Lift the small bowel upward to allow access to the retroperi-toneum. Incise the peritoneum over the aorta, above the inferior mesenteric artery (Fig. 5.3a). A large perirenal haematoma may obscure the correct site for this incision. If this is the case, look for the inferior mesenteric vein and make your incision medial to it. Once on the aorta, the inferior vena cava may be exposed, then the renal veins and the renal arteries. Pass slings around all of these vessels so you can control bleeding by compressing the renal artery and vein (Fig. 5.3b).
The kidney can now be exposed by mobilising the colon. Divide the white line of Toldt lateral to the ascending (right side) or descending (left side) colon and pull the colon upward to expose the kidney, which will be surrounded by a large haematoma.
Bleeding may be reduced by applying pressure to the vessels via the slings. Control bleeding vessels within the kidney with 4/0 Vicryl or monocryl sutures. Close any defects in the collecting system with 4/0 Vicryl. If the sutures cut out, place a strip of Surgicel over the site of bleeding, place the sutures through the capsule on either side of this, and tie them over the Surgicel. This will stop them from cutting through the friable renal parenchyma.
Iatrogenic Renal Injury: Renal Haemorrhage After Percutaneous Nephrolithotomy
Significant renal injuries can occur during percutaneous nephrolithotomy (PCNL) for kidney stones. This is the surgical equivalent of a stab wound and serious haemorrhage (necessitating some form of intervention) occurs in approximately 1% of cases (Martin et al. 2000).
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Figure 5.3. a: The surgical approach for control of the renal vascular pedicle. b: Gaining vascular control with slings around the renal veins and artery.
Bleeding during or after a PCNL can occur from vessels in the nephrostomy track itself, from an arteriovenous fistula or from a pseudoaneurysm that has ruptured. Track bleeding will usually tamponade around a large-bore nephrostomy tube. Traditionally persistent bleeding through the nephrostomy tube is managed by clamping the nephrostomy tube and waiting for the clot to tamponade the bleeding. While this may control bleeding in some cases, in others a rising or persistently elevated pulse rate (with later hypotension) indicates the possibility of persistent bleeding and is an indication for renal arteriogra-phy and embolisation of the arteriovenous fistula or pseudo-aneurysm (Fig. 5.4). Failure to stop the bleeding by this