Bleeding from the hilum

Ask the room

You are doing this case. Where is the danger, and what is your first move if it happens?

Take answers before advancing. The point of the debrief is what they say now, not what the next slide says.

• A lumbar vein avulsed off the back of the left renal vein, or a stapler fired across the short right renal vein onto the IVC, bleeds faster than you can see.

port view (transperitoneal)

1. Position lateral, establish pneumoperitoneum, place ports and reflect the colon medially along the line of Toldt.
2. Identify and follow the gonadal vein and ureter upward as the guide to the lower pole and hilum.
3. Mobilise the kidney within Gerota fascia, freeing the lower pole and lateral attachments while leaving the hilum until last.
4. Skeletonise the hilum, defining the renal vein anteriorly and the artery behind it; identify and control lumbar, gonadal and adrenal tributaries before any division.
5. Divide the artery first with clips or a stapler, confirm the vein collapses, then divide the vein with a vascular stapler across a clear window.
6. Free the upper pole and remaining attachments, then place the specimen in a retrieval bag.
7. Reduce pneumoperitoneum and inspect the hilar staple lines and IVC for bleeding before closing.

• The renal vein sits anterior to the artery at the hilum.
• It is the structure you reach first and injure first.
• On the right the vein is short, so the stapler sits close to the IVC.
• A line fired too medially, or across a previously placed clip, can catch the cava itself.
• A vascular stapler that closes over a metal clip can fail rather than seal.
• The other trap is the lumbar vein.
• These tributaries enter the back of the left renal vein or the IVC directly, and medial traction on the kidney tears them before they are seen and controlled.
• The bleeding is usually low-pressure venous, but the volume is high and the field fills instantly.
• Right-sided dissection, a bulky hilar tumour, nodal disease, prior surgery and aberrant tributaries all raise the risk.

• Short right renal vein draining straight into the IVC
• Lumbar / gonadal tributaries entering posteriorly, torn by traction
• Vascular stapler fired across a previously placed clip
• Bulky hilar tumour or nodes distorting the anatomy
• Misjudged staple line landing on the IVC wall

1. Do not panic-grab. Briefly raise pneumoperitoneum pressure (around 20 mmHg) to tamponade venous bleeding and buy a few moments, then return it once control is gained, as sustained high pressure risks gas embolism.
2. Apply direct pressure to the bleeding point with a closed instrument, rolled swab or the suction tip, and hold it there.
3. Get a second sucker and a competent assistant; ask theatres to open a laparotomy set and alert the anaesthetist to active bleeding.
4. With pressure maintained, expose the source. A controlled tear may be clipped, stapled across a clean window, or oversewn laparoscopically if skills allow.
5. Uncontrolled bleeding, an IVC injury, loss of vision in the field, or haemodynamic instability is the conversion trigger: convert to open immediately and obtain proximal and distal control. escalation trigger
6. After control, reinspect the staple lines and IVC at reduced pneumoperitoneum to confirm haemostasis is real, not pressure-masked.
7. Document the vessel injured, the mechanism (eg stapler over clip, avulsed lumbar vein), the control method, estimated blood loss, conversion and the consultant present.

Three questions

1. Why divide the artery before the vein?
2. Why is the right side more dangerous?
3. How do you control an IVC injury once converted to open?

Answers are on the card under the viva section. Hold them back until everyone has tried.

• Anyone can say increase the pressure and convert.
• The strong answer prevents the injury by skeletonising the hilum and controlling lumbar tributaries before traction, names the clip-over-stapler misfire mechanism, respects the short right renal vein next to the IVC, and gives a concrete plan for proximal and distal caval control on conversion.