Surgical complication of SMA and celiac artery ligation during radical nephrectomy for large renal tumor: A fatal outcome

Abstract

Iatrogenic ligation of extrarenal vessels during left nephrectomy is a rarely reported yet life-threatening complication, typically occurring due to anatomical vascular variation, distorted anatomy or large lymphadenectomy. Preoperative assessment of anatomy through radiological imaging and careful identification of each vessel intraoperatively is important to prevent this complication. Such complications often result in fatal tissue ischemia and multi-organ failure if not diagnosed and managed in time. We present a case of a 35-year-old female who presented with a large left renal tumor along with retroperitoneal lymphadenopathy distorting the normal vascular anatomy. She underwent an open radical nephrectomy and lymphadenectomy. During the procedure, inadvertent ligation of the celiac artery and SMA occurred, which remained unrecognized for about 36 hours post-surgery and led to major organ ischemia, failure and ultimately death. Proximity of major mesenteric vessels to the renal hilum and distorted anatomy caused by a large tumor or lymphadenopathy are the major risk factors for such complications. Preoperative vascular mapping by cross-sectional imaging and intraoperative identification of major vessels is crucial to prevent such complications. Postoperatively, high suspicion for such complications and urgent surgical intervention are important to prevent significant morbidity and mortality. This fatal case underscores the importance of preoperative vascular mapping and multidisciplinary planning, intra-operative vigilance and postoperative early diagnosis and prompt intervention for better patient outcomes.

Keywords: Celiac artery ligation; Left renal mass; Renal tumor; Superior mesenteric artery (SMA) ligation; Surgical complications.

Fig. 1

Axial CT images of the upper abdomen with contrast showing enlarged para-aortic lymph nodes distorting the normal mesenteric vascular anatomy (white arrows on A and B) and a large left renal mass (red arrow on B).

Fig. 2

Sagittal (A) and axial (B) Ct images of abdomen with contrast show abrupt cut off of celiac artery and superior mesenteric artery just distal to their origins (red arrows). Status post left nephrectomy and para-aortic lymphadenectomy.

Fig. 3

Axial CT abdomen with contrast showing hepatic perfusion defects and non- enhancing spleen (A), amorphic and non-enhancing walls of stomach (B) duodenum (C) in keeping with multiorgan ischemia.