Operative Findings and Reconstruction

The overall exploration rate for blunt trauma is less than 10% (Baverstock et al. 2001; McAninch et al. 1991) and may be even lower in the future as more centers adopt a very conservative approach to the management of these patients (Rogers 20040; Hammer 2003). The goal of renal exploration following renal trauma is control of hemorrhage and renal salvage. Most experienced authors suggest the transperitoneal approach (McAninch et al. 1991; Robert et al. 1996; Nash et al. 1995). Access to the renal vascular pedicle is best obtained through the posterior parietal peritoneum, which is incised over the aorta, j ust medial to the inferior mesenteric vein.

Temporary vascular occlusion before opening of Ge-rota's fascia is a safe and effective method during exploration and renal reconstruction (Gonzalez 1999). It tends to lower blood loss and the nephrectomy rate, and appears not to increase postoperative azotemia or mortality (Atala et al. 1991). Renal reconstruction is feasible in most cases (Fig. 15.4.14-15.4.17).

The overall rate of patients who have a nephrectomy during exploration is around 13%, usually in patients with higher rates of shock, injury severity scores, and

Fig. 15.4.15. Extroperitoneal incision over aorta to expose renal vessels
Fig. 15.4.14. Exploration and reconstruction of injured kidney. Fig. 15.4.16. Exposure and placement of vessel loops around Midline incision (Fig. 15.4.14-17 © Hohenfellner 2007) renal vessels
Fig. 15.4.17. Exposure of renal fossa after vascular control is achieved

mortality rates (Nash et al. 1995). The mortality in this group of patients is associated with the overall severity of the injury and is not a consequence of the renal injury itself (DiGiacomo et al. 2001). In gunshot injuries caused by a high-velocity bullet, reconstruction maybe difficult and nephrectomy may be required (Ersay and Akgun 1999).

Renorrhaphy is the most common reconstructive technique. Partial nephrectomy is required when nonviable tissue is detected. Watertight closure of the collecting system if open maybe desirable, although some experts merely close the parenchyma over the injured collecting system with good results. If renal capsule is not preserved, an omental pedicle flap or perirenal fat bolster may be used for coverage (McAninch et al. 1990). In a review by Shekarriz et al., the use of fibrin sealant in traumatic renal reconstruction proved to be helpful (Shekarriz et al. 2002). Newly developed hema-static agents, which have proven useful in open and laparoscopic partial nephrectomy(Richter et al. 2003), may also be helpful but are largely unproven. In all cases, drainage of the ipsilateral retroperitoneum is recommended to provide an outlet for any temporary urinary leak. Renal wrapping with absorbable mesh is valuable in organ preservation in cases of multiple lacerations (Kluger et al. 1999).

All penetrating injuries are explored via a transabdominal approach for preserving the kidney if feasible, exploring the contralateral kidney, and controlling other abdominal injuries, since in many cases preoperative evaluation is insufficient (Kuvezdic et al. 1996). Patients with hematuria undergoing an exploration following a gunshot wound should be evaluated for the entire urinary tract. The kidney should be explored by opening Gerota's fascia in the presence of active bleeding, an expanding perirenal hematoma, or urine leak. Inspection of the hilum and proximal ureter but no incision of Ge-rota's fascia is mandatory in stable hematomas. Hilar control is achieved prior to renal exploration only in hemodynamically stable patients; otherwise the kidney should be immediately delivered to the laparotomy wound and active hemorrhage be controlled by manual compression. In cases of uncertainty on the adequacy of the urinary tract exploration, intravenous dye (methylene blue or indigo carmine) should be administered to unmask suspected injuries (Velmahos and De-giannis 1997).

Renovascular injuries are uncommon. They are associated with extensive associated trauma and increased peri- and postoperative mortality and morbidity. Knudson et al. (2000) found that after blunt trauma, repair of Grade 5 vascular injury was seldom if ever effective. Repair may be attempted in those very rare cases in which there is a solitary kidney or the patient has sustained bilateral injuries (Tillou et al. 2001). In all other cases, nephrectomy appears to be the treatment of choice (el Khader et al. 1998a).

Arteriography with selective renal embolization for hemorrhage control is a reasonable alternative to lapa-rotomy, provided no other indication for immediate surgery exists (Hagiwara et al. 2001). The rate of successful hemostasis by embolization is reported to be identical in blunt and penetrating injuries (Velmahos et al. 2000; Sofocleous et al. 2005).

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