On the left, the vessels can be exposed through the posterior peritoneum, by dividing it vertically between the inferior mesenteric vein and the fourth part of the duodenum. The renal vein and artery can then be identified an controlled with vessel loops. On the right side, it is often easier to control the renal vein and artery after mobilisation of the colon. If bleeding occurs on mobilisation of the colon or opening of perinephric fascia, atraumatic vascular clamps may be placed on the renal artery and vein. Warm ischaemia is poorly tolerated, and acute tubular necrosis develops after 20 minutes, though this is usually transient.
Partial nephrectomy is often possible.
Preserving the capsule of the kidney if possible, devitalised tissue is debrided and bleeders controlled with diathermy or suture. The collecting system is closed with a running absorbable suture. Alternatively, pledgeted matress sutures may be placed across the capsule. If possible the capsule is closed, or an omental flap closed over the defect. Nephrectomy is inidicated in the shattered kidney or renal pedicle injury in an unstable patient.