A man underwent a laparoscopic colectomy on March 28, 2016, to remove a large polyp identified during a routine colonoscopy.
The Operative Report says: “...The tattoo in the mid transverse colon was readily identified […] We began by inspecting the ileocolic pedicle. Windows were created on each side of the vascular pedicle. The pedicle was then divided using a single fire of the powered Echelon stapler with a vascular load. We then continued the dissection in the medial to lateral direction. The duodenum was identified and kept out of harm’s way. In order to have a tension-free anastomosis, the splenic flexure required mobilization […] Once the splenic flexure was mobilized, the specimen was ready for extraction...”
An extra-corporeal anastomosis was performed.
Then the Operative Report continues: “All 4 quadrants of the pelvis were inspected and noted to be hemostatic”.
The operation was then concluded.
Afterwards, the patient complained of abdominal pain, general malaise, and bilateral lower extremity adema. A CT scans showed fluid collections thought to be an abscess. A sample of the fluid showed a creatinine of 38 (indicating a urine leak into the abdomen). An attempt to insert a ureteral stent via cystoscopy on April 19, 2016, did not successfully bridge the injury. During that attempt, it was recognized that the right ureter had been transected. The urologist noted extravasation of contrast from the right ureter at the level of the pelvic brim. Ureteroscopy revealed a pinpoint opening at the level of the obstruction. When the scope was advanced through the opening, retroperitoneal fat was visualized.
A nephrostomy tube was placed into the right kidney on April 20. On August 25, 2016, a laparoscopic right nephrectomy was performed.
Are ureteral injuries uncommon during colectomy procedures?
What can surgeons do to avoid those injuries?
How critical is it to insure that any damage is recognized immediately and repaired?
Is this a case you can help us with?
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Do you believe there might have been medical error?
"Are ureteral injuries uncommon during colectomy procedures?" These injuries are rare but not uncommon. What makes me believe that this might be a medical error is that in "easy" cases this complication should be a "never" event. Patients with diverticulitis and with dense inflammation are more prone to this injury because of the scar tissue present that tends to make the identification of the ureter more difficult. "What can surgeons do to avoid those injuries?" In cases with inflammation some use lighter stents that allow the recognition of an injury more easily. They do not prevent the injury. In case as "easy" as this, no adjuncts are employed, as the rate of injury is close to zero. "How critical is it to insure that any damage is recognized immediately and repaired?" Like all injuries, time is of the essence and the sooner the injury is recognized the better it is. Should the injury be recognized intraoperatively in this case, the patient could have not be needed to undergo a nephrectomy.
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
The ureter should have been visualized during surgery. If not, all efforts should have been made to keep the dissection very superficial, as this was not a cancer operation that would have involved taking the mesocolon where the ureter usually lies. Also, I totally question the use of the stapler in this case. Should the surgeon had used clips and a individual dissection of the vessels of the pedicle, extremely likely the ureter would have not be caught in.
What makes you a good expert for this case?
I provide the full spectrum of general surgery and I have done these operation and witnessed these complications in my practice
How often do you encounter cases similar to this one in your practice?
Probably twice to 5 times a year
Do you believe there might have been medical error?
Iatrogenic ureteral injuries can occur during various abdominopelvic and retroperitoneal surgical procedures [8-10], as well as during endoscopic manipulation, or dissolution of ureteral calculi. Recognition and treatment of ureteral injuries at the time of injury is associated with the least morbidity. It is incumbent for the surgeon to demonstrate that due diligence was taken during the course of surgery or another procedure. At a minimum, when the procedure is anticipated to occur in the vicinity of the ureters, the surgeon should document that the ureters were identified and protected, or he/she should provide the reason why if this is not possible (eg, adhesions, distorted anatomy). Why was the surgeon in the pelvis for this operation? Should have been far away from where the injury occurred. Any mention of ureteral identification in the OP note?
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
Very unusual location for an injury in a transverse colectomy. The surgeon should not have been in the pelvis for the mobilization and anastomosis.
What makes you a good expert for this case?
Been involved in many cases over 20+ years. Very good at explaining complex medical issues at a simple level.
How often do you encounter cases similar to this one in your practice?
Yes. One of the more common injuries.
Do you believe there might have been medical error?
For a routine laparoscopic right hemicolectomy it is extremely rare to injure the right ureter. If performing a medial to lateral dissection as describe the vessels should be skeletonized and the retroperitoneal structures are swept posteriorly. Ureteral injuries are very rare. To minimize this, the vessel should be skeletonized prior to transection. One could also injure the ureter at the pelvic brim with mobilization of the cecum and terminal ileum. When using a stapler or energy device, it is at time to know that the ureter is transected and difficult to identify intraoperatively. It is unclear why an attempt was not made to repair the ureter and save the kidney. I would be happy to review the case further.
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
It is very rare and a complication to transect the ureter during a right hemicolectomy leading to nephrectomy.
What makes you a good expert for this case?
I am a national expert in surgical oncology with an expertise in colorectal cancer.
How often do you encounter cases similar to this one in your practice?
I perform approximately 100 colorectal cases per year.
Do you believe there might have been medical error?
Transecting a ureter is definitely an error. One of the major steps in this operation is identifying the ureters. However, this is one of the known complications of this surgery. Although it should not happen this is one of the known risks of the operation.
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
Misidentifying the ureter leads to inadvertent transection of the ureter.
What makes you a good expert for this case?
General surgery, colon surgery and abdominal surgery is my main practice. I have also had my own transection of a ureter and understand why this happens and how it happens and what is normal and not normal after the transection happens. As a side note, I think the question that should be asked is not about the ureter but about when it was identified and how it was handled and most importantly why the patient had a left nephrectomy. This does not seem normal after a ureteral injury.
How often do you encounter cases similar to this one in your practice?
At least once per month or twice per month I do colon surgery.
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