Abstract
Clinical History:
Our patient was a 28-year-old woman with a 1.3 cm left posterior renal mass. She underwent uncomplicated left robotic partial nephrectomy. Notably, prominent lymphatic vessels were encountered near the left renal hilum, which were ligated using Hem-o-lok clips. Final pathology analysis returned angiomyolipoma. Two weeks later, she re-presented with chylous ascites (CA). A percutaneous drain was placed with initial aspiration of 3 L chyle, and over 1 L of chylous drainage daily.
Physical Examination:
Patient presented with a soft distended abdomen and chylous fluid leaking from her incision sites.
Diagnosis:
The clinical diagnosis of CA was made.
Intervention:
After failing conservative dietary management, interventions were discussed. Because of her severely high output, it was determined that she was not a candidate for lymphangiogram or shunt procedure. She subsequently underwent robot-assisted diagnostic laparoscopy. The lymphatic fistulae were identified beneath and between the previously placed clips. These defects were ligated with permanent suture.
Follow-Up/Outcomes:
After the repair, drain output significantly decreased, and symptoms resolved. Her drain was removed 2 weeks postoperatively when output was minimal. Lymphatic leaks after renal surgery occur more frequently on the left side because ascending lumbar lymphatic channels are encountered during hilar dissection. Although several strategies may be employed in treating this complication, prevention would be most ideal. In the retrospective series of nephroureterectomy with retroperitoneal lymph node dissection, meticulous clipping was associated with a lower rate of CA. Several studies have suggested that bipolar energy is equally effective in ligating lymphatic vessels during lymph node dissection.
Informed Consent:
Author(s) have received and archived patient consent for video recording/publication in advance of video recording of procedure.
Funding:
No funding was received for this project.
None of the authors listed have any conflicts of interest to disclose.
Runtime of video: 4 mins 58 secs
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