Intraoperative Guidelines

When consulted for an intraoperative injury, there is often a sense of urgency to correct an iatrogenic injury immediately. However, in most cases a urologic injury is not life-threatening. One would never perform an elective operation without reviewing the patient's history and we should have the same standards when consulted for an iatrogenic injury. Depending on the situation, a brief conversation with the surgeon of record, a review of the chart, or a conversation with the patient's family maybe appropriate. Knowledge about preoperative renal function or prior pelvic surgery could significantly alter one's reconstructive plans. In order to make the surgical experience as familiar and comfortable as possible, one should order special instruments or re tractors early. Rather than trying to make do with what's available, optimize the surgical situation. Should bleeding be a problem, packing the wound with laparotomy pads can control the situation while preparation for repair is underway. If the incision is one with which you are not familiar, then take some time to familiarize yourself with the anatomy or extend the incision before making any moves. Since many injuries occur at the limits of a surgeon's exposure, extending the incision also helps one look for unrecognized concomitant injuries. Stage the injury completely. Assess the blood supply of the structure you are repairing. This is especially true in the case of a ureteral injury. If the ureter has been devascularized as well as transected it will alter your plan for repair. Additionally, while we recommend making the operative situation as much like an elective case as possible, this cannot always be done -one may have to modify the operative plan in light of the limitations of the operating room. For instance, whereas one may feel most comfortable staging a ure-teral injury by performing cystoscopy and retrograde pyelograms, patient positioning or the orientation of the operating table may prohibit cystoscopy and/or fluoroscopy. Finally, consider the patients overall condition and the limitations of the operative setting. While it might be possible to reconstruct an injury in a single setting, it may be more judicious to temporize drainage of the urinary system until a later date if the patient is unstable.

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