V05-03: Near miss in urological surgery: definition and tips for preventing unexpected complications

Stefano Parodi, Stefano Tappero*, Giovanni Guano, Andrea Pacchetti, Francesco Chierigo, Guglielmo Mantica, Marco Borghesi, Nazareno Suardi, Carlo Terrone, Genoa, Italy

Introduction: A surgical near miss (NM) is defined as an unintentional incident that could have caused damage to the patient but was narrowly avoided because of pure chance or because it was intercepted. 

In this video we aim to depict a clear example of NM during a left robot-assisted partial nephrectomy (PN), having potentially consisted of wrong renal artery clamping.

Methods: We present the case of a 66-year-old woman submitted to left PN at a tertiary care referral centre for a 55 mm upper pole left renal mass (SPARE 9), cT1-cN0M0.  

The preoperatory CT scan showed a single renal artery on both sides.

Preoperative Hb and GFR were 14.9 mg/dl and 53 ml/min, respectively. The Da Vinci Xi robot was employed. The fist operator was a skilled laparoscopic/robotic surgeon (=1000 procedures). The patient was placed in right flank position. Three 8-mm trocars for the 30° camera and the operative robotic arms and 2 trocars for the assistant were placed. At the abdominal exploration a high amount of visceral fat was found. Once incised the peritoneum at the level of the Toldt line and medialized the descending colon, a direct access to renal vessels was performed.

In the specific case, after the identification of left renal vein and renal artery, the latter was underpassed with a vessel loop. Before starting the isolation of renal mass a careful identification of the aorta was attempted. However, after exposure of the left gonadal vein, the aorta was identified laterally to the isolated renal artery. Therefore, the surgeon realized that the isolated artery was the right renal one. The vessel loop was removed, the left renal artery identified and isolated and the PN with warm ischemia was performed.

Results: Operative time was 240 min, estimated blood loss was 300 ml and no complications occurred. Final pathology revealed a clear cell RCC with eosinophilic variant, pT1b-pNx-R0.

Follow-up period was uneventful and 2-y postoperative GFR was 52 ml/min.  After a specific surgical audit the predisposing factors for our NM were identified: suboptimal evaluation of preoperative CT scan, no 3D reconstructions available, abundant visceral fat, left-sided surgery and direct access to the renal pedicle without identification of gonadal vein.

Conclusions: Procedural errors in the OR may come along with tremendous complications for the patient. The identification of the anatomical landmarks is mandatory and the discussion of the potential NM helps the prevention of adverse dangerous events. In our case, failure to recognize the error would result in serious complications, especially if a radical nephrectomy had been planned.

Source of Funding: None.