WCET 2024: Managing Complications During Robotic Surgery

(UroToday.com) The 2024 World Congress of Endourology and Uro-Technology Conference in Seoul, Korea, continued its tradition of delivering cutting-edge educational sessions with Wednesday afternoon’s SURS plenary, which focused on the topic of managing complications during robotic surgery. The session was led by Dr. Rene Sotelo, who emphasized the importance of reviewing surgical complications as a means of continuous improvement and enhancing patient outcomes.

Dr. Sotelo opened the session by addressing the complications related to patient positioning during robotic surgery. He presented data showing the incidence of serious complications such as compartment syndrome (0.28%), rhabdomyolysis (0.67-0.95%), and ischemic optic neuropathy (0.05%), stressing the need for careful monitoring and preventive strategies.

One of the first scenarios discussed involved a patient with a history of significant prior abdominal surgery scheduled for robotic lower urinary tract surgery. The panel recommended an extraperitoneal approach to minimize complications. However, if a transperitoneal approach was necessary, they suggested using Palmer’s point for Veress needle access or considering an open port placement. Dr. Sotelo also highlighted a case where a camera port accidentally penetrated the small bowel, underscoring the importance of careful port placement and prompt recognition of complications. In this case, the bowel was repaired primarily with general surgery consultation.

In another striking case, a robotic arm inadvertently passed through a patient’s colostomy. The panel recommended immediate removal of the robotic arm and consultation with general surgery, which led to a revision of the colostomy.

Dr. Sotelo presented a case involving severe bleeding from the right iliac artery. The panel emphasized the need for swift action—compressing the artery and securing both proximal and distal control. They recommended primary repair using a non-absorbable monofilament suture like Prolene and advised involving a vascular surgeon for optimal management.

The discussion then moved to upper tract kidney complications, where Dr. Sotelo showcased a case involving an artery found anterior to the vein, initially mistaken for the renal artery but later identified as the superior mesenteric artery (SMA). This case served as a reminder of the importance of thorough exposure and confirmation of vascular anatomy during surgery. One of the panelists recalled a similar experience where the vascular surgery team successfully reimplanted the SMA stump into the aorta, offering a potential solution for such challenging situations. Dr. Sotelo mentioned that if there is not enough length to reimplant the SMA in the aorta, the proximal stump of the true renal artery may be considered.

Stapler use during robotic surgery was another key topic. Dr. Sotelo cautioned that the presence of a hemolock could interfere with the stapler’s function, leading to complications. He demonstrated a case where a stapler failed to open after cutting, but because it was placed distally enough, hemolocks could be applied proximally before the stapler was released. This example highlighted the need for meticulous attention when using staplers in robotic surgery.

Dr. Sotelo also addressed complications specific to partial nephrectomy, including ureteral injury, tumor spillage, and lower pole artery injury. He presented a case of accidental proximal ureter transection during partial nephrectomy, where the panel recommended primary repair with wide debridement to expose healthy tissue given the use of cautery. In cases of tumor spillage due to excessive traction, the panel advised suctioning tumor material and thoroughly washing the abdomen with sterile water. For lower pole artery injury, they recommended primary arterial repair and suggested using indocyanine green (ICG) to assess the extent of the damage.

The session concluded with a discussion on nerve injuries, particularly obturator nerve injuries, which can manifest as leg movement when the nerve is transected or clipped. Dr. Sotelo advised that if a Weck clip is involved, it should be removed promptly to prevent further complications. If transected, the obturator nerve could be repaired primarily, but adequate exposure of the distal and proximal end of the transected nerve is essential.

Dr. Sotelo’s session provided invaluable insights into the management of complications during robotic surgery, offering practical advice and highlighting the importance of vigilance, quick decision-making, and collaboration with other surgical specialties. As robotic surgery continues to evolve, these discussions play a crucial role in improving surgical outcomes and patient safety.

Presented by:

Moderator: Rene Sotelo, MD, Keck School of Medicine of USC

Written by: Bruce Gao, MD, FRCSC, Endourology Fellow, Department of Urology, University of California Irvine, @b_gao on Twitter during the 2024 World Congress of Endourology and Uro-Technology (WCET) Annual Meeting, August 12 -16, 2024, Seoul, South Korea