Laparoscopic Retroperitoneal Removal of an Anteriorly Migrated Interbody Cage Following Posterior Lumbar Interbody Fusion: A Case Report

This prospective randomized study compares the safety and efficacy of transperitoneal laparoscopic adrenalectomy (TLPA) and retroperitoneal approach (RLPA) in obese patients with Cushing's syndrome. Recently, a retroperitoneal laparoscopic approach has been described with benefits of avoiding the respiratory and hemodynamic effects of carbon dioxide (CO2) pneumoperitoneum and giving direct access without the need to mobilize abdominal organs. Twenty-one adrenalectomies were performed in 9 patients (2 men, 7 women; mean age, 46.33 +/- 19.41 years old; range, 16 to 74 years old) with Cushing's adenoma and in 6 women (mean age, 41.83 +/- 9.97 years old; range, 34 to 62 years old) with Cushing's disease. Randomization gave 10 TLPA and 11 RLPA. Arterial blood gas samples, mean arterial pressure, heart rate, and clinical parameters were evaluated. The partial pressure of carbon dioxide (PaCO2) increased in both retroperitoneal and transperitoneal CO2 insufflation compared with basal values (p < 0.01), and the TLPA showed a greater rise in the PaCO2 level compared with the RLPA at 30 minutes (p < 0.05); simultaneously, a significant increase (p < 0.05) of mean arterial pressure was observed in the TLPA compared with RLPA. No significant changes in heart rate were observed in both groups. The operative time with the TLPA and RLPA in patients with adenoma was 88.75 versus 105 minutes, respectively (p = not significant [NS]), and in patients with bilateral hyperplasia was 271.66 versus 305 minutes, respectively (p = NS). No patients required blood transfusions. The number of doses of analgesic with TLPA and RLPA in patients with adenoma was 3.25 versus 3.5, respectively (p = NS), and in patients with bilateral hyperplasia was 7.66 versus 7.33, respectively (p = NS). The hospital stay with TLPA and RLPA in patients with adenoma was 3.0 versus 2.75 days, respectively (p = NS), and in patients with bilateral hyperplasia was 6.0 versus 6.66 days, respectively (p = NS). The days to return to normal activity with TLPA and RLPA in patients with adenoma were 12.5 versus 12.25, respectively (p = NS), and in patients with bilateral hyperplasia were 19.66 versus 19.33, respectively (p = NS). Two patients with bilateral hyperplasia and TLPA had urinary infection. Transperitoneal laparoscopic adrenalectomy and RLPA may become the techniques of choice for surgical removal of the adrenal lesions in Cushing's syndrome. The retroperitoneoscopic approach might be a better option in patients with previous abdominal surgery and in patients with pre-existing cardiorespiratory disease.

Background Current options for ureteral stones include medical treatment, extracorporeal shockwave lithotripsy (SWL), and various endoscopic procedures, with the standard open ureterolithotomy being less frequently practiced nowadays. The use of laparoscopy in the management of ureteral stones was one of the earliest applications of laparoscopy in urology, the first report being made by Wickham in 1979. Objective To compare the laparoscopic Retroperitoneal ureterolithotomy with the Laparoscopic Transperitoneal ureterolithotomy as a better alternative to conventional open surgery to extract a large, impacted and hard stones at the proximal two thirds of the ureter. Methods In this study we present our experience with laparoscopic ureterolithotomy comparing both transperitoneal approach and retroperitoneal approach through a retrospective randomized comparative study that conducted on 50 patients admitted through the outpatient clinic of Urology in Ain shams University Hospitals and Nasser institute hospital. The 50 patients divided into two groups each one was 25 patients, first group was performed by the laparoscopic transperitoneal approach and the other group by the laparoscopic retroperitoneal approach Between October 2017 and October 2018. Results This study revealed that the length of the Hospitalization period and the duration of drainage and urethral catheter were shorter in the transperitoneal approach than in the retroperitoneal approach with statistical significance between the groups. In the present study, the mean time to oral intake was significantly shorter in the Retroperitoneal group than in the Transperitoneal group. This is due to the mobilization of the colon, dissection and retraction of the viscera, and blood and urine leak in the peritoneal cavity, causing intestinal movements and sounds to be more delayed in the LTU group. In contrast, the lost blood during the retroperitoneal procedure does not come into contact with the bowel, and if urine leakage occurs, it would be contained within the retroperitoneal space. Also we find that both approaches are safe with few complications that were significantly wider at the transperitoneal group; vascular injury didn’t occur at any of the cases with no need for blood transfusion. Conclusion Through our study we concluded that Laparoscopic ureterolithotomy is technically feasible and safe and both of its two approaches either transperitoneal or retroperitoneal are successful procedures with a success rate nearly the same in both techniques, but and based on our results through this study, we recommend the retroperitoneal approach for laparoscpic extraction of the ureteral stones due to the fact that it has the least operative time than the transperitoneal approach, getting rid of the all stone burden, lower rate of complications and a better postoperative recovery.

Laparoscopic adrenalectomy: transperitoneal vs retroperitoneal approaches

Retroperitoneal Laparoscopic Radical Nephrectomy for Renal Cell Carcinoma with Infrahepatic Vena Caval Thrombus

Vascular and bowel complications during retroperitoneal laparoscopic surgery.

Damage control: collective review.

Introduction/BackgroundThe retroperitoneal laparoscopic approach has proved several benefits for excising lymph nodes in the aortocaval space in gynecological cancers, as it allows to avoid intraperitoneal adhesions and bowel manipulation. It...

Effectiveness of supplemental screw fixation for the prevention of anterior cage migration in oblique lateral interbody fusion at L5-S1

To present our technique and initial results of dual combined retroperitoneal and transperitoneal laparoscopic approach for the treatment of renal-cell carcinoma (RCC) with level 0-II venous tumor thrombus. We included nine consecutive patients with RCC and level 0-II inferior vena cava (IVC) thrombus who underwent laparoscopic radical nephrectomy and IVC thrombectomy using dual combined laparoscopic approach in our department between January 2016 and June 2017. The mean operative time was 150 minutes when cavotomy was not performed and 240 minutes when cavotomy with thrombectomy was required. The mean IVC clamping time was 24 minutes and the mean blood loss was 300 mL. We encountered no major intraoperative or postoperative complications (Clavien III-IV). The patients were discharged a mean of 7 days after the procedure. At the 6-month follow-up, all patients were alive. One patient presented a retroperitoneal enlarged lymph node and started systemic treatment. The dual combined laparoscopic approach for kidney tumors with level 0-II IVC thrombus is feasible, reproducible, and especially useful in patients with complex renal pedicle. The technique provides early arterial control by retroperitoneal approach, which reduces the blood flow through the renal vein and has the advantage of minimal mobilization of the thrombus-bearing renal vein; it therefore lowers the risk of tumor embolism and intraoperative hemorrhage.

ObjectiveTo evaluate the feasibility and safety of pure laparoscopic radical nephrectomy and thrombectomy for renal tumor patients with venous tumor thrombus.MethodsFrom Jan 2013 to Dec 2014, records of patients with renal tumor and venous thrombus treated in our institute were retrospectively reviewed. Thirteen patients underwent pure laparoscopic radical nephrectomy and thrombectomy, including seven patients with renal vein (RV) thrombus and six patients with inferior vena cava (IVC) thrombus. Retroperitoneal approach was undertaken for RV thrombus patients, while transperitoneal approach or combined retroperitoneal and transperitoneal approach for IVC thrombus patients. During the combined approach surgery, renal artery and lumbar vein were controlled through retroperitoneal approach, and the thrombectomy procedure was completed through transperitoneal approach.ResultsThere were nine male patients and four female patients. All patients ranged from 30 to 78 years old (median, 55 years old). Seven patients were diagnosed by routine medical examination, while six patients had clinical symptoms, including four with gross hematuria and two with flank pain. All patients underwent operations successfully. Operation time ranged from 84 to 456 minutes (median 195 minutes). The blood loss ranged from 50 to 150 mL (median, 50 mL) for RV tumor thrombus patients, and 100 to 2,500 mL (median, 325 mL) for IVC tumor thrombus patients. All patients recovered well after surgery without major complications. With the postoperative pathological examination, the average tumor maximum diameter was 7.9±2.5 cm. Eleven cases of clear cell renal cell carcinoma, one case of chromophobe renal cell carcinoma and one case of renal metastatic osteosarcoma were showed in our study. Median follow-up time was 13 months (2-22 months). No decease was observed at the last follow-up. Three patients experienced distant metastasis after surgery, including two patients with multiple pulmonary metastases and one patient with lumbar vertebral metastasis.ConclusionsPure laparoscopic radical nephrectomy and thrombectomy is feasible and safe, with promising oncological prognosis. Combined retroperitoneal and transperitoneal procedures can take both the advantages of these two approaches and simplify operative manipulations.

Knowledge of the anatomy of renal vessels and their anatomical variations (diverse branching from abdominal aorta) represents an indispensable moment for planning and performing surgical operations in this area. Renal arteries originate from abdominal aorta at L1-L2 level. Normally the right renal artery passes behind inferior vena cava and right renal vein, the left one is shorter and passes behind left renal vein. Each renal artery gives inferior adrenal gland arteries and divides in four or five branches close to the hilum. Usually, shortly below the right renal artery, right gonadic artery arises and runs in front of the inferior vena cava. In our Department, during a routine gross anatomy dissection of a 98-year-old Caucasian male cadaver for undergraduated, postgraduated students and residents, we observed that right renal artery exhibit an early bifurcation. The two arteries have a peculiar running, in spite of the more frequent behavior. They cross each other at the middle of the path between abdominal aorta and renal hilum forming a sort of knot. The lower branch goes up looking like a superior polar artery, from which stems a short retropielic artery. Right gonadic artery originates from right renal artery in spite of its more frequent origin from abdominal aorta at L3 level. These monolateral variations are of course unusual but not responsible for any hemodynamic impairment. Probably as concerning the right renal artery variation it looks like that it is due to a non complete fusion of the primitive segmental arteries at the first steps of formation of right dorsalis aorta. This impinges on the fact that also the right gonadic artery stays close to the upper part of dorsalis aorta and therefore originates eventually from the right renal artery.

To summarize the experience of diagnosis and operation related to massive adrenal area tumor with venous tumor thrombus in clinic. From October 2017 to March 2019, a total of 8 cases of massive adrenal area tumor (>7 cm) with venous tumor thrombus were admitted at Peking University Third Hospital including 5 males and 3 females with mean age 50.6 years (31-62 years). There were 6 cases on the right side and 2 cases on the left side. The first symptoms included abdominal discomfort, hypertension, Cushing syndrome and abnormal menstruation; special past history included cirrhosis and lung cancer. Computed tomography (CT) and routine endocrine hormone tests were examined. Preoperative imaging confirmed 5 cases masses with tumor thrombus in inferior vena cava (IVC) and 1 case with tumor thrombus in left renal vein. Two cases presented with tumor thrombus in central adrenal vein were found intraoperatively. Open adrenalectomy and thrombectomy were performed in 4 cases of right side complicated with high tumor thrombus of inferior vena cava. Laparoscopic adrenalectomy and thrombectomy were performed in 3 cases, including 2 cases on the right and 1 case on the left. The case with tumor thrombus in left renal vein gave up operation. The patients were followed up with outpatient and telephone. The mean size of the tumor was 8.9 cm (7-11 cm), the mean operative time was 319 min (120-510 min), while the estimated blood loss was 629 mL (50-1 200 mL). Intraoperative blood transfusion was required in 2 cases and 1 case encountered wound infection. The pathological types included pheochromocytoma, adrenocortical carcinoma, adrenal metastases of haptic carcinoma, and leiomyosarcoma. The case with left lung carcinoma who underwent left pneumonectomy one month before was highly suspected adrenal metastases of lung carcinoma. Tumor thrombus of pheochromocytoma was combined with blood thrombus. Capsule of adrenocortical carcinoma was fragile in adrenocortical carcinoma. Abundant blood supply existed in adrenal metastases. The leiomyosarcoma had unabundant blood supply and invaded IVC to form tumors thrombus. The mean follow-up time was 8.4 months (1-15 months). One case with adrenocortical carcinoma died after 1 year in the follow-up. We present the rare cases of different pathological types of massive adrenal tumors with tumor thrombus extending into the IVC extension or other vein. Preoperative diagnosis needs comprehensive evaluation and perfect preoperative preparation. Surgery is difficult and varied. Open approach as well as retroperitoneal laparoscopic approach is feasible.

Objective To evaluate the effect of laparoscopic adrenalectomy for adrenal tumors by transperito-neal or retroperitoneal approaches. Methods Atotal of 41 laparoscopic adrenalectomy for adrenal tumor patients were pertormed,inchiding 16 patients by transperitoneal approach and 25 patients by retroperitoneal approach. The tumor size,operative time,intraoperative blood loss, postoperative hospital stay, postoperative ambulatory day and postopera-tive complications were observed. Results Of the 41 cases ,3 cases were transferred to open surgery and the other 38 cases were achieved successful operations. No significant differences( all P>0.05) were found in tumor size,intraop-erative blood loss, postoperative hospital stay, postoperative ambulatory day between the transperitoneal group and ret-roperitoneal group ,but there were significant differences( P<0.05) in operative time and intraoperative blood loss be-tween the two group. Conclusion Both the transperitoneal and retroperitoneal laparoscopic approaches are feasible and safe for adrenal tumors, and the latter has more advantages in operative time, but the operative approach still should be chosen based on the pathological changes,tumor size and position as well as the individual conditions of the patients. Key words: Adrenal gland neoplasms; Laparoscopy

Vascular and Bowel Complications During Retroperitoneal Laparoscopic Surgery

Renal artery variations are more important for surgeons and clinicians. As these variations alter and influence the surgical procedures including intervention methods. These variations are associated with physiological and embryological changes which will alter the medical treatment. The present work is conducted in the department of anatomy, Andhra medical college, Visakhapatnam for 50 cadavers for a period of 3 years. In one case 3 additional renal arteries arising from abdominal aorta one on right, two on left side were found. INTRODUCTION: The renal arteries usually arise from the abdominal aorta just below the origin of superior mesenteric artery, laterally or antero laterally (Williams).1,2 Renal artery variations are more frequently reported than other large vessels. Graves(1956)3 described variations regarding renal arteries as an (a)accessory where arteries arise from abdominal aorta in addition to main renal arteries. (b) aberrant arising from sources other than abdominal aorta. Incidence of pre caval right renal arteries varies from 0.8% (Petit. P)4 to 5% Yeh et al.5 suggested that most of precaval right renal arteries were accessory lower polar arteries. In 2008 SHOJA.M.M et al.6 described prehilar pattern of renal artery. The embryological explanation of these variations has been presented and discussed by Keibel F & Mall F7. Accessory renal arteries are found frequently on the left side. Their occurrence is as high as 30-35% of the cases. These arteries usually enter the upper or lower pole of the kidneys (Singh G, NGYK, Bay BH)8. According to kadir et al.9 accessory renal arteries are of two types. The most common first type is where the accessory renal arteries enter into the renal hilum along with the main renal artery, the other type is where the accessory arteries enter directly into the capsule of polar regions. Ozkan et al.10 named second group of accessory renal arties as polar or aberrant arteries. There are a few other renal vascular variations that must be differentiated from the accessory renal arteries (Netter FH, Shapter RK, Yonkman F F)11. Opinion of earlier authors differ in regard side of accessory renal arteries, some authors have reported a high frequency on the left side (Saldarriaga. B, Perez. AZ)12 while others (Nayak, Budhiraja)13, 14 reported it to be more frequent on the right side. Lower polar arteries which typically pass in front of ureter are associated with a relatively higher incidence of hydronephrosis resulting from obstructions of ureter in uretro pelvic region (Anson.BJ)15. The right renal artery that passes ventral to the inferior vena cava is important for pre surgical planning, because chances of injury especially during retroperitoneal approach are high when only the right gonadal vein is expected to lie in pre caval area. This anterior origin may also result in misidentification of vessels during laparoscopy, such as the inferior mesenteric, superior mesenteric or hepatic artery. OBJECTIVES: Identification of anomalous vascular supply to the kidneys and their anatomical relationship to abdominal aorta and inferior vena cava and to represent their interpretation in surgical procedures. DOI: 10.14260/jemds/2014/2016