Ureteral injuries during laparoscopic colon surgeries

Causes and Prevention

Ureteral injuries during laparoscopic colon surgeries

Causes and Prevention

Morris E. Franklin Jr, MD., F.A.C.S.

Director Texas Endosurgery Institute

Karla Russek, MD.

Research Fellow, Texas Endosurgery Institute

Morris E. Franklin Jr, MD., F.A.C.S.

Director Texas Endosurgery Institute

Karla Russek, MD.

Research Fellow, Texas Endosurgery Institute

MISS, 2011MISS, 2011

The pessimist sees difficulty in every opportunity. The optimist

sees the opportunity in every difficulty.

Winston Churchill

The pessimist sees difficulty in every opportunity. The optimist

sees the opportunity in every difficulty.

Winston Churchill

Increasing numbers of ureteral Increasing numbers of ureteral injuries in pelvic surgeryinjuries in pelvic surgery

Increasing numbers of ureteral Increasing numbers of ureteral injuries in pelvic surgeryinjuries in pelvic surgery

• From 1986-2006, 72 ureteral injuries found

– Only 7 during 1986-1992

• The actual incidence is 0.5% to 3%

• 53% in lap surgery – 33% open surgery

• 64% after gyn procedures, 25% gen surgery

• 79% delayed diagnosis ( 6 days ): Cautery?

• From 1986-2006, 72 ureteral injuries found

– Only 7 during 1986-1992

• The actual incidence is 0.5% to 3%

• 53% in lap surgery – 33% open surgery

• 64% after gyn procedures, 25% gen surgery

• 79% delayed diagnosis ( 6 days ): Cautery?Cholkeri-Singh et al. Laparoscopic ureteral injury and repair. J Minim Invasive Bynecol, 2007 14(3) 356-61Teija, PS, Illka P, Marrku S, et al. Increasing numbers of ureteric injuries after the introduction of laparoscopic surgery. Scand J of Uro and Nephr, 2008, 42: 422-427

Cholkeri-Singh et al. Laparoscopic ureteral injury and repair. J Minim Invasive Bynecol, 2007 14(3) 356-61Teija, PS, Illka P, Marrku S, et al. Increasing numbers of ureteric injuries after the introduction of laparoscopic surgery. Scand J of Uro and Nephr, 2008, 42: 422-427

IntroductionIntroductionIntroductionIntroduction• Most iatrogenic lesions occur in the lower ureter

(at or below pelvic rim)

• Surgical ureteral injuries are of five types:

– Laceration– Ligation– Crush– Devascularization– Electrical burns

• Most iatrogenic lesions occur in the lower ureter (at or below pelvic rim)

• Surgical ureteral injuries are of five types:

– Laceration– Ligation– Crush– Devascularization– Electrical burns

Dowling RA, Corriere JN Jr, et al. Iatrogenic ureteral injury. J Urol 1986; 135:912-5Guerriero WG. Ureteral injury. Urol Clin North Am 1989; 16: 237-48Dowling RA, Corriere JN Jr, et al. Iatrogenic ureteral injury. J Urol 1986; 135:912-5Guerriero WG. Ureteral injury. Urol Clin North Am 1989; 16: 237-48

Etiology or injuryEtiology or injuryEtiology or injuryEtiology or injury

• Most common causes of injuries:

• Severe adhesions• Obesity• Incorrect dissection plane• Bundling• Misidentification of anatomy• Tumor encasement

• Experience lessens likelihood but does not eliminate it

• Most common causes of injuries:

• Severe adhesions• Obesity• Incorrect dissection plane• Bundling• Misidentification of anatomy• Tumor encasement

• Experience lessens likelihood but does not eliminate it

Reported DataReported DataReported DataReported Data

• The insertion of preoperative ureteral catheters has been advocated as a means of preventing ureteral injury

• Complications as a direct result of the catheter insertion have been described – UI, inability to advance stent, OR time

IS IT WORTH IT ROUTINELY?

• The insertion of preoperative ureteral catheters has been advocated as a means of preventing ureteral injury

• Complications as a direct result of the catheter insertion have been described – UI, inability to advance stent, OR time

IS IT WORTH IT ROUTINELY?

Bothwell, W; Bleicher, R: Dent, T. Prophylactic ureteral catheterization in colon surgery. Dis Colon Rectum 1994; 37: 330-334Bothwell, W; Bleicher, R: Dent, T. Prophylactic ureteral catheterization in colon surgery. Dis Colon Rectum 1994; 37: 330-334

Reported DataReported DataReported DataReported Data

• 150 patients underwent placement of lighted ureteral stents before lap surgery

• No ureteral injuries

• Average time from placement of the stents to start of the operation was 5 minutes

• 150 patients underwent placement of lighted ureteral stents before lap surgery

• No ureteral injuries

• Average time from placement of the stents to start of the operation was 5 minutes

JSLS. 2009 Apr-Jun;13(2):139-41.Protect the ureters.Redan JA, McCarus SD.JSLS. 2009 Apr-Jun;13(2):139-41.Protect the ureters.Redan JA, McCarus SD.

Reported DataReported DataReported DataReported Data

• The cost of the stents is $205

• OR time past the first half hour ranges from $560 to $716 for each additional half hour

• Their conclusion: Extremely useful procedure that can reduce ureter injury to 0

• The cost of the stents is $205

• OR time past the first half hour ranges from $560 to $716 for each additional half hour

• Their conclusion: Extremely useful procedure that can reduce ureter injury to 0

JSLS. 2009 Apr-Jun;13(2):139-41.Protect the ureters.Redan JA, McCarus SD.JSLS. 2009 Apr-Jun;13(2):139-41.Protect the ureters.Redan JA, McCarus SD.

Lighted stentsLighted stentsLighted stentsLighted stents

ConsequencesConsequencesConsequencesConsequences

• Injuries that are recognized and repaired have low

incidence of short and long term complications

• Unrecognized and unrepaired injuries can result

in prolonged hospitalization, sepsis, loss of

kidney, death

• Injuries that are recognized and repaired have low

incidence of short and long term complications

• Unrecognized and unrepaired injuries can result

in prolonged hospitalization, sepsis, loss of

kidney, death

Franklin ME, Plascencia, G, et al. Submitted for publicationFranklin ME, Plascencia, G, et al. Submitted for publication

Mandatory steps for lap colectomyMandatory steps for lap colectomy

• Learn anatomy and methods to recognize it

• Learn basics, intermediate and advanced skills

• Learn how to handle tissue: colon, mesentery, adjacent organs, vessels

• Learn anatomy and methods to recognize it

• Learn basics, intermediate and advanced skills

• Learn how to handle tissue: colon, mesentery, adjacent organs, vessels

Mandatory steps for lap colectomyMandatory steps for lap colectomy

• Dissect and identify all structures prior to division

• Learn more than one technique of dissection, vessel control and anastomosis

• The key to recognizing structures is to know anatomic relationships

• Dissect and identify all structures prior to division

• Learn more than one technique of dissection, vessel control and anastomosis

• The key to recognizing structures is to know anatomic relationships

Technical pearlsTechnical pearls• Use gravity

• Frequent use of:

– Trendelenburg position

– Left and right tilt

• Use blunt instruments

• Use energy sparingly

• Use gravity

• Frequent use of:

– Trendelenburg position

– Left and right tilt

• Use blunt instruments

• Use energy sparingly

Technical pearlsTechnical pearls

Blunt dissection is always better than sharp dissection unless one can actually see through the tissue being dissected

Energy sources used sparingly

Key to preventing transection of ureter

Blunt dissection is always better than sharp dissection unless one can actually see through the tissue being dissected

Energy sources used sparingly

Key to preventing transection of ureter

Texas Endosurgery Institute Experience

Texas Endosurgery Institute Experience

• In over 1800 colon surgeries

• 5 ureteral injuries + 2 intentional resection and anastomosis for tumor invasion

• Recognized and repaired intraoperatively in 6 out of 7

• In over 1800 colon surgeries

• 5 ureteral injuries + 2 intentional resection and anastomosis for tumor invasion

• Recognized and repaired intraoperatively in 6 out of 7

ID UreterID Ureter

ID ureter, vascular control of IMA and IMVID ureter, vascular control of IMA and IMVID ureter, vascular control of IMA and IMVID ureter, vascular control of IMA and IMV

Tips to prevent ureteral injuriesTips to prevent ureteral injuries• Know anatomy

• Adequate dissection

• Constant visualization of ureter from multiple directions

• Be SURE it’s ureter: Wait and see the peristalsis

• After vascular control Check ureter again!

• Know anatomy

• Adequate dissection

• Constant visualization of ureter from multiple directions

• Be SURE it’s ureter: Wait and see the peristalsis

• After vascular control Check ureter again!

Be aware of possible anomaliesBe aware of possible anomaliesBe aware of possible anomaliesBe aware of possible anomalies

Uh ohUh ohUh ohUh oh

Uh ohUh ohUh ohUh oh

Texas Endosurgery Institute Experience

Texas Endosurgery Institute Experience

– Out of the 5 ureteral injuries:

– 4 Diagnosed and repaired laparoscopically

– No postoperative complications in any of the patients

– Out of the 5 ureteral injuries:

– 4 Diagnosed and repaired laparoscopically

– No postoperative complications in any of the patients

Be prepared….Be prepared….• Check ureters after all dissection is done

• Be ready to repair ureter in necessary case

– 4-0 Vicryl

• Don’t use cautery near ureters

• Place stents

• Use Drains

• Check ureters after all dissection is done

• Be ready to repair ureter in necessary case

– 4-0 Vicryl

• Don’t use cautery near ureters

• Place stents

• Use Drains

Colon Cancer

and

Ureter Invasion

Colon Cancer

and

Ureter Invasion

StatisticsStatisticsStatisticsStatistics

• Until 50 years ago, colorectal carcinoma infiltrating surrounding tissue was considered nonresectable

• Most of the time the diagnosis is made in the OR

• Until 50 years ago, colorectal carcinoma infiltrating surrounding tissue was considered nonresectable

• Most of the time the diagnosis is made in the OR

Ureter invasion by colorectal Ureter invasion by colorectal cancercancer

Ureter invasion by colorectal Ureter invasion by colorectal cancercancer

Dtsch Med Wochenschr. 1994 Jun 3;119(22):791-5.[Routine intravenous urography before colorectal resections? Printz H, Greger B, Nies C, Rothmund M.Dtsch Med Wochenschr. 1994 Jun 3;119(22):791-5.[Routine intravenous urography before colorectal resections? Printz H, Greger B, Nies C, Rothmund M.

• Preoperative intravenous urography was performed in 279 patients

• 9 patients showed ureter invasion

Ureter encasementUreter encasement

ConclusionsConclusions

• Although technically more challenging, laparoscopic colectomy is feasable and should be performed

• Understanding of anatomy is mandatory

• If ureter encased, preoperative stent placement is good option

• Although technically more challenging, laparoscopic colectomy is feasable and should be performed

• Understanding of anatomy is mandatory

• If ureter encased, preoperative stent placement is good option

ConclusionsConclusionsConclusionsConclusions

• Mandatory to have intracorporeal suturing skills for repair

• Don’t hesitate to convert

• ? Advisability of preoperative stents in all patients

• Mandatory to have intracorporeal suturing skills for repair

• Don’t hesitate to convert

• ? Advisability of preoperative stents in all patients

ConclusionsConclusionsConclusionsConclusions

• ALWAYS check ureters after dissection!– It is easier to repair the ureter in the same

surgery!

• ALWAYS check ureters after dissection!– It is easier to repair the ureter in the same

surgery!

““Learn what is true in order to do what is right.” ”

““Learn what is true in order to do what is right.” ”

Thomas Henry HuxleyThomas Henry Huxley

www.texasendosurgery.comwww.texasendosurgery.com