What is the next step after a 3cm area of the kidney becomes ischemic during left laparoscopic adrenalectomy?

From the Guidelines

During a left laparoscopic adrenalectomy, if a 3 cm area of the upper medial pole of the kidney becomes pale after complete mobilization of the adrenal gland, the next step should be to immediately assess and restore blood flow to the affected renal tissue. This likely represents inadvertent compromise of a segmental renal artery branch during dissection. The surgeon should first identify the vascular injury, then either remove any clips or cautery that may be occluding the vessel, or perform a vascular repair if transection has occurred. Warm ischemia time is critical, as the kidney can only tolerate about 30 minutes before permanent damage occurs, as indicated by the KDIGO Executive Conclusions 1. Intraoperative Doppler ultrasound can help confirm restoration of blood flow. If blood flow cannot be restored, partial nephrectomy of the affected segment may be necessary, though this is rarely required, and complete surgical excision by partial nephrectomy is a standard of care and should be strongly considered 1. The surgeon should also consider administering intravenous fluids to maintain renal perfusion and potentially mannitol (12.5-25g IV) to promote diuresis and reduce potential ischemic injury. This complication occurs because the adrenal and renal vasculature are in close proximity, and careful attention to anatomical planes during dissection is essential to prevent such injuries. Some key points to consider in this situation include:

• Identifying the vascular injury and restoring blood flow as quickly as possible
• Using intraoperative Doppler ultrasound to confirm restoration of blood flow
• Considering partial nephrectomy if blood flow cannot be restored
• Administering intravenous fluids and potentially mannitol to reduce potential ischemic injury
• Being aware of the limited warm ischemia time and taking steps to minimize it, as prolonged warm ischemia (>25–30 min) could cause an irreversible ischemic insult to the surgically treated kidney 1.

From the Research

Intraoperative Management

• During a left laparoscopic adrenalectomy, a 3 cm area of the upper medial pole of the kidney becomes pale, which may indicate ischemia or damage to the kidney tissue 2.
• The next step would be to assess the extent of the damage and determine the best course of action to preserve kidney function.

Preservation of Kidney Function

• Studies have shown that laparoscopic partial nephrectomy can preserve renal function better than laparoscopic radical nephrectomy 3, 4.
• The use of robot-assisted partial nephrectomy has also been shown to provide better preservation of split renal function compared to laparoscopic partial nephrectomy 5.
• The preservation of kidney function is crucial to prevent chronic renal insufficiency, and every effort should be made to minimize damage to the kidney tissue.

Adrenalectomy and Kidney Function

• Adrenalectomy should not be routinely performed during partial nephrectomy, even for upper pole tumors, unless there is a suspicious adrenal lesion or invasion of the adrenal gland is suspected intraoperatively 6.
• The decision to perform an adrenalectomy should be based on the individual patient's condition and the presence of any suspicious adrenal lesions.

Surgical Techniques

• Laparoscopic adrenalectomy is a safe and effective procedure for suitable patients with adrenal masses, with acceptable complications and low conversion rates 2.
• The choice of surgical technique, such as laparoscopic or robot-assisted partial nephrectomy, should be based on the individual patient's condition and the surgeon's expertise.