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EDITORIAL COMMENTARY
Year : 2022 | Volume
: 68
| Issue : 3 | Page : 131-132
Pulmonary complications of supracostal percutaneous nephrolithotomy – Must know facts for surgeons
MV Sharma
Correspondence Address:
M V Sharma
Department of Respiratory Medicine, A J Institute of Medical Sciences and Research Centre, Mangalore, Karnataka
India
Source of Support: None, Conflict of Interest: None
CheckDOI: 10.4103/jpgm.JPGM_341_21
How to cite this article:Postoperative respiratory complications can occur in up to 5–10% of patients following nonthoracic surgery.[1] Respiratory complications account for about 25% of postoperative deaths within 1 week following surgery.[2] Early identification and management of postoperative respiratory complications will reduce the morbidity and mortality in these patients. Knowledge about the possible postoperative respiratory complications is essential for prevention, risk stratification, early diagnosis, and management.
Minimally invasive endoscopic surgical techniques are gaining growing popularity over open surgery since last few decades. Minimally invasive endoscopic surgeries have many advantages compared to open surgery.
Minimally invasive surgical techniques and approaches require a thorough knowledge of anatomy, possible postoperative complications, measures to prevent them, and early identification and management if any complications arise. Competency reduces the complications.
In this issue of the journal, Bhat et al.[3] have reported a rare case of left diaphragmatic paresis following percutaneous supracostal nephrolithotomy. Authors have discussed the possible mechanism of phrenic nerve injury, clinical implications, and management of the same. This case report also highlights the importance of clinical evaluation and imaging to detect postoperative complications early.
Preferred surgical treatment for staghorn calculous of kidney is percutaneous nephrolithotomy.[4] Supracostal approach is preferred over the traditional subcostal approach; but it requires greater expertise as pulmonary complications are more when compared to infracostal approach.[5] A thorough review of the computed tomography (CT) scan with regard to the size and location of the renal calculous, relation to the surrounding structures, and anatomical abnormalities if any (which can be appreciated by 3-dimensional reconstruction CT scan) will help the surgeon to plan percutaneous nephrolithotomy. Rehearsal of the procedure with 3D bioprinted material may help to improve the skill and confidence of the surgeon.
Supracostal approach can lead to pulmonary, pleural and diaphragmatic injury, and associated complications. Pulmonary complications are uncommon as most often the procedure is done under image guidance.[6],[7] Pulmonary complications, being rare, may be overlooked. It should be remembered that intra-thoracic and upper abdominal structures move with respiration. In key hole surgery only a limited area is directly visualized by the surgeon. These factors may increase the likelihood of injury during surgery unless the procedure is done with a real-time imaging of the surrounding structures.
Pulmonary complications can be more serious in patients who have underlying respiratory disease, cardiac disease, and in morbid obesity. Preoperative respiratory and cardiac evaluation and optimization of cardiorespiratory function will reduce the postoperative complications.[1] Following supracostal percutaneous nephrolithotomy, respiratory complications like pleural effusion, pneumothorax, diaphragmatic injury, diaphragmatic paresis, and peripheral lung injury can occur rarely.[5] Patients with emphysema and hyperinflation of lungs will have a low down diaphragm. This can increase the risk of diaphragmatic and lung parenchymal injury during supracostal puncture. Patients with chest wall abnormalities, anatomical variations in diaphragm, and eventration of diaphragm may also be at higher risk of injury. Since diaphragm moves with respiration, if the patient is under conscious sedation, breath holding during supracostal puncture may reduce the chances of diaphragmatic injury. Image-guided procedure (ultrasound or fluoroscopy) also reduces the risk of injury.[7]
After surgery, physical examination and imaging is essential to identify complications, if any. Postoperative chest x-ray is essential to detect lung parenchymal lesions and pleural complications, if any. But it should be remembered that a small pleural effusion, small pneumothorax, and diaphragmatic injury may be missed in a chest x-ray. Focused thoracic ultrasound is the ideal investigation as it can detect pleural effusion, pneumothorax, diaphragmatic injury, diaphragmatic paresis, and peripheral lung lesion.[8] Portable ultrasound can be done bedside, repeated without any radiation risk, used for image guidance during the procedure, and assess the renal system and abdomen at the same time. If any diaphragmatic injury is suspected, CT scan may be required for detailed assessment.
Because of pain and analgesia, patients may not manifest with symptoms due to postoperative complications. Physical examination may fail to elicit signs in the early stages. Imaging has the advantage to detect complications early, even in the absence of symptoms or signs. Hence, for all patients who undergo minimally invasive procedures, postprocedure ultrasonography is useful to detect complications early. Once detected, the complication should be treated promptly. Early detection and management of complications will reduce morbidity and mortality.
In conclusion, competency, a thorough knowledge about anatomy, possible postoperative complications, measures to prevent them, and early identification and management if any complications arise are essential for performing keyhole surgery.
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