Sunrise in Shaker HeightsSunrise in Shaker HeightsSunrise in Shaker HeightsSunrise in Shaker Heights

Charles Modlin, M.D., MBACharles Modlin, M.D., MBACharles Modlin, M.D., MBACharles Modlin, M.D., MBA

• College:College: Northwestern Northwestern UniversityUniversity

• Medical School:Medical School: Northwestern UniversityNorthwestern University

• Internship/Residency:Internship/Residency: New York UniversityNew York University

• FellowshipFellowship Renovascular Surgery/ Renovascular Surgery/ Renal Transplant: Renal Transplant: Cleveland ClinicCleveland Clinic

• Staff:Staff: Cleveland Clinic Cleveland Clinic

Renal AllograftRenal AllograftRenal AllograftRenal Allograft

Implanted Kidney AllograftImplanted Kidney AllograftImplanted Kidney AllograftImplanted Kidney Allograft

Dual Deceased Allograft DonorDual Deceased Allograft DonorDual Deceased Allograft DonorDual Deceased Allograft Donor

Laparoscopic Donor Laparoscopic Donor NephrectomyNephrectomy

Laparoscopic Donor Laparoscopic Donor NephrectomyNephrectomy

Pediatric Enbloc KidneysPediatric Enbloc KidneysPediatric Enbloc KidneysPediatric Enbloc Kidneys

Pediatric Enbloc KidneysPediatric Enbloc KidneysPediatric Enbloc KidneysPediatric Enbloc Kidneys

Pediatric Enbloc Kidney Pediatric Enbloc Kidney AllograftsAllografts

Pediatric Enbloc Kidney Pediatric Enbloc Kidney AllograftsAllografts

Pediatric Enbloc AllograftsPediatric Enbloc AllograftsPediatric Enbloc AllograftsPediatric Enbloc Allografts

Pediatric Enbloc Post PerfusionPediatric Enbloc Post PerfusionPediatric Enbloc Post PerfusionPediatric Enbloc Post Perfusion

Multiple Renal ArteriesMultiple Renal ArteriesMultiple Renal ArteriesMultiple Renal Arteries

End-To-Side Arterial End-To-Side Arterial AnastamosisAnastamosis

End-To-Side Arterial End-To-Side Arterial AnastamosisAnastamosis

Dual Kidney with 3 ArteriesDual Kidney with 3 ArteriesDual Kidney with 3 ArteriesDual Kidney with 3 Arteries

Dual Kidney with 4 ArteriesDual Kidney with 4 ArteriesDual Kidney with 4 ArteriesDual Kidney with 4 Arteries

Capsular Repair Vicryl MeshCapsular Repair Vicryl MeshCapsular Repair Vicryl MeshCapsular Repair Vicryl Mesh

Capsular RepairCapsular RepairCapsular RepairCapsular Repair

Renal Angiomyolipoma in Living Renal Angiomyolipoma in Living DonorDonor

Renal Angiomyolipoma in Living Renal Angiomyolipoma in Living DonorDonor

ADPCKADPCKADPCKADPCK

Autosomal Dominant Polycystic Autosomal Dominant Polycystic Kidney DiseaseKidney Disease

Autosomal Dominant Polycystic Autosomal Dominant Polycystic Kidney DiseaseKidney Disease

Renal Trauma Renal Trauma Renal Trauma Renal Trauma

• 19 y/o AA male19 y/o AA male• Admitted with 2 Gun Shot Wounds: ERAdmitted with 2 Gun Shot Wounds: ER• Physical Exam:Physical Exam:

- Vitals BP 90/50, Pulse 150 regular, RR labored Vitals BP 90/50, Pulse 150 regular, RR labored breathing, no breath-sounds left lung semi-breathing, no breath-sounds left lung semi-conscious, uncooperative, pain, abdomen distended conscious, uncooperative, pain, abdomen distended and tender +rebound, rigidity, bullet entry posterior and tender +rebound, rigidity, bullet entry posterior left chest, exit site right anterior abdominal wall, left chest, exit site right anterior abdominal wall, another entry site left gluteusanother entry site left gluteus

- Stat Hematocrit 18%, ABG 7.28 pH,pCO2 60,pO2 68Stat Hematocrit 18%, ABG 7.28 pH,pCO2 60,pO2 68

- Bladder Catheterized: Urine Clear (NO Hematuria)Bladder Catheterized: Urine Clear (NO Hematuria)• WHAT WOULD YOU DO????WHAT WOULD YOU DO????

Immediate ResuscitationImmediate ResuscitationImmediate ResuscitationImmediate Resuscitation

• Femoral Venous Lines/ Large Bore IVsFemoral Venous Lines/ Large Bore IVs• Normal Saline HydrationNormal Saline Hydration• AlbuminAlbumin• BloodBlood• FFPFFP• (PT/PTT coagulopathic)(PT/PTT coagulopathic)• CXR: Pneumothorax: Chest Tube InsertionCXR: Pneumothorax: Chest Tube Insertion• Hypoventilation/ Acidotic /IntubationHypoventilation/ Acidotic /Intubation• Serial Hematocrits; Hct Stable/ BP stableSerial Hematocrits; Hct Stable/ BP stable• What would you do????What would you do????

What would you do???What would you do???What would you do???What would you do???

• Admit to the ICU and Observe.Admit to the ICU and Observe.

• Obtain a CT scan.Obtain a CT scan.

• Prepare the O.R. for Immediate Surgical Prepare the O.R. for Immediate Surgical Exploration.Exploration.

Surgical ExplorationSurgical ExplorationSurgical ExplorationSurgical Exploration

• Midline-abdominal Incision madeMidline-abdominal Incision made

• Trauma to Gallbladder, L Kidney, Tail of Trauma to Gallbladder, L Kidney, Tail of PancreasPancreas

• Retroperitoneal Hematoma BilaterallyRetroperitoneal Hematoma Bilaterally

• Gallbladder removedGallbladder removed

• Retroperitoneal Hematoma Non-ExpandingRetroperitoneal Hematoma Non-Expanding

- Kidney Partially Visualized (trauma to Kidney Partially Visualized (trauma to lower pole)lower pole)

- Retroperitoneal hematoma Retroperitoneal hematoma

- Drains Placed, Patient ClosedDrains Placed, Patient Closed

Surgical ExplorationSurgical ExplorationSurgical ExplorationSurgical Exploration

• What type of incision?What type of incision?

- Left Flank IncisionLeft Flank Incision

- Left Thoraco-AbdominalLeft Thoraco-Abdominal

- Abdominal MidlineAbdominal Midline

- ChevronChevron

• Why? Hint: What is the most important Why? Hint: What is the most important thing you must do upon entering the thing you must do upon entering the patients body?patients body?

Renal Trauma GradingRenal Trauma GradingRenal Trauma GradingRenal Trauma Grading

• Renal injuries are gradedRenal injuries are graded by the American by the American Association for the Surgery of Trauma Association for the Surgery of Trauma (AAST) (AAST)

- on the basis of the depth of injury and on the basis of the depth of injury and the involvement of vessels or the the involvement of vessels or the collecting system as followscollecting system as follows (Moore, (Moore, 1989). 1989).

Grading Grading Classified according to the Organ Injury Scaling (OIS) Classified according to the Organ Injury Scaling (OIS)

Committee ScaleCommittee Scale

   

Grading Grading Classified according to the Organ Injury Scaling (OIS) Classified according to the Organ Injury Scaling (OIS)

Committee ScaleCommittee Scale

    • MinorMinorII • Contusion Microscopic or gross haematuria,  Urological studies Contusion Microscopic or gross haematuria,  Urological studies

normalHaematomaSubcapsular, nonexapnding without parenchymal normalHaematomaSubcapsular, nonexapnding without parenchymal laceration.laceration.

IIII • Haematoma Nonexapnding perirenal haematoma confined to renal Haematoma Nonexapnding perirenal haematoma confined to renal

retroperitoneum. Laceration<1cm parenchymal depth of renal cortex retroperitoneum. Laceration<1cm parenchymal depth of renal cortex without urinary extravasation.without urinary extravasation.

• MajorMajorIIIIII • Laceration>1cm depth of renal cortex, without  collecting system Laceration>1cm depth of renal cortex, without  collecting system

rupture or urinary extravasationrupture or urinary extravasationIVIV • LacerationParenchymal laceration extending through the renal cortex, LacerationParenchymal laceration extending through the renal cortex,

medulla and collecting system.VascularMain renal artery or vein injury medulla and collecting system.VascularMain renal artery or vein injury with  contained haemorrhage.with  contained haemorrhage.

VV • Laceration Completely shattered kidney. Vascular Avulsion of renal Laceration Completely shattered kidney. Vascular Avulsion of renal

hilum which devascularizes kidney.hilum which devascularizes kidney.

Grade III Renal InjuryGrade III Renal InjuryGrade III Renal InjuryGrade III Renal Injury

Conjoined UretersConjoined UretersConjoined UretersConjoined Ureters