OPERATIONS PERFORMED:
1. Exploration of the left kidney and left partial nephrectomy with frozen section.
2. Chest tube insertion by Dr. Doe for left pleural intraoperative injury.
OPERATION IN DETAIL: The patient was premedicated and brought to the operating room. General anesthesia was extremely difficult and details can be seen from the anesthesia chart. After intubation, finally, and insertion of A-line and central line, a Foley catheter was inserted into the bladder, 16 French. The patient was then turned to a right lateral position, and after proceeding with the proper kidney position, the part was prepped with Betadine and draped in a sterile manner. The incision selected was the 11th rib bed, on account of the size of the patient and the need for a possible access to the upper pole lesion. The incision was carried from the renal angle and along the rib, all the way anteriorly to the lateral border of the rectus muscle. The incision was deepened and all the muscular layers were incised. The posterior part of the rib was excised with the help of a periosteum elevator, rib raspatory, rib shear and followed by the filing of the cut end of the rib. During this process, a small, inadvertent, opening was made in the pleura which was recognized. This was closed immediately with 3-0 chromic catgut.
Further dissection was carried out into the depth of the wound. The psoas muscle was identified in the Gerota fascia and front of the same was opened to reveal the kidney. The kidney was then carefully dissected and mobilized all around. Since the lesion on the superior pole was seen to be a cyst and also in close apposition to the adrenal gland, it was decided not to excise the cyst at this point. The contents of the cyst was seen to be clear straw-colored fluid. There was no neovascularity.
Accordingly, the dissection now carried out towards the lower pole. The ureter was visualized and looped around, after which the inferior pole was completely mobilized. Further dissection was proceeded down to the medial aspect where all the above vascular structures were seen and looped around with vessel loops.
At this point, the tumor sections were evident, and therefore, after careful delineation of the same, an argon beam coagulator was used to perform a partial nephrectomy for the lower pole which included both the above tumors. The pathology specimen was sent for frozen section and, as per the pathologist, the margin of the tissue in the depth of the wound was only 1 mm. Therefore, a second section was obtained to proceed even deeper after clamping the renal artery with a vascular clamp. Eight minutes of vascular clamping was carried in this time. Specimen was sent for pathology and the bleeding points were under run with figure-of-eight sutures of 4-0 chromic. The argon beam coagulator was now used to carefully coagulate the rest of the kidney. The FloSeal was now applied onto the cut surface of the kidney and Surgicel was also applied within the same. The capsule which had been reflected beyond the need for the nephrectomy was now brought down and covered over the defect successfully. The clamp was removed and no active bleeding was seen from the nephrectomy site. The pathology report was in the meantime obtained and confirmed as being benign for the second sample and therefore the closure of the lateral abdominal wall was carried out using a #1 PDS in a continuous manner with a looped suture. Fluid was now poured into the posterior part of the wound and some escape of air was seen upon hyperinflation of the lung.
Therefore, an intraoperative STAT consultation was obtained with Dr. Doe, cardiothoracic specialist, and as per his advice, a chest tube was inserted by him and the details will be dictated by him. After closure of the muscular layer, the subcutaneous tissue was closed, after which the skin was closed with staples. The procedure was considered complete, the patient was given proper dressing and the patient was taken to the recovery room with a chest tube. Postoperative chest x-ray was advised.
Total operating time was 2 hours 30 minutes. Blood loss was about 200 mL. The patient withstood surgery and anesthesia well and did not receive any transfusion or Cell Saver return.
