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 Table of Contents  
CASE REPORT
Year : 2018  |  Volume : 3  |  Issue : 2  |  Page : 119-120

Splenic injury during retroperitoneal nephrectomy


1 Department of Urology, BT Savani Kidney Hospital, Rajkot, Gujarat, India
2 Consultant Urologist, BT Savani Kidney Hospital, Rajkot, Gujarat, India

Date of Submission06-Apr-2018
Date of Acceptance19-Jul-2018
Date of Web Publication26-Dec-2018

Correspondence Address:
Dr. Suresh K Jariwala
C/202, Vraj Dham, Rambaug Lane, Off S. V. Road, Borivali West, Mumbai - 400 092
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/bjhs.bjhs_18_18

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  Abstract 


Iatrogenic splenic injury (SI) is known to occur during various procedures. Any unusual course in postoperative period or hypotension should raise suspicion of SI, especially in the left nephrectomy or colonic resection. Sonography of abdomen by an expert should be the first investigation after a medical cause is ruled out. Splenic salvage may be attempted. There should be a low threshold for splenectomy to save the life of the patient.

Keywords: Iatrogenic, injury, nephrectomy, retroperitoneum, spleen


How to cite this article:
Jariwala SK, Dholaria P. Splenic injury during retroperitoneal nephrectomy. BLDE Univ J Health Sci 2018;3:119-20

How to cite this URL:
Jariwala SK, Dholaria P. Splenic injury during retroperitoneal nephrectomy. BLDE Univ J Health Sci [serial online] 2018 [cited 2019 Jul 17];3:119-20. Available from: http://www.bldeujournalhs.in/text.asp?2018/3/2/119/248548



Iatrogenic injury during surgery is known. It varies from operating on the wrong side to forgetting a mop or instrument inside a cavity. They are not intentional. Splenic injury (SI) during abdominal operations has been reported. SI during retroperitoneal surgery is not common. We describe the case of an SI during retroperitoneal nephrectomy.


  Case Report Top


A 50-year-old male was admitted with complaints of hematuria, fever, pain in the left flank, and loss of appetite of 2 months' duration. He smoked 6–7 bidies/day and taking metoprolol 20 mg once a day for hypertension. On examination, his vitals were stable and a hard ballotable mass measuring 5 cm × 6 cm was found in the left flank. There was no varicocele. A clinical diagnosis of renal cell carcinoma on the left side was made. Biochemical and hematological investigations and X-ray chest were normal. Sonography (USG) of abdomen showed a 9.4 cm × 9.4-cm mass in the upper and middle pole of the left kidney, increased vascularity, and left renal vein thrombosis. Right kidney, liver, and inferior vena cava (IVC) were normal. Contrast-enhanced computed tomography (CECT) scan of abdomen showed left kidney tumor, left renal vein thrombus, IVC free, and no lymph nodes. Retroperitoneal radical nephrectomy was planned. The flank incision was used. Thrombus was found in the renal vein, IVC free, and a single renal artery. Artery and vein were ligated. No lymph nodes were found. Radical nephrectomy was done. No drain was kept. The peritoneum was not opened or breached. The patient's condition was stable during surgery. In the recovery room, there was a fall of blood pressure (BP) to 90/60 mmHg and pulse rate of 50/min. He was treated with atropine and noradrenalin. Bedside USG by a surgeon showed no collection in the renal fossa. His condition did not improve. Next day, his BP was 90/40 mmHg and hemoglobin (Hb) 6.4 g%. Three units of packed cells were transfused. He was taken up for emergency exploratory laparotomy. The flank incision was opened. Renal fossa was empty. Blood was seen in the peritoneal cavity through the intact peritoneum. The latter was opened. Shattered spleen with 1½ l of blood was found in the peritoneal cavity [Figure 1]. Splenectomy was done. The wound was closed with a tube drain. The patient developed paralytic ileus postoperatively which was treated conservatively. Altogether, the patient received 7 units of blood transfusion. The patient was discharged home on the 9th postoperative day. Histopathology report was clear cell carcinoma of the kidney. Pneumococcal vaccine was advised. On 6-month follow-up, the patient was alright without evidence of metastasis.
Figure 1: Shattered spleen

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  Discussion Top


Iatrogenic injury means unintentional or unintended harm or suffering arising from any aspect of health-care management.[1] There is a cost to iatrogenic injury, from financial burden[1] to the death of the patient.[2] Medical error is the third leading cause of death in the USA.[2]

Accidental SI is known to occur during various surgeries such as percutaneous nephrolithotomy,[3] colonic surgery,[4] nephrectomy,[4],[5] and abdominal vascular surgery.[6] Coon[4] contributed 21% of splenectomies to iatrogenic injuries between 1957 and 1967. Wang et al.[5] reported the incidence of 0.8%. It is common in transperitoneal approach. Our patient had retroperitoneal approach. It is less common during laparoscopic approach, probably due to better visualization and less vigorous retraction.

It is not that SI occurs during operation on the left side of the trunk. It has been reported during the right nephrectomy also.[5]

Factors contributing to SI are transperitoneal approach, retraction, previous abdominal surgery, large renal tumor, mobilization of splenic flexure of colon, adrenal surgery, and direct injury to spleen.[5] Knowledge of anatomy of ligaments and peritoneal folds around spleen is important to prevent SI.

Our patient had large renal tumor (T3). The spleen was damaged due to retraction. The patient had intraperitoneal bleed. He developed shock in recovery room. Missed SI has been reported.[4],[6] Shock was presumed due to cardiac event or pulmonary embolism. Bleeding was ruled out by bedside USG of the renal fossa. CECT of abdomen was not done. USG of abdomen by an expert would have picked up SI. He was taken up for emergency exploration next day as his condition did not improve and Hb fell to 6.4 g%. On exploration, 1½ l of blood and shattered spleen was found in the peritoneal cavity.

Splenectomy was the standard procedure in the past for SI. Spleen is an essential component of the immune system. Postsplenectomy status predisposes the patient to lifelong risk of severe infection. Bisharat et al.[7] reported the incidence of 3.2%. Protocols of splenic salvage[8] have been developed. The aim is to save the life of the patient first and then spleen. Our patient's condition was unstable and spleen shattered. Hence, splenectomy was done. Splenic salvage may not be feasible in vascular surgery patients.[6] Vaccination is advised 2 weeks before elective splenectomy and earliest in emergency surgery.[8] Our patient was advised pneumococcal vaccine.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Runciman WB, Moller J. Iatrogenic Injury in Australia. An Executive Summary. Australian Patient Safety Foundation; 2001. Available from: https://www.trove.nla.gov.au/work/33398626. [Last accessed on 2018 Feb 12].  Back to cited text no. 1
    
2.
Makary MA, Daniel M. Medical error-the third leading cause of death in the US. BMJ 2016;353:i2139.  Back to cited text no. 2
    
3.
Thomas AA, Pierce G, Walsh RM, Sands M, Noble M. Splenic injury during percutaneous nephrolithotomy. JSLS 2009;13:233-6.  Back to cited text no. 3
    
4.
Coon WW. Iatrogenic splenic injury. Am J Surg 1990;159:585-8.  Back to cited text no. 4
    
5.
Wang JK, Tollefson MK, Kim SP, Boorjian SA, Leibovich BC, Lohse CM, et al. Iatrogenic splenectomy during nephrectomy for renal tumors. Int J Urol 2013;20:896-902.  Back to cited text no. 5
    
6.
Eaton MA, Valentine J, Jackson MR, Modrall G, Clagett P. Incidental splenic injury during abdominal vascular surgery: A case-controlled analysis. J Am Coll Surg 2000;190:58-64.  Back to cited text no. 6
    
7.
Bisharat N, Omari H, Lavi I, Raz R. Risk of infection and death among post-splenectomy patients. J Infect 2001;43:182-6.  Back to cited text no. 7
    
8.
Finlayson E. Complications of appendectomy and colon and rectal surgery. In: Mulholland MW, Doherty GM, editors. Complications in Surgery. 2nd ed. Philadelphia: Walters Kluwer/Lippincott Williams & Wilkins; 2011. p. 483-99.  Back to cited text no. 8
    


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