Laparoscopic splenorenal venous bypass for nutcracker syndrome

Abstract

Nutcracker syndrome is a rare entity caused by extrinsic compression on the left renal vein as it crosses between the superior mesenteric artery and the aorta. It can clinically present with flank pain and hematuria. Accepted treatments include open vascular bypass procedures or endoluminal stenting. We present the first description, to our knowledge, of a laparoscopic splenic vein-left renal vein bypass to relieve the outflow obstruction. The patient, a 29-year-old woman with debilitating left flank pain, presented with nutcracker syndrome. Left renal vein outflow was obstructed at the level of the intersection between the aorta and the superior mesenteric artery. The option of laparoscopic splenic to left renal vein bypass was discussed and performed. A five-port transperitoneal approach was used. Meticulous vascular control was achieved with numerous laparoscopic vascular bulldog clamps. With completely intracorporeal suturing techniques, the splenic vein was anastomosed to the superior aspect of the anterior left renal vein. Total warm ischemia time was 37 minutes. The anastomosis was watertight immediately upon unclamping. Interestingly, upon unclamping, the luminal diameter of the splenic vein appeared to increase to twice its native diameter. The proximal left renal vein appeared less distended, indicating preferential venous outflow through the newly created venous bypass. Blood loss was minimal, no intraoperative or postoperative complications occurred, and the patient's symptoms improved. This report continues to augment the indications for laparoscopic surgery in even complex, urologic vascular situations.

Laparoscopic Extravascular Renal Vein Stent Placement for Nutcracker Syndrome

“…8 Currently, laparoscopic surgery for management of the nutcracker syndrome has evolved. 14,27,28 Application of laparoscopic extravascular stent placement for the nutcracker syndrome has been limited. Only one such case has been described in English published reports by Scultetus and coworkers 14 in 2001.…”

Retroperitoneal Laparoscopic Extravascular Stent Placement for Renal Nutcracker Syndrome: Initial Experience

“…Numerous treatment modalities have been described, including surveillance, open surgical procedure and intra- or extravascular stent placement, with different results and associated complications [4,5,6,7,8,9,10]. Herein, we report our initial experience of retroperitoneal laparoscopic extravascular stent placement for the treatment of renal NCS.…”

Associated Da Vinci and Magellan Robotic Systems for Successful Treatment of Nutcracker Syndrome

“…It has been previously used to perform direct transposition of the LRV in the IVC, 7 LOV transposition, 8 and splenorenal venous bypass. 9 In the present case, we proposed a sequential treatment approach. We performed the LRV transposition first and performed the LOV embolization on the next day in order to decrease the renal risk of early thrombosis of the LRV.…”