Dr. Wolf, a member of the Urology Times Editorial Council, is professor and associate chair for clinical integration and operations, department of surgery and perioperative care, Dell Medical School at the University of Texas at Austin.
Postoperative hemorrhage can and will occur in a minority of patients, despite the most careful of laparoscopic procedures.
As experience with laparoscopic renal and adrenal surgery increases, it has become apparent that some complications present and are best managed differently from those following open surgery. The treatment of postoperative hemorrhage is one such condition.
The post-laparoscopy patient has suffered less tissue trauma than has the patient undergoing open surgery, however. The natural history of and the body's response to postoperative hemorrhage may differ, as well.
Supportive care might be more appropriate than re-operation in non-critical circumstances that prompt re-exploration after open surgery. Our experience at the University of Michigan suggests that surgical re-exploration is usually not required to address postoperative hemorrhage in the setting of laparoscopic renal and adrenal surgery.
Scope of the problem
We reviewed 911 upper retroperitoneal laparoscopic operations performed from August 1996 through November 2004 at the University of Michigan, including 598 nephrectomies (simple, radical, donor, and nephroureterectomies), 121 partial nephrectomies, 74 cyst resections, 61 reconstructive procedures (pyeloplasties and nephropexies), 37 adrenalectomies, and 20 other procedures (J Urol 2006; 176:1458-62). We defined postoperative hemorrhage as the requirement of red blood cell transfusion that could not be accounted for by operative blood loss, definable cause outside the surgical field, or hemodilution.
Of the 911 total procedures, 34 patients (3.7%) suffered postoperative hemorrhage, which was noted only after nephrectomy (3.3%), partial nephrectomy (9.9%), or adrenalectomy (5.4%).
Presentation and diagnosis
Most patients exhibit hemorrhage within 24 hours of surgery. Patients typically complain of more abdominal pain than expected. Abdominal examination almost uniformly reveals diffuse tenderness and hypoactive bowel sounds, although the severity of the tenderness varies. Occasionally, hemorrhage is not suspected until the postoperative hematocrit comes back and, as such, a hematocrit on the morning of the first postoperative day is recommended after laparoscopic nephrectomy, partial nephrectomy, and adrenalectomy.
Given the increased incidence of hemorrhage in the partial nephrectomy group, we routinely obtain an immediate postoperative hematocrit in these patients, as well. In other patients, the clinical situation is so striking that blood products should be ordered before laboratory confirmation of a decreasing hematocrit.