Challenging Case in Urology
Surgeon Explains his Approach to the Unique Situation
By Rebecca Rudolph-Witt, editor
”The raw surface of
liver began to bleed
nothing seemed to
control the bleeding
effectively, so I used a
Dr. Jayram Krishnan
Surgical Products connected with
Dr. Jayram Krishnan, who is an
Urologist at the Cleveland Clinic
in Las Vegas, specializing in minimally invasive urology and general urology, to talk about unique
challenges in the operating room.
He described a challenging case he
He wrote: Recently I performed
an open simple nephrectomy
through a retroperitoneal approach
on a 62 year old woman. She had
a dead infected right kidney that
needed to be removed as it was
causing an infection throughout
her body. The patient had had
multiple previous trans-abdominal
surgeries including a colostomy
and ileostomy. She had been
sent to me because I specialize in
retroperitoneal kidney removal. Her
tissue was compromised and her
nutrition was poor. The kidney was
basically fused to the edge of the
liver anteriorly due to her previous
multiple abdominal surgeries.
SP: Why was it challenging?
There were no normal surgical
planes. Usually the retroperitoneal
space is protected and there are
few adhesions. In my patient, this
space was violated and the intimacy between the kidney and liver
made it very challenging. There was
no peritoneal layer between the
two making dissection extremely
SP: How did you handle it?
I thought using the retroperitoneal
approach would help me avoid
many problems, but this was a
The raw surface of liver began to
bleed uncontrollably. Normally I use
topical absorbable hemostats like
ORC (Oxidized Regenerated Cel-
lulose) or more advanced methods
like electrocautery or fibrin sealants
when I’ve encountered this kind of
bleeding. But nothing seemed to
control the bleeding effectively, so
I used a new hemostat called the
EVARREST® Fibrin Sealant Patch,
to get hemostasis. This was the
first time I used the product and it
worked very fast.
SP: If faced with similar cases
what would you do it differently?
It’s hard to say – most of my cases
are extremely challenging and difficult,
and each situation is unique. I just
take my time, have patience and don’t
give up easily in surgery.
SP: Are there learnings you
would like to share with
other surgeons who may find
themselves in similar situations?
If you have liver lacerations or liver
bleeding, place EVARREST®, hold
pressure and you will not have to
worry about it. This can be a life-sav-ing product. Whenever you have
liver bleeding, visibility is limited.
Use EVARREST® early on in the
case when the bleeding is apparent.
This will save you time and improve
SP: How is the patient doing
The patient made a full recovery and
is doing well.
Dr. Krishnan has no disclosures
Dr. Jayram Krishnan
unique situation. I usually perform
many of these retroperitoneal cases
robotically and in fact, I started this
case robotically. It was a challenging case to start and it became
more difficult due to the inflammation and scarring from previous surgeries. Since there were no normal
planes, I converted to open early
on. I had to peel the kidney off from
the liver, and ultimately, there was
such a large raw surface of liver.