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<p>Percutaneous nephrolithotomy (PCNL) remains the gold standard for managing large renal calculi. Although traditionally performed in the prone position, the supine approach offers improved ergonomics, shorter operative time, better anaesthetic access, and easier calyceal entry. Bowel injury is a rare but serious complication of PCNL, with small bowel involvement being exceedingly uncommon due to its anatomical separation from the kidney. We report a case of jejunal perforation with peritonitis following supine PCNL in a 45-year-old male with a left staghorn calculus measuring 3.2 × 1.6 × 1.8&#xa0;cm. The procedure was performed in the modified Valdivia–Galdakao position with lower pole access under fluoroscopic guidance, stone fragmentation using a pneumatic lithoclast, and placement of a Double-J stent with a nephrostomy tube. Postoperatively, the patient developed signs of peritonitis, and imaging revealed the nephrostomy tube traversing the jejunum. Exploratory laparotomy confirmed a 2 × 2&#xa0;cm perforation located 60&#xa0;cm distal to the duodenojejunal flexure, which was repaired primarily, resulting in an uneventful recovery. This case underscores the importance of meticulous preoperative CT analysis to identify high-risk anatomical variations and the critical role of accurate surface landmarking in the true neutral position prior to patient repositioning. The adjunctive use of intraoperative ultrasonography can further enhance the safety of calyceal access, particularly in high-risk scenarios. In the absence of ultrasonography, a “double-check” fluoroscopic technique in multiple planes may help ensure a safe retroperitoneal trajectory. Early recognition and prompt surgical management remain essential for optimal outcomes. </p>

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Enhancing Supine Percutaneous Nephrolithotomy Access with Precise Surface Landmarking and Adjunctive Real-Time Ultrasound: Safeguarding Against Bowel Injury

  • 期刊论文

  • 发表日期：

    2026年5月9日

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  • Saroj Kumar Yadav,
  • Siddhant Bolar,
  • H. Sakthivel,
  • Sidhartha Kalra

摘要

Percutaneous nephrolithotomy (PCNL) remains the gold standard for managing large renal calculi. Although traditionally performed in the prone position, the supine approach offers improved ergonomics, shorter operative time, better anaesthetic access, and easier calyceal entry. Bowel injury is a rare but serious complication of PCNL, with small bowel involvement being exceedingly uncommon due to its anatomical separation from the kidney. We report a case of jejunal perforation with peritonitis following supine PCNL in a 45-year-old male with a left staghorn calculus measuring 3.2 × 1.6 × 1.8 cm. The procedure was performed in the modified Valdivia–Galdakao position with lower pole access under fluoroscopic guidance, stone fragmentation using a pneumatic lithoclast, and placement of a Double-J stent with a nephrostomy tube. Postoperatively, the patient developed signs of peritonitis, and imaging revealed the nephrostomy tube traversing the jejunum. Exploratory laparotomy confirmed a 2 × 2 cm perforation located 60 cm distal to the duodenojejunal flexure, which was repaired primarily, resulting in an uneventful recovery. This case underscores the importance of meticulous preoperative CT analysis to identify high-risk anatomical variations and the critical role of accurate surface landmarking in the true neutral position prior to patient repositioning. The adjunctive use of intraoperative ultrasonography can further enhance the safety of calyceal access, particularly in high-risk scenarios. In the absence of ultrasonography, a “double-check” fluoroscopic technique in multiple planes may help ensure a safe retroperitoneal trajectory. Early recognition and prompt surgical management remain essential for optimal outcomes.