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PROCEDURE PERFORMED: Was exploratory laparotomy, ligation of left renal vein, ligation of her right renal artery, right nephrectomy, undoing ligation of left renal vein and the left renal vein to vena cava saphenous vein bypass.

PROCEDURE AND FINDINGS: Are as follows: This patient had been a reported pedestrian struck by a motor vehicle. On preoperative CAT scan, it was noted that the patient had nonvisualization of right kidney, apparent avulsion thrombosis injury of the right renal artery. It was also noted the patient had apparent avulsion of the left renal vein off of the vena cava and hematoma in that area. The patient was hemodynamically unstable. The patient had been taken to the operating room and exploratory laparotomy performed through a midline incision. At the time that I joined the case, the small bowel had been examined, the stomach had been examined, the rest of the abdomen had been explored. There was a central hematoma and staining noted over the area of the kidney on the left side. The Bookwalter retractor was used. The small bowel was eviscerated and the Bookwalter retractor used to maintain the exposure, the transverse colon was retracted cephalad. The small bowel retracted towards the right side. The peritoneum posteriorly down by the aortic bifurcation was incised. There was purple staining overlying the aorta in this position and extended superiorly. The peritoneum was incised, dissection taken down to the aorta and then dissection taken up cephalad along the surface of the aorta. The aorta appeared not to be injured. The inferior mesenteric artery was identified as dissection was taken superiorly. The clot overlying the aorta and vena cava in that area became thicker. As the area of the presumed renal arteries was approached, bleeding was encountered from the center of the thick clot. Manual compression was held. A space was then developed between the stomach and the liver, dissecting down to the peritoneum, dissecting down to the aorta at the area of the aorta hiatus. The sponge stick was used then to maintain a pressure control of the aorta in that area. The aorta distally was clamped just above the inferior mesenteric artery and then dissection was continued up to the dense clot. Bleeding was encountered and then direct pressure was placed on the area with a sponge stick. As the aorta was controlled and the area was explored, the bleeding that was encountered was noted to be from the avulsed renal vein. The vein was controlled with a right angle clamp. The avulsed end of the left renal vein was controlled with a right angle clamp and in performing this maneuver, 300 to 400 mL of blood was probably lost. The left renal vein, where it was controlled with a right angle clamp was oversewn with a running 4-0 Prolene suture. The compression of the aorta was released and aortic clamp released distally. There was no further bleeding encountered and the left renal vein having been controlled. The smaller veins had been controlled during the dissection with hemoclips in the areas overlying the aorta. This then addressed the avulsed left renal vein. The renal vein had been avulsed overlying the aorta right off the surface of the vena cava. The ligament of Treitz had been mobilized and reflected towards the right side. Underlying that right vena cava, there is an area of some venous oozing. Rather than completely skeletonized, this area of oozing which was presumed to contain the remaining stump of the left renal vein on the vena cava was oversewn also with a running 4-0 Prolene suture. The exposure of the aorta was continued then to be carried out. The left renal artery was dissected free and visualized. The Doppler was used and there was a normal arterial flow signal in the left renal artery. The right renal artery was somewhat caudad to the left renal artery and this artery was examined, approximately a cm removed from the aorta, the left renal artery had been avulsed and it was purple and thrombosed. It had not been avulsed and separated but it had been avulsed and thrombosed. The right renal artery was then ligated on the surface of the aorta with a 2-0 silk tie and also secured with large hemoclips. As stated, the patient had Doppler flow in the left renal artery with a normal apparent flow signal and a decision was made at this point to proceed with the right nephrectomy. The small bowel and right colon were mobilized medially with a Cattell type maneuver and then Gerota's fascia was entered. The vena cava was nicely exposed with the Cattell maneuver and when this was performed one could clearly visualize the vena cava and then the right renal artery. The right renal artery was dissected free, extending laterally and controlled with vessel loops. The renal artery had been ligated at its communication with the aorta but in this lateral position approaching the kidney, the renal artery was identified also once again further ligated and controlled with hemoclips. Vascular control maintained Gerota's fascia and the fatty tissue around the kidney was incised and dissection taken down using primarily Bovie cautery through the fatty Gerota's fascia down onto the kidney. The kidney was dissected free from its fascial attachments laterally, inferiorly and superiorly and mobilized medially then right on the surface of the kidney. The right renal vein was controlled with two 2-0 silk ties, hemoclips and then incised. Similarly the renal artery was controlled with silk ties and hemoclips incised and the kidney continued to be mobilized. The ureter was identified and the ureter was dissected free, controlled with a 3-0 Prolene suture ligature near the kidney and then it was incised and when this was performed, the ureter, right renal vein, right renal artery having been controlled the kidney was able to be removed and delivered as a specimen. Some minor oozing points were controlled with Bovie cautery from Gerota's fascia and one small to medium-size vein with oozing was controlled with a hemoclip. When this was completed, then our attention was then directed back to the area of the left renal vein ligation. Doppler examination demonstrated continuing flow into the left renal artery. There was an arterial flow signal on the surface of the kidney. The left renal vein was distended. We discussed with anesthesia urine output, the patient had not had significant urine output since the beginning of the case. At this point, the dissection was taken along the renal vein extending laterally. When what was felt to be the testicular vein was approached, Doppler examination was used on the vein. There appeared to be flow in the gonadal vein but with the fact that the patient was essentially anuric and the left renal vein was distended, the decision was made to perform a left renal vein vena cava bypass. Saphenous vein was harvested in the usual fashion from the right femoral area. The skin was incised, subcutaneous space entered, dissection taken down to the saphenous vein. Saphenous vein skeletonized for a length felt to be adequate for the bypass. It was controlled proximally with a Satinsky clamp. A 4-0 Prolene suture was used to suture ligate the proximal portion, the vein was incised distally, the vein was ligated with a silk tie. The harvested saphenous vein then was irrigated with heparin saline solution. It was used in a reversed saphenous vein position. Satinsky clamp was placed on the vena cava. Venotomy made. The proximal end of the saphenous vein, which was more generous than the distal port, although the vein was felt to be of adequate dimensions to be used. The proximal portion of vein was spatulated and an end-to-side anastomosis of the saphenous vein on the vena cava was performed with running 6-0 Prolene suture. When the Satinsky clamp was removed, the anastomosis was hemostatically adequate. The left renal vein was controlled with a Satinsky clamp and it was noted that when it was suture ligated that what appeared to be an adrenal branches extending superiorly had been tethered into that suture. A venotomy had been made to perform the anastomosis in an end-to-side fashion to the left renal vein but seeing that this small adrenal branch been compromised and reasoning that the patient needed maximum venous outflow, the decision was made to undo the previously placed suture. The 4-0 Prolene suture that had been placed was removed. Backflow was achieved from the adrenal vein. Vigorous prograde flow was established out of the renal vein when the Satinsky clamp was released. The lateral venotomy that had been made was closed with a running 6-0 Prolene suture. Then the saphenous vein bypass was incised to appropriate dimensions, its ends spatulated and an anastomosis performed in an end-to-end fashion to the saphenous vein. The length of the anastomosis was approximately a cm and a half to 2 cm and although it was done end-to-end, it was somewhat an end-to-side fashion, the saphenous vein being smaller than the left renal vein. When the anastomosis was completed, one further 6-0 Prolene suture was used to make that anastomosis hemostatically adequate. The left renal vein appeared decompressed compared to the pre-bypass condition. It was difficult to ascertain with the Doppler that was available Doppler flow in the left renal vein, the testicular vein, the adrenal vein, the saphenous vein vena cava bypass but the left renal vein appeared somewhat decompressed from its previous condition. Doppler exam again demonstrated biphasic arterial flow signal in the renal artery and there was flow on the surface and one could hear arterial flow on the surface of the kidney with Doppler. The abdomen was one more time examined for hemostasis, it was felt to be adequate. Then the abdomen was not closed but it was secured with a VAC-type temporary closure. The patient was then delivered to the intensive care unit in a critical condition.