1. Intraoperative bleeding and injury to major vessels (approx. 5.4%)
Intraoperative bleeding represents the most common complication. An increased risk exists in particular with large tumours and difficult vascular anatomy.
Particular feature on the right side: The right adrenal vein is usually very short and drains laterodorsally directly into the V. cava inferior. Injuries can occur particularly through traction.
Severe vascular injuries: Injuries to the V. cava inferior or major hepatic veins can lead to massive bleeding and, in addition, to an air embolism.
Treatment and management:
Manual compression for immediate bleeding control
Proximal vascular control, particularly at the V. cava inferior
Vascular clips, ligation, suture ligature or oversewing of the injured vessel or vessel stump
In the case of injury to the V. cava inferior: tangential clamping with subsequent oversewing
In the case of severe, uncontrolled bleeding: temporary occlusion of the V. cava inferior caudal and, if necessary, cranial to the liver
In exceptional cases: suprahepatic vascular control after opening the diaphragm
Prevention:
Early identification of the adrenal vein
Secure ligation early in the course of dissection, before the adrenal gland is fully mobilised
Avoidance of excessive traction on the right adrenal vein
A structured and rapid approach as well as early vascular control are crucial in order to avoid haemodynamic instability.
2. Injury to adjacent organs
All organs that have to be mobilised to expose the adrenal gland are potentially at risk.
Hepatic and renal capsule lesions (right)
Capsular injuries frequently occur through retraction or instrument contact.
Treatment:
- Bipolar coagulation
- Use of fibrin glue
- Sealing with fibrin-coated collagen fleece
Duodenal injury
Injuries to the duodenum are rare but clinically relevant.
Treatment:
- Immediate intraoperative oversewing
- If necessary, additional drainage
Diaphragmatic injury and pleural lesion
An injury to the diaphragm can lead to opening of the pleura.
Consequences:
- Pneumothorax
- Pneumomediastinum
Treatment:
- Primary closure of the defect
- In the case of haemodynamic relevance: placement of a chest drain
3. CO₂ or air embolism
Particularly in the case of injury to large venous vessels, gas may enter the circulation.
Clinical signs:
- Sudden haemodynamic instability
- Fall in end-tidal CO₂
Treatment:
- Immediate desufflation
- Circulatory stabilisation
- Positioning measures (e.g. left lateral position)
4. Hormonal reactions (particularly in phaeochromocytoma)
In hormonally active tumours, particularly phaeochromocytomas, manipulation of the tumour can lead to a massive release of catecholamines.
Consequences:
- Hypertensive crises
- Tachycardia
- Arrhythmias
- Intraoperative circulatory dysregulation
Management:
- Close coordination with anaesthesia
- Preoperative pharmacological preparation (e.g. alpha-blockade)
- Minimisation of tumour manipulation before ligation of the vein
5. Tumour rupture and oncological risks
An intraoperative injury to the tumour capsule can lead to dissemination of tumour cells and worsen the oncological prognosis.
Prevention:
- Gentle dissection
- Avoidance of excessive traction
- Use of suitable retrieval bags
6. Nerve injuries
· Rare but relevant complications are injuries to retroperitoneal nerve structures, which can lead to postoperative pain or sensory disturbances.
7. Technical problems with the robotic system
Robotic systems may exhibit technical limitations intraoperatively:
- Instrument failure
- Restrictions in mobility
- System shutdown
This may necessitate a conversion.
8. Conversion to open surgery
Conversion is not a complication but an important safety measure and should be carried out early in the case of:
- Uncontrollable bleeding
- Unclear anatomy
- Tumour infiltration that cannot be managed robotically in oncological surgery