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Surgery: Bilateral Nephrectomy, umbilical herniorrhapy, and incidental appendectomy

"Case studies highlight the variety of methods utilized in the Bloodless field. We will feature studies done at St. Vincent Charity Hospital, as well as, studies submitted by physicians across the United States. Do you have an interesting case? Please contact BMSI for publication information."

Irene Kopen, RN
CBMS
St. Vincent Charity Hospital, Cleveland, Ohio

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F.S. a 46 year old male presenting with bilateral polycystic kidney disease, self referred to the Center for Bloodless Medicine and Surgery (CBMS) at St. Vincent Charity Hospital for bilateral nephrectomy. Mr. F.S. had been diagnosed, evaluated, and accepted into the kidney transplant program at hospital A. He was then accepted for surgical removal of his polycystic kidneys. A two stage operation was recommended for this bilateral removal of the diseased kidneys. It was decided by the surgical team at hospital A that Mr. F.S. undergo surgery of the largest kidney first, and after sufficient recovery periods, the second non-functioning kidney would be removed. This two-stage operative plan, would entail two surgical interventions, along with the required hospitalization and recovery time. Mr. F.S. requested this operation to be a one time intervention with both kidneys being removed, sparing him of having to undergo two separate surgical experiences with the resultant double expenses and work time lost due to double recovery periods. Since Mr. F.S. was a Jehovah's Witness, he also requested this surgery be done without the use of homologous blood transfusions.
After evaluating the risk factors of this one-stage intervention without the use of blood backup, the surgical team at hospital A recommended that Mr. F.S. have his surgery outside the Cleveland area where another opinion may be sought. They felt, however, that most second opinions would support hospital A's decision. It was after this episode that F.S. contacted the Center for Bloodless Medicine and Surgery (CBMS) at St. Vincent Charity Hospital in Cleveland Ohio for his second opinion.
On admission into the CBMS Department at St. Vincent charity Hospital, F.S. pre-surgery examination revealed bilateral abdominal masses and an umbilical hernia. Multiple x-rays including renal arteriograms, CT scans, and ultrasounds showed massively enlarged polycystic kidneys and multiple cysts in the liver.
His past history included neck and back skin cancer removed, cardiac cauterization following myocardial infarct in 1987, right bundle branch block, bi-lateral rotator cuff tear (non-repaired), hypertension, secondary to kidney disease and peptic ulcers. His medication included: Zestril, Cadura, Minoxidil, zinc, betacarotene and Vit. A. He was dosed with erythropoietin 2500u 3x/ week beginning in August, 1997 when he was started on hemodialysis. Two weeks prior to surgery, F.S. was dosed with Procrit 30,000u 3 x/week with IV iron loading dose the first day of his procrit regimen. Renal dialysis was ordered 3 consecutive days before surgery.

Surgery performed: Bilateral Nephrectomy, umbilical herniorrhapy, and incidental appendectomy.
With the patient under general anesthesia, a chevron incision was made, and the surgical team began removal of the right kidney while sparing the right adrenal gland. Homeostasis was achieved with electrocautery, clamping, and ligatures. The left kidney was then removed in the same fashion, the left adrenal gland, not being identified with certainty. These massive kidneys made for a difficult dissection, while the spleen was avoided. Oozing was controlled with clamping and blood loss was 400cc, with cell saver replacement of approximately 80cc. The patient received1400cc crystalloid and 500 cc albumisol over a period of 2 hours. The entire surgery lasted 2hr/55min. His post operative course was uneventful, although slightly prolonged because of CRF and his need for dialysis. His presurgical Hgb was 13.3, and Hct was 40. Immediate post operative Hgb was 12.8/Hct38.8 dropping to 10.8/Hct32 , rebounding with epo dosing to 12.0/Hct35 on the day of discharge. His BP ranged from 140/80 on the day of surgery to 170/90. This was controlled with Lotensin 20mg. qd. His uremia was satisfactorily controlled, although Bun/Creat. ranged between 47/10 to 69/14. K levels were kept in the range of 4,0--5.0.
He was discharged 10 days post op. and in good condition with a good prognosis. He is on a transplant protocol. His nutrition is maintained with his normal renal diet and he was put on limited activity. Hemodialysis regimen was established at a local dialysis center.

Pathology Report:
The #1 specimen consists of a polycystic right kidney measuring 30cm. X 16cm. x 12cm. and weighing 2,430 gms. The adrenal gland is not identified. Serial sections through the kidney reveal variably sized cysts and markedly dilated calceal systems. Small islands of medium tan to reddish tissue are noted between the cyst wall. The #2 specimen consists of the left polycystic kidney, measuring 28.cm x16cm. x12cm. weighing 2,635 gms. with similar gross characteristics as described in #1. The adrenal gland is not identified. Microscopic exam shows multiple sections of kidney demonstrating variable sized cysts lined by flattened and cuboidal epithelium. Other cysts show organizing hemorrhage with erosion of the surface epithelium and chronic inflammation with multinucleated giant cell reactions indicative of acute and diffuse chronic pylonephritis, atrophy and interstitial fibrosis. Microcalcification is also present.

Discussion:
Coming from a small rural area 90 miles from a major industrial center with a variety of healthcare facilities should have been a one visit endeavor to find appropriate care for this seriously ill patient. However, this patient found himself being turned down because he requested surgery without the risks associated with allogeneic blood transfusions. Under standard protocol, this patient would have had to extend his hospital experience and expenses to double the extraordinary costs (including time lost from work and earning capabilities) incurred from two separate difficult surgeries and rehabilitative courses involved in recovery. Because he had the fortitude to pursue his choices, he could be referred to a hospital and surgical team that were confident and practiced in the "bloodless" approach to medical and surgical management. The uniqueness of a coordinated hospitalwide "bloodless" specialty can only be successful with the support and input from all players in this approach to healthcare. Blood conservation techniques and protocol are of prime importance as well as the use of technology and trained professionals. Both of these massive kidneys were removed along with the hernia repair and appendectomy with one major surgical intervention using these technologies and skills of the team organized to perform this high-risk surgery. Because of this patient's exercise of his rights of choice for bodily integrity, he was able to maintain a measure of control over this serious disease with a peace of mind and comfort knowing his wishes would be met within the protocol of a well coordinated, dedicated and accredited "bloodless medicine and surgery" program. Managed care entities would benefit as well as the patient and families by taking advantage of these well-run facilities.

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