Editing Open Kidney Surgery (section)

==== Complications ====

* '''Injury to the GI vasculature'''
** The celiac trunk supplies the esophagus, stomach, pancreas, liver, spleen, and part of the duodenum
** '''The superior mesenteric artery supplies the small bowel, cecum, ascending and transverse colon'''
** '''The inferior mesenteric artery supplies the transverse, descending, and sigmoid colon'''
** '''The inferior mesenteric artery can be safely ligated as long as the marginal artery of the colon is patent and can supply blood from the SMA to the left colonic arcades'''
** '''Ligation of either the SMA or the celiac trunk is a catastrophic event that occurs predominantly with left-sided nephrectomy and that must be rapidly reversed if the patient is to survive.'''
** '''The inferior mesenteric vein''' (IMV) is found in the mesentery of the descending colon, immediately lateral to the ligament of Treitz. The IMV '''can be safely ligated during surgery without consequence. In contrast, the superior mesenteric vein (SMV) should not be ligated unless that is the only surgical option.''' '''The abdomen should not be closed primarily in cases of SMV injury because abdominal compartment syndrome will occur.'''
* '''Injury to the liver and spleen:'''
** '''Small splenic or hepatic injuries''' (capsular tears and minor lacerations) '''can usually be managed effectively by''' '''electrocautery''' or argon beam coagulation. '''Fibrin glue and topical hemostatic meshes (e.g., Surgicel) are useful adjuncts.'''
** '''More serious splenic injuries can be managed by splenorrhaphy or splenectomy'''
** Minor hepatic lacerations can be repaired using the same basic principles as for a partial nephrectomy closure.
* '''Injury to bowel'''
** Minor electrocautery or laceration injuries should be managed by careful debridement of the nonviable tissue and closure in two layers, the mucosal layer with continuous 4-0 chromic or Vicryl suture on a 1 2 circle tapered needle, and the serosa and muscularis layer with 3-0 silk interrupted suture on a 1 2 circle tapered needle. An omental flap is placed over the injury and a closed suction drain is inserted
* '''Injury to the pancreas:'''
** First step is a thorough inspection of the pancreas
** '''Superficial lacerations and contusions can usually be managed by applying fibrin glue and inserting a closed suction drain. The drain is monitored for an alkaline pH and lipase/amylase levels to determine whether a pancreatic fistula is developing.'''
** If the injury to the pancreas is deep and/or involves the pancreatic duct, consultation with a gastrointestinal surgeon is essential for appropriate repair and management.
* '''Pulmonary complications:'''
** Large postoperative pleural effusions can be managed by aspiration initially, followed by chest tube drainage if necessary
* '''Chylous ascites'''
** '''Results from disruption of the major para-aortic lymphatic channels leading to the cisterna chyli and is predominantely noted in left-sided procedures (radical or donor nephrectomy) or RPLND'''
** '''Patients classically have abdominal distention without significant pain or fevers and will have normal bowel habits.''' 
** '''Diagnosed by paracentesis''' with ascitic fluid found to have classically white and turbid appearance with fluid analysis showing elevated lymphocytes, associated with a high cholesterol and triglyceride content.
** '''Initial treatment is to reduce the flow of chyle into the lymphatics by a low-fat medium-chain triglyceride diet'''
** '''If chylous ascites persists despite dietary management, the next step should involve bowel rest and TPN with the concurrent use of octreotide, a somatostatin analog'''.
*** Somatostatin has been documented to significantly decrease postprandial increase in TG levels by inhibiting lymphatic flow
** '''Open or laparoscopic treatment using suture ligation and fibrin glue to control the leak can be pursued if conservative management fails'''.
*** Intraoperatie location of the lymphatic leakage can be challenging and the combined use of preoperative lymphangiography and consumption of “fatty” meal immediately before surgery has been documented to be beneficial in helping the surgeon locate the site of the leak