Iatrogenic aortic and iliac artery transections during robotic nephrectomies requiring emergent open vascular repair.

A 78-year-old man found to have a right lower pole renal mass of 4.1 × 3.9 cm in diameter consistent with renal cell carcinoma papillary grade 2, underwent robotic right nephrectomy. Preoperative scans documented low-lying, malrotated right pelvic kidney ( Fig 6 ). Additional contrast-enhanced CT urogram slices demonstrate the right renal artery and its relationship to the low-lying malrotated kidney and adjacent right iliac artery ( Fig 7 ). The patient was positioned in the left lateral decubitus position at the time of injury. Intraoperatively, there was significant desmoplastic reaction and scarring noted around the entire kidney and hilum. The kidney was clearly attached to the psoas and the vena cava. Sharp dissection of scarred tissue was performed thus circumferentially dissecting the kidney and identifying the presumed renal artery at the hilum which was staple-divided. Upon transection, there was suspicion of common iliac artery transection due to its stapled end proximity to patient’s high aortic bifurcation. Vascular surgery was emergently consulted intraoperatively, and right distal lower-extremity pulses were nonpalpable. Exploratory laparotomy confirmed stapled transection of right common iliac artery. An interposition 8 mm polytetrafluoroethylene graft was placed in an end-to-end fashion between the proximal and distal iliac stumps. Full restoration of iliac flow with strong distal pulses were confirmed on Doppler. Fig 6 Ptotic positioning of the malrotated right kidney in the right lower abdomen. A solid renal mass is seen in the lower pole of the right kidney, measuring 4.1 × 3.9 cm. Fig 7 Contrast-enhanced computed tomography (CT) urogram slices with the right renal artery highlighted in red , demonstrating the relationship of the low-lying malrotated right pelvic kidney to the adjacent right iliac artery. Ptotic positioning of the malrotated right kidney in the right lower abdomen. A solid renal mass is seen in the lower pole of the right kidney, measuring 4.1 × 3.9 cm. Contrast-enhanced computed tomography (CT) urogram slices with the right renal artery highlighted in red , demonstrating the relationship of the low-lying malrotated right pelvic kidney to the adjacent right iliac artery.

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Minimally invasive radical nephrectomy is widely implemented due to its faster patient recovery, durable oncologic outcomes, and reduced perioperative morbidity compared with open surgical approaches. 6 Despite this favorable safety profile, major vascular injury remains one of the most significant intraoperative complications in laparoscopic and robotic procedures. 7 , 8 , 9 Bleeding and distorted anatomy can rapidly impair perception. Large series and pooled analyses consistently demonstrate low overall rates of major complications. 1 , 10 However, these studies also emphasize that vascular injury, although infrequent, remains among the most consequential intraoperative events because it can rapidly result in exsanguination, end-organ ischemia, and possible increase in overall morbidity and mortality. The presented case series describe major arterial transections during robotic nephrectomy; two involving infrarenal aorta and one involving right common iliac artery. In each instance, injury resulted during stapled division of a presumed renal vessel and was recognized intraoperatively followed by emergent conversion to open surgery. This enabled immediate vascular control and reconstruction which reduced any delay in recognition and treatment resulting in more favorable prognosis. Published literature reports partial aortic injury or postoperative identification of aortic compromise rather than complete intraoperative transection. 3 , 4 Fei et al 3 described partial supraceliac aortic transection from stapling during laparoscopic nephrectomy that presented with acute limb and mesenteric ischemia which required resection with thoracoabdominal bypass plus a celiac jump graft. Almudaiheem et al 4 reported delayed complete infrarenal aortic occlusion after right robotic nephrectomy due to Hem-o-lok clips (Teleflex Incorporated) clamping the aorta, diagnosed on CT angiography and treated with prosthetic interposition grafting. Reports of iliac artery injury during nephrectomy are equally rare, though it represents a recognized complication in pelvic and retroperitoneal laparoscopic surgery. 5 , 11 , 12 Bertolo et al 5 described a case of right external iliac artery injury in nephroureterectomy where endometriosis, a benign infiltrative disease, distorted planes and increased the risk of iliac vascular injury. Understanding the pattern of major arterial injury during nephrectomy is vital for interpreting mechanisms and developing preventive approaches. In this case, the mechanism is best explained by anatomic misperception in a hostile hilum rather than by proximity-based injury. The literature on life-threatening arterial injuries during nephrectomy most frequently describes injuries to extrarenal visceral arteries, particularly the SMA and celiac axis, often when these vessels are mistaken for the left renal artery during challenging hilar dissection. 1 , 2 , 3 , 4 , 13 Limited academic literature and narrative reviews emphasize that vascular injuries commonly stem from the surgeon committing to a vessel that appears correct before its origin and course are conclusively established. 1 , 2 , 3 , 4 Our operative findings mirror these reports, in which a vessel presumed to be the renal artery was stapled, and the error became evident only after proximal filling was observed, raising suspicion of aortic or iliac transection that was confirmed intraoperatively by absent distal pulses in the lower extremities. Contributing factors included hostile hilar anatomy, previous embolization procedures, scarring, high bifurcation of aorta with malrotated pelvic kidney, and loss of normal retroperitoneal planes. In hostile hilar anatomy, preventing catastrophic vascular injury requires deliberate, structured anatomic confirmation before any irreversible step. It is critical to re-establish fixed landmarks, reidentify the aorta as a midline reference, and tracing any presumed renal artery to a confirmed renal takeoff. Safe stapling practice by visualizing the distal ends of the tips would further prevent collateral injuries to nearby vessels. In addition, stop points can be included during the minimally invasive surgery where the team stops to confirm (1) the psoas and gonadal vein/ureter relationship, (2) the renal vein course into the inferior vena cava, (3) the expected takeoff and direction of the renal artery relative to the vein, (4) the absence of too-large or too-midline caliber or pulsatility inconsistent with a renal artery, (5) and possible test-clamping the vessel before division. 12 , 14 If these checks cannot be satisfied, early conversion should be treated as a deliberate safety step to regain exposure and anatomic certainty. With major vascular injury, outcomes depend on rapid recognition, prompt conversion, early vascular surgery involvement, and swift proximal/distal control. Across all three patients in this series, immediate conversion and interposition graft reconstruction resulted in restoration of distal pulses and favorable outcomes. Because of the severity of the crush injury to the affected segments of aorta and common iliac caused by the staple loads, endovascular approaches were untenable. The proximal and distal edges of the transected vessels required debridement in order to reach healthy enough tissue for repair. Interposition grafting was the best option for the patients involved and all patients had positive outcomes due to the method used.

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