Ureteral damage is one of the intraoperative complications most feared by surgeons. The first thing that we must all have in mind is avoiding the section of such an important structure. There are two possibilities regarding prevention. Some surgeons prefer to perform a complete dissection of the inferior mesenteric vessels and the retrocolic space which allow them to look for the ureter before the vessel section and complete the procedure. On the other hand, there are surgeons who argue that if you are in the correct surgical plane, preserving correctly the retrooperitoneum, there is no need to look for the ureter before continuing the procedure. In our group we are in favor of the latter.
Nevertheless there are some dificult situations such as obese patients, hostile abdomen with a lot of adherences, fatty mesocolon, dolicosigmas, etc. which increase the risk of ureteral lesions. But this unpleasant complication is not a synonymous with conversion to open surgery. In experienced hands, the laparoscopic approach, together with the use 3D view systems, provides a high definition view which makes it possible to diagnose complications, guide an ureteral catheter correctly and suture the ureter over it.
In the next video we will show a ureteral section that took place during the abdominal access in a transabdominal-transanal total mesorrectal excision. We describe the main surgical steps to complete its correct repair
The clinical case is a 77-year-old woman with a BMI of 34 Kg/m2 and a diagnosis of middle rectum cancer cT3N0 treated with neoadjuvant chemoradiotherapy. Due to obesity and intrabdominal adherences, the definition of the surgical planes was especially difficult and a ureteral lesion occurred.
The perianal approach performed during the TaTME allowed accurate pelvic dissection. The increased traction obtained by the two teams working at the same time better defines the surgical plane and improves the visualization of the surrounding organs.
These advantages are especially important in both laterals and the anterolateral region to preserve the nerves, the vessels and the entrance of the ureter into the pelvis in the upper rectum. The anatomical landmarks from the pelvis should be known. After the resection the correct intact presacral plane could be visualized as well as the hypogastric vessels and nerves.
Thanks to this close evaluation we were able to observe a lateral damage of the ureter with a partial section. In the video you can see the ureter, with its creeping movement, crossing over the division of the iliac artery. This unpleasant complication is not synonymous with conversion into open surgery. In experienced hands, the laparoscopic approach provides a high definition view which makes it possible to diagnose the complications, guide a ureteral catheter correctly and suture the ureter over it.
The transanal approach combined with a 3D camera provided a direct view of the ureter, so we were able to make a first simple prolene stitch through the sectioned ureter. To check the correct lumen of the ureter we introduce an avocath, also transanally. You can introduce the catheter through the 10 mm trocar or taking out the silicon device, which is also easy and fast.
The other surgeon on the abdominal side can help by performing gentle traction of the proximal side of the ureter. This way we can check that we have properly respected the lumen of the ureter before finishing the end to end anastomosis with 3 single stitches.
Finally, a pig tail catheter is introduced by cystoscopy localizing the left ureteral lumen.
The patient’s evolution was correct, and she was discharged 6 days after surgery. In conclusion, the ureteral injury is a feared intraoperative complication that can be solved laparoscopically. Its transanal repair is feasible and safe, providing a direct high definition view of the damage. The 3D view can add depth, helping us to perform such a demanding procedure.