EDITORIAL COMMENT
1
DISCUSSION Pneumothorax has been reported as a complication of open nephrectomy. 2, 3 Inadvertent entry into the pleural space during open flank surgery is typically recognized intraoper- atively and repaired without sequela. Unlike its open coun- terpart, laparoscopic nephrectomy is performed using carbon dioxide insufflated under pressure in either the retroperito- neal or peritoneal space. Insufflated gas may enter the ipsi- lateral thorax through small diaphragmatic tears, leading rapidly to collapse of the ipsilateral lung. The resulting pneu- mothorax may produce changes in auscultation, end inspira- tory pressure, blood pressure, end tidal carbon dioxide levels or arterial blood gasses. As during open nephrectomy, sus- pected diaphragmatic injuries should be repaired primarily. If no pulmonary parenchymal injury exists, simple aspiration of the pneumothorax will lead to complete resolution. REFERENCES 1. Cadeddu, J. A., Ono, Y., Clayman, R. V. et al.: Laparoscopic nephrectomy for renal cell cancer: evaluation of efficacy and safety: a multicenter experience. Urology, 52: 773, 1998 2. Hamilton, W. K.: Pneumothorax following subdiaphragmatic surgery. JAMA, 204: 255, 1968 3. Olsson, L. E., Swana, H., Friedman, A. L. et al: Pleurotomy, pneumothorax, and surveillance during living donor nephroureterectomy. Urology, 52: 591, 1998 EDITORIAL COMMENTS During the last 15 years laparoscopy has continued in its develop- ment for urological procedures and yet there still remains some debate as to whether laparoscopy is for everyone. This case demon- strates the importance of working as a team of physicians with the anesthesia group. If the anesthesiologists had not mentioned the changes in respiratory status during the mid portion of the proce- dure, the diaphragmatic injury may have been missed and only found postoperatively in the recovery room when the patient had pneumothorax. It is unclear from the report as to whether this injury was made with any of the laparoscopic instrumentation, or if it was simply a blowout of the pneumoperitoneum from carbon dioxide insufflation. Clearly, this complication is an additional potential problem from performing this procedure laparoscopically. After 15 years of laparoscopic experience, I believe that sometimes we find reasons for performing laparoscopy for the sake of perform- ing laparoscopy, rather than considering the best interest and best benefit of the patient. A 75-year-old man with a 6-inch midline incision could undergo radical nephrectomy in a quarter of the op- erative time of this particular case. I think getting patients on and off the operating room table as quickly as possible should be condidered an important issue, especially in those with the added co-morbidities of coronary artery disease and chronic obstructive pulmonary dis- ease. Chronic obstructive pulmonary disease in itself may be an added risk factor associated with any laparoscopic procedure. Lapa- roscopy has almost become a subspeciality of urology. Therefore, many are expanding the indications for laparoscopy perhaps beyond what is reasonably practical for most urologists in the country. Advanced laparoscopic procedures require an increase in surgical experience and ability, but is this new mouse trap really a better mouse trap? I believe that the question is unresolved as to whether this particular approach was best for this patient. The operating time of 4 and a half hours is clearly not practical for most busy urology practices. It should not be considered good care to leave patients on the operating table for this extended period. Michael Kozminski St. Joseph, Missouri The authors present a nice technique for diaphragmatic repair and aspiration of the associated pneumothorax following diaphragmatic injury during laparoscopic radical nephrectomy. It is not surprising that these injuries can occur during laparoscopic nephrectomy of other upper retroperitoneal/abdominal laparoscopic procedures. I have created 2 such injuries during laparoscopic surgery. My tech- nique of repair was not as technically neat as that reported by the authors but was equally successful in both cases. Laparoscopic tech- niques for the repair of diaphragmatic injury during laparoscopy have been reported previously. 1,2 However, in this report the injury was not recognized immediately but only after the anesthesiologist informed the surgeons of elevated end inspiratory pressures and the operative field was inspected at the conclusion of the procedure. With the excellent visualization afforded by the laparoscope, it would be hoped that such an injury would be recognized immediately. If not, at least this report demonstrates that the good practices of communi- cation with the anesthesia team and careful inspection of the oper- ative field can serve to identify otherwise unsuspected problems during laparoscopy. J. Stuart Wolf Section of Urology University of Michigan Ann Arbor, Michigan 1. Naito, S., Uozumi, J., Shimura, H. et al: Laparoscopic adrenalectomy: review of 14 cases and comparison with open adrenalectomy. En- dourol, 9: 491, 1995 2. Seiler, C., Glattli, A., Metzger, A. et al: Injury to the diaphragm and its repair during laparoscopic cholecystectomy. Surg En- dosc, 9: 193, 1995 REPLY BY AUTHORS Diaphragmatic injuries are usually recognized intraoperatively. However, they may initially be missed, highlighting the importance of communication between the anesthesiologist and surgeon in diag- nosing this type of injury. It must be noted that a junior member of our faculty was undertaking this case. As such, operative time was prolonged due to the experience level of the surgeon and the time required to consult a more experienced laparoscopic urological sur- geon to help with the repair. Operative time is directly related to experience. Review experience of a single surgeon at our institution reveals a decrease in the average operative time for laparoscopic radical nephrectomy from 302 to 206 minutes. Operative times are now equivalent to those reported with open nephrectomies per- formed at our institution during the same period. Despite the mod- erately longer operative time (270 minutes) and complication of diaphragmatic injury, the patient had minimal postoperative dis- comfort and rapid recovery, and thus maintained the benefits of a laparoscopic approach. DIAPHRAGMATIC INJURY DURING LAPAROSCOPIC NEPHRECTOMY 1204
Transcript of EDITORIAL COMMENT
DISCUSSION
Pneumothorax has been reported as a complication of opennephrectomy.2, 3 Inadvertent entry into the pleural spaceduring open flank surgery is typically recognized intraoper-atively and repaired without sequela. Unlike its open coun-terpart, laparoscopic nephrectomy is performed using carbondioxide insufflated under pressure in either the retroperito-neal or peritoneal space. Insufflated gas may enter the ipsi-lateral thorax through small diaphragmatic tears, leadingrapidly to collapse of the ipsilateral lung. The resulting pneu-mothorax may produce changes in auscultation, end inspira-tory pressure, blood pressure, end tidal carbon dioxide levelsor arterial blood gasses. As during open nephrectomy, sus-pected diaphragmatic injuries should be repaired primarily.If no pulmonary parenchymal injury exists, simple aspirationof the pneumothorax will lead to complete resolution.
REFERENCES
1. Cadeddu, J. A., Ono, Y., Clayman, R. V. et al.: Laparoscopicnephrectomy for renal cell cancer: evaluation of efficacy andsafety: a multicenter experience. Urology, 52: 773, 1998
2. Hamilton, W. K.: Pneumothorax following subdiaphragmaticsurgery. JAMA, 204: 255, 1968
3. Olsson, L. E., Swana, H., Friedman, A. L. et al: Pleurotomy,pneumothorax, and surveillance during living donornephroureterectomy. Urology, 52: 591, 1998
EDITORIAL COMMENTS
During the last 15 years laparoscopy has continued in its develop-ment for urological procedures and yet there still remains somedebate as to whether laparoscopy is for everyone. This case demon-strates the importance of working as a team of physicians with theanesthesia group. If the anesthesiologists had not mentioned thechanges in respiratory status during the mid portion of the proce-dure, the diaphragmatic injury may have been missed and onlyfound postoperatively in the recovery room when the patient hadpneumothorax. It is unclear from the report as to whether this injurywas made with any of the laparoscopic instrumentation, or if it wassimply a blowout of the pneumoperitoneum from carbon dioxideinsufflation. Clearly, this complication is an additional potentialproblem from performing this procedure laparoscopically.
After 15 years of laparoscopic experience, I believe that sometimeswe find reasons for performing laparoscopy for the sake of perform-ing laparoscopy, rather than considering the best interest and bestbenefit of the patient. A 75-year-old man with a 6-inch midlineincision could undergo radical nephrectomy in a quarter of the op-erative time of this particular case. I think getting patients on and offthe operating room table as quickly as possible should be condideredan important issue, especially in those with the added co-morbiditiesof coronary artery disease and chronic obstructive pulmonary dis-ease. Chronic obstructive pulmonary disease in itself may be anadded risk factor associated with any laparoscopic procedure. Lapa-roscopy has almost become a subspeciality of urology. Therefore,many are expanding the indications for laparoscopy perhaps beyondwhat is reasonably practical for most urologists in the country.Advanced laparoscopic procedures require an increase in surgicalexperience and ability, but is this new mouse trap really a better
mouse trap? I believe that the question is unresolved as to whetherthis particular approach was best for this patient. The operatingtime of 4 and a half hours is clearly not practical for most busyurology practices. It should not be considered good care to leavepatients on the operating table for this extended period.
Michael KozminskiSt. Joseph, Missouri
The authors present a nice technique for diaphragmatic repair andaspiration of the associated pneumothorax following diaphragmaticinjury during laparoscopic radical nephrectomy. It is not surprisingthat these injuries can occur during laparoscopic nephrectomy ofother upper retroperitoneal/abdominal laparoscopic procedures. Ihave created 2 such injuries during laparoscopic surgery. My tech-nique of repair was not as technically neat as that reported by theauthors but was equally successful in both cases. Laparoscopic tech-niques for the repair of diaphragmatic injury during laparoscopyhave been reported previously.1,2 However, in this report the injurywas not recognized immediately but only after the anesthesiologistinformed the surgeons of elevated end inspiratory pressures and theoperative field was inspected at the conclusion of the procedure. Withthe excellent visualization afforded by the laparoscope, it would behoped that such an injury would be recognized immediately. If not, atleast this report demonstrates that the good practices of communi-cation with the anesthesia team and careful inspection of the oper-ative field can serve to identify otherwise unsuspected problemsduring laparoscopy.
J. Stuart WolfSection of UrologyUniversity of MichiganAnn Arbor, Michigan
1. Naito, S., Uozumi, J., Shimura, H. et al: Laparoscopic adrenalectomy:review of 14 cases and comparison with open adrenalectomy. En-dourol, 9: 491, 1995
2. Seiler, C., Glattli, A., Metzger, A. et al: Injury to the diaphragmand its repair during laparoscopic cholecystectomy. Surg En-dosc, 9: 193, 1995
REPLY BY AUTHORS
Diaphragmatic injuries are usually recognized intraoperatively.However, they may initially be missed, highlighting the importanceof communication between the anesthesiologist and surgeon in diag-nosing this type of injury. It must be noted that a junior member ofour faculty was undertaking this case. As such, operative time wasprolonged due to the experience level of the surgeon and the timerequired to consult a more experienced laparoscopic urological sur-geon to help with the repair. Operative time is directly related toexperience. Review experience of a single surgeon at our institutionreveals a decrease in the average operative time for laparoscopicradical nephrectomy from 302 to 206 minutes. Operative times arenow equivalent to those reported with open nephrectomies per-formed at our institution during the same period. Despite the mod-erately longer operative time (270 minutes) and complication ofdiaphragmatic injury, the patient had minimal postoperative dis-comfort and rapid recovery, and thus maintained the benefits of alaparoscopic approach.
DIAPHRAGMATIC INJURY DURING LAPAROSCOPIC NEPHRECTOMY1204
