Extraperitoneal Incision Research Articles

A Technique for Kidney Retransplantation After Simultaneous Kidney Pancreas Transplantation

Isolated failure of the renal graft after simultaneous kidney-pancreas transplantation (SPK) is a rare but potential outcome. Many of these patients are candidates for kidney retransplantation. This paper describes a series of 3 patients who underwent successful kidney retransplantation after SPK. The operation was completed through an extraperitoneal incision without disruption of the pancreas graft or need for a transplant nephrectomy.

Indications for the anterior extraperitoneal approach in pediatric urologic surgery: The Chicago experience

Abstract Introduction: The usefulness of the anterior extraperitoneal surgical approach is recognized for adult donor and radical nephrectomy. As this technique has not received wide pediatric examination, we report our experience with this procedure and present usage guidelines. Methods: Between 1999 and 2003, patients underwent surgery at our institution via an anterior extraperitoneal incision when there was atypical renal anatomy or planned simultaneous renal and lower ureteral surgery. Results: The anterior extraperitoneal approach was successfully used in ten patients (11 kidneys) between the ages of 2 months and 15 years. Six patients underwent pyeloplasties for ureteropelvic junction (UPJ) obstruction in kidneys with additional anatomical considerations (# cases): ptotic kidney (1), horseshoe kidney (2), crossed fused ectopia (1), redo pyeloplasty (1), and multiple renal calculi mandating nephrostolithotomy (1). Two patients had urinary undiversions and one had a nephroureterectomy for an ectopic ureter to the prostate. Another patient with end-stage renal disease and refractory hypertension underwent bilateral nephrectomies via bilateral incisions to leave the peritoneum intact for future renal transplantation. All procedures were performed without complications and the surgical exposure was excellent in all cases. The surgical exposure likely would have been restricted if a traditional flank incision had been done in these cases. Conclusions: We recommend the anterior extraperitoneal approach for pediatric renal surgery if exposure of anomalous renal anatomy would be restricted by traditional flank surgery. Also, access to both kidneys can be obtained with bilateral incisions without violating the peritoneal cavity.

Donor nephrectomy in the era of hand-assisted laparoscopic urologic surgery.

Living-donor nephrectomy has traditionally been performed through a flank incision with or without rib resection or by an anterior extraperitoneal incision, both of which reduce the willingness of potential donors to undergo the procedure. The first successful human laparoscopic donor nephrectomy was reported in 1995. In order to reduce warm ischemia and operative time and to make the operation safer and easier, some laparoscopic surgeons have used hand assistance. The authors describe their technique for this operation and review the results.

Obturator Bypass: A Classic Approach for the Treatment of Contemporary Groin Infection

As the number of cardiac and interventional radiologic procedures has risen, the frequency with which surgeons are called to treat groin complications has increased. Infectious groin problems that often involve foreign prosthetic material or remnants of percutaneous femoral closure devices are particularly challenging and require control of bleeding, removal of foreign material, wide debridement, and sometimes arterial resection. Management of the consequential limb ischemia in such cases is controversial. The purpose of this study is to review the utility of extra-anatomic common femoral bypass through the obturator foramen (obturator bypass) as a method of treating limb ischemia after arterial groin infection. From July 1992 through June 2001 a total of 12 patients (six male) presented with severe vascular infections of the groin and underwent obturator bypass. Infections occurred as a consequence of an isolated vascular graft infection (nine) or after a percutaneous interventional femoral access procedure (three). Patients presented with systemic sepsis and a draining sinus (six), infected pseudoaneurysm (two), or hemorrhage (four). Treatment included debridement of the groin wound, sartorius muscle flap coverage of the femoral vessels, antibiotics and synthetic (eight polytetrafluoroethylene and four Dacron) obturator bypass via a lower abdominal extraperitoneal incision from an aortobifemoral bypass graft limb to the superficial femoral artery (six), native iliac to femoral artery (three), iliac to popliteal artery (two), and aortobifemoral bypass limb to the popliteal artery (one). Graft patency and limb salvage were assessed by Kaplan-Meier life table analysis. There were two (17%) deaths (multisystem organ failure at postoperative days 9 and 6) and four major complications (25%) requiring reoperation in the first 30 days. Ten patients (83%) survived, healed their groin wounds, and are infection free. With a mean follow-up of 37 months graft patency and limb salvage at 60 months were 80 and 60 per cent, respectively. There were no late graft infections. We conclude that the obturator bypass is an effective and durable means of revascularization in the presence of the septic groin. This procedure belongs in the armamentarium of all surgeons managing these complications.

OMENTAL INTERPOSITION FOR REPAIR OF A VESICO-ACETABULAR FISTULA

An 84-year-old woman underwent revision of a previous right total hip replacement for degenerative joint disease. Shortly after surgery the metallic hip prosthesis became infected and required removal. The acetabular space was preserved using polymethyl-methacrylate cement. Persistent cellulitis and drainage of clear yellow fluid from the hip incision led to suspicion of a vesico-acetabular fistula. Urethral catheter bladder drainage for 4 weeks was unsuccessful and, subsequently, the patient was referred to our facility. A computerized tomography cystogram confirmed the diagnosis of vesico-acetabular (fig. 1, A). Cystoscopy revealed a solitary fistulous tract between the right lateral bladder wall and acetabular hemispheric shell which was cannulated using a 5Fr ureteral catheter (fig. 2). Through an infraumbilical extraperitoneal incision, the right lateral aspect of the bladder was mobilized off of the adhesed pelvic sidewall and the fistula was identified. A longitudinal cystotomy was made at the dome allowing bladder exploration and precise excision of the cannulated fistulous tract. The most challenging aspect of this procedure involved dissection and excision of the fistulous tract in its entirety as it coursed towards the acetabulum. After dissection to well vascularized tissue, a multilayered tension-free bladder closure was performed. To secure the repair, omentum was mobilized through a small peritoneotomy and interposed between the right pelvic sidewall and bladder. A cystogram (Fig. 1) after 3 weeks of continuous uninterrupted bladder drainage revealed successful closure of the vesico-acetabular (fig. 1, B).

LAPAROSCOPIC BILATERAL SYNCHRONOUS NEPHRECTOMY FOR AUTOSOMAL DOMINANT POLYCYSTIC KIDNEY DISEASE: THE INITIAL EXPERIENCE

We report our experience with laparoscopic bilateral synchronous nephrectomy for giant symptomatic autosomal dominant polycystic kidney disease (ADPKD) and compare outcome data with open bilateral nephrectomy. Since March 1998, 10 patients underwent bilateral synchronous laparoscopic nephrectomy for giant symptomatic ADPKD. A 3 port retroperitoneal laparoscopic approach was used to secure the renal hilum and mobilize the kidney. Intact specimen extraction was performed through a midline infraumbilical extraperitoneal incision. The patient was then repositioned for the contralateral retroperitoneoscopic nephrectomy, with the second specimen also delivered through the same infraumbilical incision. Data were retrospectively compared with 10 patients who had undergone bilateral synchronous open nephrectomy for ADPKD between 1981 and 1992. Patients in the laparoscopic and open groups were comparable in regard to age (53 versus 47 years, p = 0.54) and Anesthesiologist Society of America class (3 versus 3, p = 0.84) but patients in the laparoscopic group were significantly more obese (body mass index 35.9 versus 23.8, p = 0.02). For comparable total specimen weights (3 versus 3 kg, p = 0.69) surgical time was longer in the laparoscopic group (4.4 versus 3.8 hours, p = 0.007). However, the laparoscopic group was superior in regard to blood loss (150 versus 325 cc, p = 0.05), postoperative requirement of nasogastric tube (10% versus 100%, p = 0.0001), narcotic analgesics (34.2 versus 120.4 mg. morphine sulfate equivalent, p = 0.03) and hospital stay (1.5 versus 9 days, p = 0.004). Complications occurred in 5 patients (50%) in the laparoscopic group and 4 (40%) in the open group (p = 0.66). No laparoscopic case was converted to open surgery. Synchronous bilateral retroperitoneal laparoscopic nephrectomy for giant symptomatic adult polycystic kidney disease is feasible, safe and efficacious, and can be performed either before or after renal transplantation. Compared to open surgery, the laparoscopic approach results in significantly shorter hospital stay, decreased morbidity and quicker recovery. Laparoscopy is currently our technique of choice in this setting.

AN ANTERIOR EXTRAPERITONEAL INCISION FOR DONOR NEPHRECTOMY THAT SPARES THE RECTUS ABDOMINIS MUSCLE AND ANTERIOR ABDOMINAL WALL NERVES

To perform open donor nephrectomy with the least amount of body alteration and complication, a short extraperitoneal incision was developed that preserves the ipsilateral rectus abdominis muscle and abdominal branches of the intercostal nerves. Donor nephrectomy using the new incision was performed in 11 consecutive patients. Morphine was required for pain relief for 1 to 3 days (mean 1.8), patients tolerated diet at 1 to 4 days (mean 2.2) and postoperative stay was 2 to 5 days (mean 3.5). Complications were minimal, consisting of postoperative fever 1 day in duration. A viable kidney was provided for transplantation in each case. The extraperitoneal, rectus abdominis muscle and nerve sparing incision resulted in a short course of pain medication, early diet toleration and a short hospital stay.

Immune response: Effects of operative stress in a pediatric model

Purpose: The purpose of this study is to delineate the effect of different operative procedures on the cell-mediated immune response in a pediatric animal model using the delayed type hypersensitivity (DTH) skin test. Methods: Sprague Dawley rats (1 week old) were sensitized against keyhole limpet hemocyanin (KLH). Animals were challenged 2 weeks later by an intradermal injection of KLH (0.3 mg) in sterile saline. Rats with positive DTH skin reactions at 24 and 48 hours after challenge (baseline) were divided randomly into five groups (n = 10 each): group I, unmanipulated control; group II, anesthesia; group III, anesthesia and midline extraperitoneal incision; Group IV, anesthesia and laparoscopy (pneumoperitoneum with carbon dioxide); Group V, anesthesia and midline laparotomy. Before each procedure (day 0) and on postoperative days 3 and 6, animals were again challenged intradermally with KLH (0.3 mg). DTH skin reaction was evaluated 24 and 48 hours later. Results: A statistically significant difference ( P < .05) in DTH skin reaction at 24 and 48 hours was observed between postoperative days 1 to 5 in the extraperitoneal and laparotomy groups with respect to baseline and the control group. Statistically significant differences were found in postoperative days 1, 4, and 5 between laparoscopy and laparotomy. The laparoscopy group showed a statistically significant decrease in DTH skin induration on postoperative day 2 when compared with the control group. At postoperative day 7 and 8 there was no statistical difference in DTH skin response comparing baseline values or between groups. Conclusions: These results suggest that in a pediatric animal model, abdominal surgical procedures accompanied by extensive tissue dissection produce a cellular immunosuppression, lasting up to 7 days, which is not observed in less invasive procedures. Observations concerning lesser immunosuppressive effects of laparoscopy when compared with laparotomy in adult models, as previously described by our laboratory, were also found in this pediatric model.

Renal transplantation in very young children.

Results of renal transplantation in very young children with end-stage chronic renal failure have been poor compared with those in older children and adults. Consequently small children either may not be treated or may be placed on chronic dialysis programmes. Between 1988 and 1992, six children under the age of 5 years received seven renal transplants at the Royal Children's Hospital, Parkville, Victoria, Australia; five from live donors and two from cadaver donors. All children were treated with peritoneal dialysis before transplantation, and immunosuppressed with a standardized regimen of cyclosporine, azathioprine and prednisolone. An extraperitoneal incision was used, and the donor renal vessels were anastomosed to the lower abdominal aorta and inferior vena cava or the common iliac vein. All children received intensive monitoring and fluid replacement during the peri-operative period. Patient survival was 100%. One cadaver graft failed 1 week after transplantation because of irreversible acute rejection. This child subsequently received a successful second transplant. Two children developed postoperative urinary fistulae which were treated successfully by further operation. Current renal function in all children is excellent. The success of this programme has led us to review our attitude towards renal transplantation in this age group and to advocate live donor renal transplantation as the treatment of choice in very young children with end-stage chronic renal failure whenever possible.

Transdiaphragmatic Implantation of the Automatic Implantable Cardioverter Defibrillator

A new surgical approach for implantation of the automatic implantable cardioverter defibrillator without thoracotomy was used in 12 patients, aged 46 to 72 years. Preimplantation arrhythmia was ventricular tachycardia in 7 patients and ventricular fibrillation in 5 patients. The mean ejection fraction was 19%. Six patients were at high risk for general anesthesia for a variety of medical problems, and 2 patients had had a previous cardiac operation. Epidural anesthesia was used in 8 patients without intubation. The surgical approach used a longitudinal epigastric extraperitoneal incision with access to the heart through an incision made in the central tendon of the diaphragm. Two patches and two epicardial sensing leads were placed in all patients. All patients but one could be defibrillated with 20 J or less. There was no operative mortality and minimal morbidity. There were two late deaths due to heart failure. Thus, the transdiaphragmatic approach provides an excellent exposure for automatic implantable cardioverter defibrillator implantation, avoids general anesthesia and thoracotomy, and can be used after a previous cardiac operation.

An Incision for Extended Suprahilar Retroperitoneal Lymphadenectomy

To fulfill the necessary criteria for adequate exposure for extended suprahilar retroperitoneal lymphadenectomy we have used a thoracoabdominal midline extraperitoneal incision that affords the high exposure of a thoracoabdominal incision without sacrificing the broad exposure afforded by a midline incision and maintains the advantages of the extraperitoneal approach.

The value of the thoracoabdominal incision in the removal of kidney tumors.

ALTHOUGH the kidneys are situated below the diaphragm, they lie to a large extent within the thorax, sheltered by the lower ribs. Chiefly because the unyielding bony thoracic cage frequently bars the way to a free and satisfactory surgical exposure of the upper portion of the kidneys when they are enlarged, the lumbar extraperitoneal incision commonly used for renal surgery, with or without removal of the twelfth rib, and also the transperitoneal approach often leave a great deal to be desired in the way of exposure when one is dealing with large tumors of the kidney. While searching for an . . .

Transperiovenous nephrectomy and nephropexy

The author finds that for fixation of the kidney the most reliable methods are those where the kidney is suspended by the fibrous capsule to the rib with a piece of fascia or aponeurosis of the external oblique abdominal muscle. The normal incision for such nephropexy is an oblique, extraperitoneal incision.

THE SURGICAL TREATMENT OF URETERAL CALCULUS IN THE FEMALE.

The treatment of ureteral calculus in the female differs essentially from that in the male, owing to anatomic considerations. In the male, the comparatively straight course of the ureter from the kidney down to the bladder, and its position on the pelvic wall, make access to it comparatively easy through an extraperitoneal incision. In the female, however, the broad ligament, placed, as it is, directly above the most dependent portion of the ureter, renders access to the deep pelvic portion of the ureter a matter of some difficulty. Stones in either sex, impacted at any portion of the ureter from the kidney to the superior strait, are easy to remove. Stones in the female, impacted at any point between the base of the broad ligament and the bladder, are accessible through the vagina in the majority of instances; but stones in the female lying between the superior strait and the