text: Dr. Krishnan Describes a Challenging Case - Medical Design and Outsourcing
  Dr. Krishnan Describes a Challenging Case
  January 5, 2016 By Rebecca Rudolph-Witt
  Surgical Products connected with Dr. Jayram Krishnan, who is an Urologist at the Cleveland Clinic in Las Vegas, specializing in minimally invasive urology and general urology, to talk about unique challenges in the operating room. He described a challenging case he had recently.
  He wrote: Recently I performed an open simple nephrectomy through a retroperitoneal approach on a 62 year old woman. She had a dead infected right kidney that needed to be removed as it was causing an infection throughout her body. The patient had had multiple previous trans-abdominal surgeries including a colostomy and ileostomy. She had been sent to me because I specialize in retroperitoneal kidney removal. Her tissue was compromised and her nutrition was poor. The kidney was basically fused to the edge of the liver anteriorly due to her previous multiple abdominal surgeries.
  SP: Why was it challenging?
  There were no normal surgical planes. Usually the retroperitoneal space is protected and there are few adhesions. In my patient, this space was violated and the intimacy between the kidney and liver made it very challenging. There was no peritoneal layer between the two making dissection extremely difficult.
  SP: How did you handle it?
  I thought using the retroperitoneal approach would help me avoid many problems, but this was a unique situation. I usually perform many of these retroperitoneal cases robotically and in fact, I started this case robotically. It was a challenging case to start and it became more difficult due to the inflammation and scarring from previous surgeries. Since there were no normal planes, I converted to open early on. I had to peel the kidney off from the liver, and ultimately, there was such a large raw surface of liver.
  The raw surface of liver began to bleed uncontrollably. Normally I use topical absorbable hemostats like ORC (Oxidized Regenerated Cellulose) or more advanced methods like electrocautery or fibrin sealants when I've encountered this kind of bleeding. But nothing seemed to control the bleeding effectively, so I used a new hemostat called the EVARREST® Fibrin Sealant Patch, to get hemostasis. This was the first time I used the product and it worked very fast.
  SP: If faced with similar cases what would you do it differently?
  It's hard to say – most of my cases are extremely challenging and difficult, and each situation is unique. I just take my time, have patience and don't give up easily in surgery.
  SP: Are there learnings you would like to share with other surgeons who may find themselves in similar situations?
  If you have liver lacerations or liver bleeding, place EVARREST®, hold pressure and you will not have to worry about it. This can be a life-saving product. Whenever you have liver bleeding, visibility is limited. Use EVARREST® early on in the case when the bleeding is apparent. This will save you time and improve your visibility.