Urologia Internationalis
Urol Int 2007;78:182-184 DOI: 10.1159/000098081
Superior Mesenteric Artery Injury during en bloc Excision of a Massive Left Adrenal Tumor
Santosh Kumarª A.K. Mandala Naveen Acharyaª S.K. Thingnamb Vidur Bhallaª S.K. Singhª
Departments of ªUrology and bVascular Surgery, Postgraduate Institute of Medical Education and Research, Chandigarh, India
Key Words
Superior mesenteric artery · Adrenal tumor · Inferior vena cava thrombus . Radical nephrectomy
Abstract
Superior mesenteric artery (SMA) injury is a rare event during abdominal surgery. We report the first case of inadvertent injury of the superior mesenteric artery during surgery of a large malignant adrenocortical tumor with inferior vena cava thrombus. The cause of inadvertent injury was anatomical distortion of the great vessels due to the massive nature of the tumor. The case was managed successfully by immediate end-to-end anastomosis of the superior mesenteric artery.
Copyright @ 2007 S. Karger AG, Basel
Introduction
Iatrogenic injury to the major visceral arteries during radical nephrectomy and retroperitoneal mass excision has been rarely reported [1]. To the best of our knowledge, no case of intraoperative superior mesenteric artery in- jury (SMA) during en bloc excision of a large left adrenal
cortical carcinoma with inferior vena cava thrombus has been reported so far. Because of the relative inefficacy of chemotherapy, radiotherapy or biological response mod- ifiers, patients with locally extensive renal or adrenal masses are not infrequently offered extirpation in an at- tempt to provide survival benefit or alleviation of symp- toms. These large retroperitoneal masses may cause dis- tortion of the visceral branches of the aorta, putting them at risk for inadvertent injury.
Case History
A 44-year-old lady presented with left flank pain of 2 months’ duration. General examination was unremarkable. Abdominal examination revealed a palpable nontender mass in the left flank. Her hematological and biochemical parameters were normal. She was reported to have a large upper polar left renal mass with in- ferior vena cava thrombus (IVC) on CT imaging (fig. la, b). Mag- netic resonance imaging revealed a large heterogenous upper po- lar mass with IVC thrombus extending to the infrahepatic por- tion (fig. 2). The patient underwent exploration and en bloc mass excision of the tumor. The tumor was displacing spleen and pan- creas superiorly. Medially the mass was extending over great ves- sels. During dissection of the hilum, one artery was identified which appeared to run towards the renal hilum. The vessel was
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believed to be the left renal artery and was ligated and divided. Surprisingly, the distal arterial stump, i.e. stump towards the re- nal hilum, was pulsating and causing concern about the origin of the vessel. On further dissection, one more artery was seen di- rectly entering the left renal hilum and the previously ligated ves- sel was seen arising from the aorta which was confirmed to be SMA. The tumor was excised after ligating the renal vein. The bowels were found to be dark in color and mesenteric arterial pul- sations were absent. The superior mesenteric artery was reanas- tomosed end-to-end using 6-O polypropylene suture after re- moval and freshening of the ligated ends (fig. 3). After declamp- ing the vessels, the bowels resumed normal color and peristalsis. The surgery was completed after inferior vena cavotomy and thrombus retrieval. Cut section of the specimen showed a large adrenal tumor compressing the upper pole of kidney. Histopath- ological examination revealed adrenocortical carcinoma.
Discussion
Large adrenal masses, especially those associated with tumor thrombus extending into the IVC, are rarely seen and can mislead the clinician and radiologists to make a more common diagnosis of renal carcinoma as happened in our case [2].
Superior mesenteric artery and left renal vessels are in close proximity, and understanding of vascular anatomy and collateral circulation of the abdominal viscera is a necessity for all urological surgeons who perform extir- pation of extensive renal or retroperitoneal masses. In the setting of extensive retroperitoneal tumor, identification of the aortic arterial branches may be exceedingly diffi-
cult but critically important. There are around 12 cases of SMA injury during radical nephrectomy (7 RCC and 4 Wilm’s tumor) and retroperitoneal mass excision (retro- peritoneal hemangio-pericytoma) reported in the Eng- lish literature [1, 3]. SMA injury during en bloc excision of a large left adrenocortical carcinoma with inferior vena cava thrombus has not been reported so far.
3-D computerized tomography can be helpful in mak- ing the surgeon aware of the relationship of the visceral arteries to a large tumor and thus avoid such inadvertent injury. Prompt recognition of the injury and suitable measures for its reconstruction yield an excellent out- come [4].
References
1 Moul JW, Foley JP, Wind GG, et al: Coeliac axis and superior mesenteric artery injury associated with left radical nephrectomy for locally advanced renal cell carcinoma. J Urol 1991;146:1104-1107.
2 Hedican SP, Marshall FF: Adrenocortical carcinoma with intracaval extension. J Urol 1997;158:2056-2060.
3 Richtey ML, Lally KP, Haase GM: Superior mesenteric artery injury during nephrecto- my for Wilm’s tumor. J Paediatr Surg 1992; 27:612-615.
4 Lucas AE, Richardson JD, Flint LM, et al: Traumatic injury of the proximal superior mesenteric artery. Ann Surg 1986;1981:30- 34.
Kumar/Mandal/Acharya/Thingnam/ Bhalla/Singh
Copyright: S. Karger AG, Basel 2007. Reproduced with the permission of 5. Karger AG, Basel. Further reproduction or distribution (electronic or otherwise) is prohibited without permission from the copyright holder.