DP49: AORTIC INJURY DURING ELECTIVE ROBOTIC PARTIAL NEPHRECTOMY: THE ROLE OF TEAMWORK AND COMMUNICATION IN A PERIOPERATIVE CRISIS
Hailey M Perry, DO1; Mariah Gosling, MD1; Nathalie Abitbol, MD, MBA2
1Jackson Memorial Health System/University of Miami; 2University of Miami
Introduction: Aortic injury during robotic partial nephrectomy is rare and poorly documented, with some reports suggesting an incidence as low as 0.01%. In general, major vascular injuries can be immediately life-threatening with mortality rates up to 17%. Minor vascular injuries are more common, occurring in 15-25% of cases with a higher bleeding risk in partial compared to radical nephrectomy. Survival hinges on rapid recognition, adaptability, and clear communication. This case highlights how multidisciplinary teamwork and effective communication led to a favorable outcome after an unexpected aortic injury requiring initiation of massive transfusion protocol (MTP), despite an initial gap in communication.
Methods: The case describes a 55-year-old male with hypertension, type 2 diabetes mellitus, tobacco use, and obstructive sleep apnea that underwent robotic left partial nephrectomy for removal of a 2.7 cm left renal mass, later diagnosed as renal cell carcinoma. Standard ASA monitors were placed, and the case began with arms tucked and two peripheral IVs. Intraoperatively, the patient developed sudden hemodynamic instability due to aortic rupture, requiring activation MTP and conversion to open.
Results: During the case, the patient developed sudden hypotension and tachycardia concerning for acute hemorrhage. Shortly thereafter, aortic injury was reported. The case was converted to open exploration, and additional surgical services were activated. The anesthesiology team initiated MTP, hemodynamic resuscitation, and rapid escalation to a multidisciplinary response involving urology, vascular surgery, nursing, OR staff, blood bank, and additional anesthesia personnel.
The large operating room allowed multiple teams to work simultaneously while additional access was obtained, including a large-bore IV, arterial line, and central line, and massive transfusion while urology and vascular surgical teams controlled the bleeding. Daytime staffing facilitated rapid mobilization of consultants, blood bank personnel, and additional anesthesia support, minimizing delays in blood product delivery.
Estimated blood loss reached 26 L. The patient received 32 units of PRBCs, 19 units of FFP, 5 units of platelets, 6 units of albumin, and 4 L of crystalloid with aggressive vasopressor support. Hemostasis was secured with vascular surgery assistance, and the partial nephrectomy was completed successfully. The patient was transferred intubated to the SICU, extubated the following day, and discharged home on postoperative day 6 without long-term complications documented at subsequent follow up appointments.
Discussion: This case highlights the anesthesiologist’s role as crisis leader during unexpected intraoperative emergency. Communication failures—especially between surgical and anesthesia teams—are a well-described contributor to perioperative harm. In this case, delayed disclosure of the aortic injury increased the acuity of the situation. Once recognized, however, clear, closed-loop communication and rapid activation of MTP allowed the team to regain control. Several system factors likely supported the positive outcome: including daytime hours, large operating room for extra staff, effective communication, and efficient execution of MTP.