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Journal of Pediatric Surgery (2011) 46, E13–E15

Dangerous deliveries: lessons learned duringretroperitoneal specimen retrievalM. Upadhyaya a,⁎, L.S. Sundararajan b, M.N. Woodward a

aDepartment of Paediatric Surgery, Bristol Children's Hospital, BristolbDepartment of Paediatric Surgery, University Hospital of Wales, Cardiff

Received 1 September 2010; revised 18 October 2010; accepted 29 October 2010

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Key words:Pediatric;Retroperitoneoscopy;Laparoscopy;Complications;Specimen retrieval

Abstract Laparoscopy is now a standard technique in pediatric surgery and urology. Uniquecomplications have been reported during port/instrument insertion and dissection, often relating toissues of visibility or working space. Complications during specimen retrieval are currently unreported.We describe our experience of 2 serious complications occurring during attempted retrieval of aspecimen through a port site at the end of the laparoscopic procedure.© 2011 Elsevier Inc. All rights reserved.

Laparoscopic retroperitoneal surgery was popularized byGaur [1] following the publication of an innovativetechnique for developing the retroperitoneal space. Sincethen, a number of authors have published series showing thatretroperitoneoscopic surgery in adults is generally safe andeffective, although serious complications may rarely occur[2]. Similarly, there are an increasing number of reportsdocumenting the safety and efficacy of this approach inpediatric urology [3-8]. Most of the complications describedin the pediatric literature relate to the creation of theretroperitoneal space and port insertion or to the dissection[5,6], whereas complications related to specimen retrievalhave not been described. Our retrospective case reporthighlights 2 major gastrointestinal complications thatoccurred during specimen retrieval.

⁎ Corresponding author.E-mail address: manasviu@hotmail.com (M. Upadhyaya).

022-3468/$ – see front matter © 2011 Elsevier Inc. All rights reserved.oi:10.1016/j.jpedsurg.2010.10.031

1. Case reports

1.1. Case1

A 16-year-old girl underwent a laparoscopic rightnephrectomy for a nonfunctioning, scarred kidney (post-pyonephrosis). A 3-port, standard retroperitoneal dissectionwas performed. Dense vascular adhesions were apparent atsurgery. The renal vessels were individually dealt with aswas the ureter. The posterosuperior incision at the renal anglewas enlarged to deliver the specimen, but several initialattempts at grasping the kidney with forceps were unsuc-cessful. At a subsequent attempt, the ascending colon wasinadvertently grasped and delivered into the wound. At thispoint, the surgery was converted to an open procedure, andthe renal specimen was retrieved. The ascending colon wasfound to have 2 perforations over a length of 6 cm. A primaryresection and anastomosis of the injured colonic segmentwas performed. The child made an uneventful recovery andremained well at follow-up at 6 months. The histology

E14 M. Upadhyaya et al.

showed chronic inflammation but no evidence of xantho-granulomatous pyelonephritis.

1.2. Case 2

A 3-year-old boy underwent retroperitoneoscopic rightnephrectomy for nonfunctioning right kidney in associationwith multiple renal calculi. Initial dissection was difficult asa result of inflammation around the pedicle. After vesseldivision and mobilization of kidney, the specimen wasplaced in an endopouch. An unrecognized puncture wasmade in the retrieval bag during attempts at instrumentmorcellation. Following this, the second part of duodenumwas grasped and avulsed into the wound. At this point, theport sites were linked to create an incision for laparotomy.Full-thickness damage to the lateral aspect of the secondpart of the duodenum was identified, with mucosal avulsionof the medial duodenum adjacent to pancreas but an intactseromuscular layer and an undamaged common bilesurrounded by an island of mucosa. The duodenal endswere mobilized and anastomosed around the common bileduct. In the postoperative period, the child had transientpancreatitis and some delay in onset of duodenal function,but otherwise recovered well. Subsequent histologicexamination of the kidney showed chronic inflammation,but again no evidence of xanthogranulomatous pyelone-phritis. On follow-up, now as far as 3 years postprocedure,he has normal ultrasound scans of bile ducts, liver, andcontralateral kidney.

2. Discussion

Pediatric laparoscopic surgery has evolved from being adiagnostic tool to one used for ablative purposes and nowincreasingly for reconstructive surgery [8], with mostpediatric procedures following on from those performedin adults. Retroperitoneoscopy is mainly used in the field ofurology for renal/upper urinary tract surgery and may alsobe used for adrenalectomy and retroperitoneal lymph nodebiopsy. Retroperitoneoscopy has a steep learning curve,with limited working space and limited space for portplacement [6].

Gastrointestinal complications relating to dissectionduring retroperitoneoscopy have been reported in adultpractice [2,9,10], but infrequently by pediatric surgeons[3,7]. In one large adult series, the authors looked at 600retroperitoneoscopic procedures and recorded 2 intestinalinjuries and a pancreatic fistula. They concluded that withappropriate training, the retroperitoneal approach could besafe, simple, reproducible, and effective. A second series of404 adult patients included one serosal tear of the duodenum[10]. In another large series of 200 adult patients operated onby 2 surgeons, there were 2 pancreatic fistulas. The authorshighlighted the fact that there was a steep learning curve and

suggested that in their experience, it would take about 50procedures to overcome this [9]. Importantly, they showedthat all parameters (complication rates, operative times, andconversion rates) were all lower with their second surgeon,who had the opportunity to learn from the experience of thefirst [9]. The lead surgeon for case 1 encountered thisproblem having performed 19 previous retroperitonealprocedures with one prior conversion caused by inability tocreate an adequate retroperitoneal space. The lead surgeonfor case 2 experienced this complication having performed60 retroperitoneal procedures previously, and this remainsthe only case requiring conversion in a series of 101 to date.Finally, in a recent review article, Schwartz et al reported anincidence of 0.65% for bowel injuries from a total of morethan 14,000 adult cases, with a mortality risk in unrecognizedinjuries [11].

In the pediatric literature, only 2 duodenal injuries havebeen described during the dissection for upper poleheminephrectomy, one in a series of 24 procedures [6] andanother in a series of 42 procedures [7]. Because these aresmall series typical of pediatric practice, there is an apparenthigher rate of a serious gastrointestinal complication.

In the adult literature, complications associated withspecimen retrieval include internal specimen loss, specimenrupture, wound infection, tumor seeding of site, and visceralinjury caused by entrapment during extraction [12]. Wehave not identified other pediatric series where problemsduring specimen retrieval have been specifically mentioned,but this may represent underreporting. In our first patient,the renal tissue was fairly bulky and could not readily beremoved by port site enlargement. Use of a bag to retrievethe specimen could have avoided repeated attempts atretrieval (with loss of CO2 in the retroperitoneal spaceleading to inadequate vision) and subsequent colonic injury.In the second case, the injury happened as a result of anunrecognized perforation of the bag by an instrument, at thepoint when the surgical team members were beginning torelax at the end of a difficult nephrectomy, reemphasizingthe fact that the operation cannot be considered to be overuntil the specimen has been retrieved, all wounds have beenclosed, and the surgeon has “degloved.”

In summary, we report 2 patients who had serious visceralinjury during retrieval of a kidney at the end of aretroperitoneoscopic nephrectomy. Awareness of thesecomplications will hopefully help other surgeons avoid them.

References

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[2] Liapis D, de la Taille A, Ploussard G, et al. Analysis of complicationsfrom 600 retroperitoneoscopic procedures of the upper urinary tractduring the last 10 years. World J Urol 2008;26:523-30.

[3] Kim C, McKaya K, Docimoa SG. Laparoscopic nephrectomy inchildren: systematic review of transperitoneal and retroperitonealapproaches. Urol 2009;73:280-4.

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[7] El-Ghonemi A, Valla JS, Steyaert H, et al. Laparoscopic surgery via aretroperitoneal approach in children. J Urol 1998;160:1138-41.

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[9] Rassweiler JJ, Seemann O, Frede T, et al. Retroperitoneoscopy:experience with 200 cases. J Urol 1998;160:1265-9.

[10] Meraney AM, Samee AA, Gill IS. Vascular and bowel complicationsduring retroperitoneal laparoscopic surgery. J Urol 2002;168:1941-4.

[11] Schwartz MJ, Faiena I, Cinman N, et al. Laparoscopic bowel injury inretroperitoneal surgery: Current incidence and outcomes. J Urol2010;184:589-94.

[12] Deizel DJ. Principles of specimen retrieval. In: Scott-ConnerCEH, editor. The SAGES manual: fundamentals of laparoscopy,thoracoscopy, and GI endoscopy. 2nd ed. Springer; 2006. p. 76.