Journal of Indian Association of Pediatric Surgeons
Journal of Indian Association of Pediatric Surgeons
                                                   Official journal of the Indian Association of Pediatric Surgeons                           
Year : 2007  |  Volume : 12  |  Issue : 3  |  Page : 156--157

Mistaken ligation of the right renal artery: A risk in the surgical management of massive left-sided Wilms' tumor


Samer Katmawi-Sabbagh, Peter Cuckow 
 Department of Paediatric Urology, The Great Ormond Street Hospital for Children, London, United Kingdom

Correspondence Address:
Samer Katmawi-Sabbagh
3 Braithwaite Close, Leisure Village, Kettering, Northamptonshire, NN15 7JS
United Kingdom

Abstract

Massive left sided Wilm«SQ»s tumours can be associated with significant distortion of the vascular anatomy. An anatomical explanation of mistaken ligation of the right renal artery will be provided in this article so that such a catastrophic complication can be avoided.



How to cite this article:
Katmawi-Sabbagh S, Cuckow P. Mistaken ligation of the right renal artery: A risk in the surgical management of massive left-sided Wilms' tumor.J Indian Assoc Pediatr Surg 2007;12:156-157


How to cite this URL:
Katmawi-Sabbagh S, Cuckow P. Mistaken ligation of the right renal artery: A risk in the surgical management of massive left-sided Wilms' tumor. J Indian Assoc Pediatr Surg [serial online] 2007 [cited 2017 Nov 24 ];12:156-157
Available from: http://www.jiaps.com/text.asp?2007/12/3/156/34960


Full Text

 Introduction



We present two cases in which the vascular anatomy was distorted and particularly, the mobility of the aorta combined with hilar lymphadenopathy rendered the correct identification of the artery to the tumor to be difficult.

 Case Reports



Case 1

The index patient had a massive left-sided abdominal mass. CT suggested Wilms' tumor (WT) with the displacement of the aorta toward the right. Poor responsiveness to chemotherapy and continued enlargement mandated early nephrectomy.

The tumor was mobilized with difficulty to the left for better exposure of its pedicle, which remained obscured by the matted hilar lymph nodes. The vein could be observed, but no artery could be seen; hence, in such a difficult situation, the was first divided and an artery was found behind it. This was identified as the left renal artery and divided as well. The further dissection of the lymphoid mass revealed that the aorta was stuck to the back of the tumor. When the tumor displaced to the left, the aorta also moved along with it and presented the right artery behind the left renal vein and to the left of the midline. The mistaken ligation of the right artery was confirmed and this was reanastomosed after the removal of the tumor. Unfortunately, the right kidney never recovered and the child required hemodialysis. After this he has received a successful renal transplant and remained tumor free.

Case 2

This boy also had a massive left tumor with the aorta displaced to the right of the midline [Figure 1]. Mobilization to expose the pedicle identified the left renal vein and an artery behind it. The aorta was subsequently found stuck to the back of the tumor and had been displaced along with the tumor to the left; therefore, the artery under consideration was the right (incorrect) renal artery. The left (correct) renal artery was identified within the lymphoid mass and the tumor was safely removed.

 Discussion



The displacement of intraabdominal structures by the massive Wilms' tumor is well recognised. [1] Both cases illustrate aortic mobility resulting from the displacement due to a massive left-sided tumor.

During tumor mobilization, the aorta can move farther to the left of its normal position, thereby placing the right renal artery behind the left renal vein [Figure 2]. This is an anatomical explanation for the mistaken ligation of the right artery, which is a rare but significant complication in Wilms' tumor surgery. [2] It is vital that the aorta is identified before the artery is ligated.

References

1Ritchey ML. Diagnosis and evaluation of Wilms ' Tumor: Pediatric Urologic Oncology. Chapter 70 - Volume 3 - Campbell's Urology:2002. p. 2488-9.
2Ritchey ML, Shamberger RC, Haase G, Horwitz J, Bergemann T, Breslow NE. Surgical complications after primary nephrectomy for Wilms' tumor: Report from the National Wilms' Tumor Study Group. J Am Coll Surg 2001;192:63-8.