Laparoscopic dismembered pyeloplasty in children: five tips for the transmesenteric approach

Abstract

Purpose Laparoscopic dismembered pyeloplasty is an emerging alternative treatment for ureteropelvic junction obstruction in children. In this video, we present our transmesenteric approach experience that might make the laparoscopic dismembered pyeloplasty easier in children. Material and methods This is a 7-year-old girl who had a left ureteropelvic junction obstruction and a laparoscopic pyeloplasty was planned. We believed that transmesenteric approach would be easier because of fat-free and almost transparent. Results There are 5 major tips in this approach. First is the identification of pelvis and ureter at the peritoneum and its relationship with the marginal artery of Drummond on the left side. Second is the opening of mesentery above and below the marginal artery and the dissection of pelvis and proximal ureter at both windows. Third is the preservation of the anterior wall during the incision of ureteropelvic junction. Fourth is the positioning of the fourth trocar at the subcostal level for preoperative double J stent and retraction on the pelvis. Fifth is the suturing steps. First the most dependent suture on the posterior wall is put, and then the highest point of the ureter is sutured to its symmetrical counterpart on the pelvis and continous suture is put in between. Secondly the same procediure is done for the anterior border and lastly pelvis is closed. After satisfied with the anastomosis the mesentery is closed. Trocars are removed without leaving a drain. Children are typically discharged following overnight hospitalization on oral paracetomal and anticholinergics. Stent is removed 6 weeks later under a brief anesthesia. Conclusions We believe that laparoscopic transmesenteric pyeloplasty is a very attractive surgical technique due to its straightforwardness when these 5 tips are followed.