from different surgeons to demonstrate how the SMA was misidentified, injured, recognized intraoperatively, and repaired either in a transperitoneal or retroperitoneal robotic approach to left nephrectomy.

Results: Left robotic radical nephrectomy was started as usual. Descending colon was reflected medially, gonadal vein and ureter were used as landmarks to trace the left renal hilum. An artery arising from the aorta was apparently coursing towards the kidney and was assumed to be the left renal artery in all cases. In the first case, the SMA misidentification was timely recognized, and the injury was avoided. The second case demonstrates the SMA being clipped. Suspicious was raised after a dilated left renal vein was seen; therefore, clip removal was performed. Lastly, the third case involved a complete transection of the SMA, and it was repair intraoperatively because of awareness of severe consequences. Increases in operative time of patients experiencing an intraoperative complication are expected. Increases in length of hospital stay may occur depending on the type of complication, and sequelae can occur.

Conclusions: Proper anatomic identification and recognition of the SMA may prevent its injury. Intra-operative SMA injury should be promptly identified and repaired to avoid its severe consequences.

Source of Funding: None.