Renal vascular anatomy
AAST Renal Injury Grading
Nephrectomy
Indications
Unstable patient with the kidney being the source of hemorrhage
Failed attempts at partial nephrectomy
Extensive injury to the kidney where repair is not warranted
Avulsion injuries to the renovascular pedicle
Avulsion of the fornices seen more commonly in pediatric population
Technique
- 1.
Patient position: standard trauma laparotomy position—supine with both arms abducted to 90 degrees.
- 2.
Prep patient from mandible to thighs above the knee as in a standard trauma laparotomy fashion.
- 3.
Standard laparotomy incision with use of self-retaining abdominal retractor, such as a Bookwalter.
- 4.
Proximal renal vascular control increases the chance of kidney salvage. In an unstable patient, however, this may not be feasible. Clinicians have debated the proximal renal vascular control method gaining higher likelihood of kidney salvage.
- 5.
It is important to determine the presence and functionality of the contralateral kidney, whether by Focused Assessment with Sonography in Trauma (FAST) exam or by CT scan to look at architectural anatomy of the kidney prior to nephrectomy. In the unstable hemorrhaging patient this may not be accomplished other than by direct visualization to confirm the presence of the contralateral kidney.
- 6.
Proximal renal vascular control (Fig. 9.3)
- (a)
The transverse colon is retracted cephalad.
- (b)
The small bowel is gathered in a moist towel and retracted to the right upper quadrant and packed away with a broad malleable retractor.
- (c)
The root of the mesentery and Ligament of Treitz is identified.
- (d)
The retroperitoneum is incised lateral to the aorta medial to the inferior mesenteric vein. The incision is carried superiorly on the aorta until the renal vessels are identified.
- (e)
The renal vein and artery are dissected, and vessel loops placed around the vessels.
- (a)
- 7.
Exposure of the kidneys require medial visceral rotation.
- (a)
Left kidney
- (i)
Perform Mattox maneuver to expose the left kidney.
- (ii)
Incise along white line of Toldt and reflect the left colon medially.
- (iii)
Make a generous incision on the Gerota’s Fascia anteriorly. Use blunt and sharp dissection to deliver the kidney out of the retroperitoneum.
- (i)
- (b)
Right kidney
- (i)
Perform Cattell-Braasch maneuver to expose right kidney
- (ii)
Incise the retroperitoneum lateral to the third portion of the duodenum to perform Kocher maneuver to get better access to the right renal vessels.
- (i)
- (a)
- 8.
The renal vein and renal artery are separately ligated using 0 silk ties near the hilum to avoid the potential for developing an arteriovenous fistula. Consider oversewing the short right renal vein with a continuous 3-0 Prolene suture.
- 9.
Ligate the ureter near the kidney using 2-0 silk suture.
- 10.
Ligate the left gonadal if necessary.
- 11.
Identify any accessory arterial vessels from the aorta and ligate using silk suture.
Complications and Management
Need for dialysis due to complications of renal failure and other organ dysfunction in patients with high injury severity scores.
Retroperitoneal abscess: treated with percutaneous drainage and antibiotics.
Arteriovenous fistula or renal artery pseudoaneurysm: may be treated with interventional radiology embolization and close radiologic monitoring.
Mortality related to concurrent injuries.
Partial Nephrectomy/Renorrhaphy
Indications
During laparotomy for intra-abdominal injuries an expanding retroperitoneal (Zone 2)
Hematoma may be identified requiring renal exploration
Hemodynamically stable patient
Renal cortical disruption
Technique
- 1.
Patient position: standard trauma laparotomy position—supine with both arms abducted to 90 degrees. A Foley catheter must be placed.
- 2.
Prep patient from mandible to thighs above the knee as in a standard trauma laparotomy fashion.
- 3.
Standard laparotomy incision with use of self-retaining abdominal retractor, such as a Bookwalter.
- 4.
If there is an expanding Zone 2 retroperitoneal hematoma suspicious for kidney injury, hemorrhage is controlled by gaining proximal vascular control of the renal vessels as described above.
- 5.
Medial visceral rotation as described above (see section “Technique”, no. 7).
- 6.
Incision over Gerota’s Fascia anteriorly and exposing kidney.
- 7.
Evacuate the hematoma. If there is cortical disruption, carefully evacuate the hematoma underneath the renal capsule and attempt to preserve the renal capsule.
- 8.
Identify any injured collecting system. Suture ligate with 4-0 absorbable suture. Using absorbable suture prevents renal calculi formation along the suture. Collecting duct system repairs needs to be watertight to prevent future urinoma and urine extravasation.
- 9.
Sharply excise devitalized tissue.
- 10.
Control any parenchymal bleeding with 3-0 or 4-0 absorbable suture. Topical hemostatic agents may be used to obtain hemostasis.
- 11.
Pledgeted sutures may be used to close the defect, if small (Fig. 9.4).
- 12.
Polar cortical disruptions can be managed with a guillotine approach by transecting renal parenchyma down to healthy bleeding tissue (Fig. 9.5).
- 13.
If the renal capsule can be preserved, close the renal capsule over the parenchyma using 3-0 Vicryl suture in a running fashion, with or without the aid of pledgets.
- 14.
If the renal capsule is disrupted, an omental flap can be used and sutured to healthy renal capsule using 3-0 Vicryl suture. If omentum is not available, Gelfoam or fibrin sealant may be used. Do not attempt to close the capsule over a large parenchymal defect, as that will cause further tearing and bleeding (Fig. 9.6).
- 15.
A closed suction drain is left next to the kidney.
- 16.
If there is concern regarding the repair of the collecting system, consider a placement of nephrostomy or an internal JJ stent.
The incision of the retroperitoneum to obtain renal vascular control. Medial to the IMV and just lateral to the aorta
Complications and Management
Need for dialysis due to complications of renal failure and other organ dysfunction in patients with high injury severity scores.
Retroperitoneal abscess: treated with percutaneous drainage and antibiotics.
Urinoma or urine extravasation from repair: will need percutaneous drainage of urinoma and nephrostomy or internal ureteral stent for diversion of urine.
During debridement of the renal parenchyma, renal capsule is compromised: will need to preserve as much healthy renal capsule as possible. Buttress large defects with omentum or fibrin sealant as described above.
Renovascular injury causing renal artery thrombosis: will need interventional radiology for endoluminal stenting and thrombectomy.
Goldblatt Kidney Phenomenon: post-injury hypertension or secondary hypertension is treated medically with antihypertensives. If medical management fails, the patient will need a delayed nephrectomy.
Arteriovenous fistula or renal artery pseudoaneurysm: may be treated with interventional radiology embolization and close radiologic monitoring.
Renorrhaphy , pledgeted Renorrhaphy
Partial Nephrectomy. Guillotine of lower pole of kidney with preservation of renal capsule. Renal capsule closed with a running suture
Omental Flap closure of Guillotined kidney. If the defect is large and renal capsule is unable to be preserved, and omental flap can be mobilized for closure of defect
Ureteral Injuries
Ureteral Anatomy
Ureteral injury should be promptly diagnosed and treated to prevent acute renal failure, sepsis from urine leaks, and death. In penetrating trauma with retroperitoneal hematomas in Zone 2, the retroperitoneum must be explored to rule out ureteral injuries. The approach to ureteral injury depends on the location of the injury. The ureter is anatomically divided into three areas: the proximal, mid, and distal ureter.
The proximal ureter is above the iliac bifurcation. The mid ureter is between the iliac bifurcation and pelvis. The distal ureter is located below the internal iliac artery.
The proximal ureter receives its blood supply directly from the renal arteries. The mid ureter receives blood supply from the branches of the aorta, the common iliac, and gonadal arteries. The nutrient branches course medially when entering the ureter. The distal ureter receives blood supply from the branches of the internal iliac artery. These nutrient branches course laterally into the ureter.
The ureter courses inferiorly from the kidneys in the retroperitoneum. The gonadal vessels cross over the ureter proximally. The genitofemoral nerve courses behind the ureter on top of the psoas muscle. At the pelvic brim the ureter crosses over the common iliac vessels near the bifurcation. The ureter then dives into the pelvis. In females it courses posterior to the ovary and courses next to the uterine vessels. In males the ureter runs parallel to the inferior hypogastric plexus and artery to the vas deferens before entering the bladder.
The ureter runs obliquely into the bladder wall and is encased in the muscular layer of Waldeyer, which joins the detrusor muscle.
Ureteral Repair
In damage control conditions where the patient is not hemodynamically stable for a ureteral reconstruction, a stent can be placed into the proximal ureter, into the kidney, and brought out through the abdominal wall and secured into the abdominal wall.
The proximal and distal ends of the ureter can also be ligated and marked with suture for a second-look operation for reconstruction. A nephrostomy for the kidney may not be needed if a second-look operation is planned for 48–72 hours postoperatively.
Ureteroureterostomy
Indications
Proximal to mid ureteral injury
Hemodynamically stable patient with control of hemorrhage
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