1. Ureteral injuries during laparoscopic colon surgeries Causes and Prevention Ureteral injuries during laparoscopic colon surgeries Causes and Prevention Morris E. Franklin Jr, MD., F.A.C.S. Director Texas Endosurgery Institute Karla Russek, MD. Research Fellow, Texas Endosurgery Institute Morris E. Franklin Jr, MD., F.A.C.S. Director Texas Endosurgery Institute Karla Russek, MD. Research Fellow, Texas Endosurgery Institute MISS, 2011

3. The pessimist sees difficulty in every opportunity. The optimist sees the opportunity in every difficulty. Winston Churchill The pessimist sees difficulty in every opportunity. The optimist sees the opportunity in every difficulty. Winston Churchill

4. Increasing numbers of ureteral injuries in pelvic surgery From 1986-2006, 72 ureteral injuries found –Only 7 during 1986-1992 The actual incidence is 0.5% to 3% 53% in lap surgery – 33% open surgery 64% after gyn procedures, 25% gen surgery 79% delayed diagnosis ( 6 days ): Cautery? From 1986-2006, 72 ureteral injuries found –Only 7 during 1986-1992 The actual incidence is 0.5% to 3% 53% in lap surgery – 33% open surgery 64% after gyn procedures, 25% gen surgery 79% delayed diagnosis ( 6 days ): Cautery? Cholkeri-Singh et al. Laparoscopic ureteral injury and repair. J Minim Invasive Bynecol, 2007 14(3) 356-61 Teija, PS, Illka P, Marrku S, et al. Increasing numbers of ureteric injuries after the introduction of laparoscopic surgery. Scand J of Uro and Nephr, 2008, 42: 422-427 Cholkeri-Singh et al. Laparoscopic ureteral injury and repair. J Minim Invasive Bynecol, 2007 14(3) 356-61 Teija, PS, Illka P, Marrku S, et al. Increasing numbers of ureteric injuries after the introduction of laparoscopic surgery. Scand J of Uro and Nephr, 2008, 42: 422-427

5. IntroductionIntroduction Most iatrogenic lesions occur in the lower ureter (at or below pelvic rim) Surgical ureteral injuries are of five types: –Laceration –Ligation –Crush –Devascularization –Electrical burns Most iatrogenic lesions occur in the lower ureter (at or below pelvic rim) Surgical ureteral injuries are of five types: –Laceration –Ligation –Crush –Devascularization –Electrical burns Dowling RA, Corriere JN Jr, et al. Iatrogenic ureteral injury. J Urol 1986; 135:912-5 Guerriero WG. Ureteral injury. Urol Clin North Am 1989; 16: 237-48 Dowling RA, Corriere JN Jr, et al. Iatrogenic ureteral injury. J Urol 1986; 135:912-5 Guerriero WG. Ureteral injury. Urol Clin North Am 1989; 16: 237-48

6. Etiology or injury Most common causes of injuries: Severe adhesions Obesity Incorrect dissection plane Bundling Misidentification of anatomy Tumor encasement Experience lessens likelihood but does not eliminate it Most common causes of injuries: Severe adhesions Obesity Incorrect dissection plane Bundling Misidentification of anatomy Tumor encasement Experience lessens likelihood but does not eliminate it

7. Reported Data The insertion of preoperative ureteral catheters has been advocated as a means of preventing ureteral injury Complications as a direct result of the catheter insertion have been described –UI, inability to advance stent, OR time IS IT WORTH IT ROUTINELY? The insertion of preoperative ureteral catheters has been advocated as a means of preventing ureteral injury Complications as a direct result of the catheter insertion have been described –UI, inability to advance stent, OR time IS IT WORTH IT ROUTINELY? Bothwell, W; Bleicher, R: Dent, T. Prophylactic ureteral catheterization in colon surgery. Dis Colon Rectum 1994; 37: 330-334

8. Reported Data 150 patients underwent placement of lighted ureteral stents before lap surgery No ureteral injuries Average time from placement of the stents to start of the operation was 5 minutes 150 patients underwent placement of lighted ureteral stents before lap surgery No ureteral injuries Average time from placement of the stents to start of the operation was 5 minutes JSLS. 2009 Apr-Jun;13(2):139-41.Protect the ureters.Redan JA, McCarus SD.

9. Reported Data The cost of the stents is $205 OR time past the first half hour ranges from $560 to $716 for each additional half hour Their conclusion: Extremely useful procedure that can reduce ureter injury to 0 The cost of the stents is $205 OR time past the first half hour ranges from $560 to $716 for each additional half hour Their conclusion: Extremely useful procedure that can reduce ureter injury to 0 JSLS. 2009 Apr-Jun;13(2):139-41.Protect the ureters.Redan JA, McCarus SD.

10. Lighted stents

11. ConsequencesConsequences Injuries that are recognized and repaired have low incidence of short and long term complications Unrecognized and unrepaired injuries can result in prolonged hospitalization, sepsis, loss of kidney, death Injuries that are recognized and repaired have low incidence of short and long term complications Unrecognized and unrepaired injuries can result in prolonged hospitalization, sepsis, loss of kidney, death Franklin ME, Plascencia, G, et al. Submitted for publication

12. Mandatory steps for lap colectomy Learn anatomy and methods to recognize it Learn basics, intermediate and advanced skills Learn how to handle tissue: colon, mesentery, adjacent organs, vessels Learn anatomy and methods to recognize it Learn basics, intermediate and advanced skills Learn how to handle tissue: colon, mesentery, adjacent organs, vessels

13. Mandatory steps for lap colectomy Dissect and identify all structures prior to division Learn more than one technique of dissection, vessel control and anastomosis The key to recognizing structures is to know anatomic relationships Dissect and identify all structures prior to division Learn more than one technique of dissection, vessel control and anastomosis The key to recognizing structures is to know anatomic relationships

14. Technical pearls Use gravity Frequent use of: –Trendelenburg position –Left and right tilt Use blunt instruments Use energy sparingly Use gravity Frequent use of: –Trendelenburg position –Left and right tilt Use blunt instruments Use energy sparingly

15. Technical pearls Blunt dissection is always better than sharp dissection unless one can actually see through the tissue being dissected Energy sources used sparingly Key to preventing transection of ureter Blunt dissection is always better than sharp dissection unless one can actually see through the tissue being dissected Energy sources used sparingly Key to preventing transection of ureter

16. Texas Endosurgery Institute Experience In over 1800 colon surgeries 5 ureteral injuries + 2 intentional resection and anastomosis for tumor invasion Recognized and repaired intraoperatively in 6 out of 7 In over 1800 colon surgeries 5 ureteral injuries + 2 intentional resection and anastomosis for tumor invasion Recognized and repaired intraoperatively in 6 out of 7

17. ID Ureter

18. ID ureter, vascular control of IMA and IMV

19. Tips to prevent ureteral injuries Know anatomy Adequate dissection Constant visualization of ureter from multiple directions Be SURE it’s ureter: Wait and see the peristalsis After vascular control Check ureter again! Know anatomy Adequate dissection Constant visualization of ureter from multiple directions Be SURE it’s ureter: Wait and see the peristalsis After vascular control Check ureter again!

20. Be aware of possible anomalies

22. Uh oh

24. Texas Endosurgery Institute Experience –Out of the 5 ureteral injuries: –4 Diagnosed and repaired laparoscopically –No postoperative complications in any of the patients –Out of the 5 ureteral injuries: –4 Diagnosed and repaired laparoscopically –No postoperative complications in any of the patients

25. Be prepared…. Check ureters after all dissection is done Be ready to repair ureter in necessary case –4-0 Vicryl Don’t use cautery near ureters Place stents Use Drains Check ureters after all dissection is done Be ready to repair ureter in necessary case –4-0 Vicryl Don’t use cautery near ureters Place stents Use Drains

26. Colon Cancer and Ureter Invasion

27. StatisticsStatistics Until 50 years ago, colorectal carcinoma infiltrating surrounding tissue was considered nonresectable Most of the time the diagnosis is made in the OR Until 50 years ago, colorectal carcinoma infiltrating surrounding tissue was considered nonresectable Most of the time the diagnosis is made in the OR

28. Ureter invasion by colorectal cancer Dtsch Med Wochenschr. 1994 Jun 3;119(22):791-5.[Routine intravenous urography before colorectal resections? Printz H, Greger B, Nies C, Rothmund M. Preoperative intravenous urography was performed in 279 patients 9 patients showed ureter invasion

29. Ureter encasement

30. Conclusions Although technically more challenging, laparoscopic colectomy is feasable and should be performed Understanding of anatomy is mandatory If ureter encased, preoperative stent placement is good option Although technically more challenging, laparoscopic colectomy is feasable and should be performed Understanding of anatomy is mandatory If ureter encased, preoperative stent placement is good option

31. ConclusionsConclusions Mandatory to have intracorporeal suturing skills for repair Don’t hesitate to convert ? Advisability of preoperative stents in all patients Mandatory to have intracorporeal suturing skills for repair Don’t hesitate to convert ? Advisability of preoperative stents in all patients

32. ConclusionsConclusions ALWAYS check ureters after dissection! –It is easier to repair the ureter in the same surgery! ALWAYS check ureters after dissection! –It is easier to repair the ureter in the same surgery!

33. “ ” “ Learn what is true in order to do what is right. ” Thomas Henry Huxley

34. www.texasendosurgery.com