Hand Assisted Research Articles

Laparoscopic Hand Assisted Radical Cystectomy With Ileal Conduit Urinary Diversion

Hand assisted laparoscopy was originally described in the early 1990s. Since then many studies have shown that hand assisted techniques have the same advantages of laparoscopy including decreased need for postoperative narcotics and rapid return to routine activities. Laparoscopic techniques are advancing rapidly and intracorporeal laparoscopic cystectomy is reported. To our knowledge we report the first case of hand assisted, laparoscopic radical cystectomy with ileal conduit urinary diversion. A 68-year-old male with rapidly recurring grade III transitional cell carcinoma elected to undergo hand assisted radical cystectomy. We performed a radical cystectomy with bilateral pelvic lymph node dissection removing the specimen through the hand port site. The ileal loop urinary diversion was constructed by pulling the small bowel through the hand port incision. We made another separate hole for the stoma and a drain was placed through a port site. The incisions were closed in the standard fashion. Operative time was 7 hours with 750 cc of blood loss and no complications. All surgical margins were negative. The patient did well and was discharged from the hospital on postoperative day 7 with return to normal activity without limitations at 4 weeks. To our knowledge this is the first reported case of hand assisted laparoscopic radical cystectomy with ileal loop diversion. Hand assistance facilitated this technically demanding surgery resulting in a good outcome without significant added operative time.

Comparison of Hand Assisted and Standard Laparoscopic Radical Nephroureterectomy for the Management of Localized Transitional Cell Carcinoma

Hand assisted laparoscopy affords the surgeon tactile sensation and blunt dissection, which are currently limited using the standard laparoscopic technique. Therefore, we compared standard and hand assisted laparoscopic radical nephroureterectomy for localized upper tract transitional cell carcinoma. The medical records of 27 patients who underwent standard (11) or hand assisted (16) laparoscopic radical nephroureterectomy between April 1998 and January 2001 were retrospectively reviewed. The parameters of efficacy, efficiency, safety and convalescence were compared. Mean patient age was 64 and 66 years (p = 0.72) in the standard and hand assisted groups, and the mean American Society of Anesthesiologists score was 2.5 and 2.7 (p = 0.64), respectively. All standard and 15 of the 16 hand assisted (94%) procedures were successfully completed via laparoscopy. Total operative time was more than 1 hour shorter for hand assisted than for laparoscopic radical nephroureterectomy (4.9 versus 6.1 hours, p = 0.055). Mean estimated blood loss was similar in the standard and hand assisted groups (190 and 201 ml., p = 0.78). In each group 1 patient required blood transfusion. Mean specimen weight was significantly higher in hand assisted cases (576 versus 335 gm., p = 0.036). Mean time to oral intake was similar in patients who underwent standard and hand assisted laparoscopic radical nephroureterectomy (13 and 20 hours, respectively, p = 0.45). The mean analgesic requirement was also similar (29 and 33 mg. morphine sulfate, respectively, p = 0.83). Mean hospital stay in uncomplicated cases was similar for standard and hand assisted surgery (2.9 and 2.5 days, respectively). Overall hospital stay in the 2 cohorts was also similar (3.3 and 4.5 days, respectively, p = 0.59). Four patients per group experienced postoperative complications. There were no deaths in the standard group but 1 patient (6%) in the hand assisted group died postoperatively. Mean time to partial and complete convalescence in the standard and hand assisted groups was 2.4 and 5.2, and 3.5 and 8.0 weeks, while mean followup was 27.4 and 9.6 months, respectively. Compared with standard laparoscopy hand assisted laparoscopy decreases operative time without significantly altering short-term parameters of convalescence. However, long-term convalescence after hand assisted laparoscopic radical nephroureterectomy is 1 to 3 weeks longer (p = 0.27). Longer followup in the hand assisted cohort is necessary to determine whether there are any differences in the 2 methods in regard to cancer control.

Repair of a Diaphragmatic Injury During Hand Assisted Laparoscopic Nephrectomy Using an Onlay Patch of Polypropylene and Polyglactin Mesh

We describe a simple and time efficient technique for repairing a diaphragmatic injury occurring during right hand assisted laparoscopic radical nephrectomy. A dual layer polypropylene and polyglactin mesh was created extracorporeally by sewing a 2 x 2 piece of polypropylene mesh to a 2 x 2 piece of polyglactin mesh with 4, 4-zero interrupted polyglactin sutures. This dual layer was then positioned manually over the diaphragmatic rent and secured with a laparoscopic stapling device. A 16Fr chest tube was placed at the conclusion of the procedure. Overall operative time was 3.5 hours with an estimated blood loss of 100 cc. Repair of the diaphragmatic injury extended operative time by 25 minutes. Extubation was done at the conclusion of the case and the chest tube was removed within 36 hours of the procedure. The patient was discharged home on postoperative day 3. At 14 months of followup the patient remained disease-free on radiography and without pulmonary or gastrointestinal sequelae. We describe a simple and time efficient technique for repairing diaphragmatic injury occurring during right hand assisted laparoscopy. This technique takes advantage of the manual and tactile sensation provided by the hand assistance device, provides a tension-free repair and avoids laparoscopic suturing.

LAPAROSCOPIC BILATERAL HAND ASSISTED NEPHRECTOMY FOR AUTOSOMAL DOMINANT POLYCYSTIC KIDNEY DISEASE: INITIAL EXPERIENCE

The laparoscopic technique for bilateral nephrectomy in patients with autosomal dominant polycystic kidney disease is technically difficult. The procedure may be more acceptable if alterations to the technique made it safer and easier to perform. We describe our initial experience with, and the feasibility and potential benefits of hand assisted laparoscopic nephrectomy for approaching these large kidneys in patients with autosomal dominant polycystic kidney disease. This approach was successfully applied in 3 patients with end stage renal disease due to autosomal dominant polycystic kidney disease. After obtaining transumbilical pneumoperitoneum ports were placed in the umbilicus (12 mm.), sub-xiphoid in the midline (12 mm.) and subcostal in the midclavicular line on each side (12 mm.). The table was tilted 40 degrees away from the planned side of initial nephrectomy with the patient in the half lateral position. A 7 cm. midline incision was made that incorporated the umbilical port and a commercially available hand assistance device was positioned. One surgeon hand was inserted into the abdomen to serve as a retractor/blunt dissector, while the other operated the electrosurgical instruments. The right hand was inserted for left nephrectomy and the left hand was inserted for right nephrectomy. The laparoscope was passed via the sub-xiphoid port and the instruments were placed through the ipsilateral subcostal laparoscopic port. Nephrectomy was completed and the specimen was removed through the hand port incision by draining the cysts as they were exposed to view via the midline incision. When dissection was difficult, an additional port was placed in the anterior axillary line at the umbilical level. Some cysts were ruptured or aspirated to decrease overall kidney size and make extraction possible via the 6 to 7 cm. midline incision. All procedures were successfully completed. Mean operative time for bilateral hand assisted laparoscopic nephrectomy was 5.5 hours (range 4.5 to 6.6). Estimated blood loss was 200 cc or less. Patients resumed oral intake on postoperative day 1. The mean amount of parenteral analgesics required postoperatively was decreased. Mean hospital stay was 4.3 days but it was 3 days when considering nephrectomy only. Patients returned to normal activity after an average of 2 weeks. There was sustained resolution of preoperative discomfort based on pain analog scales. At 1 month or less all patients recorded absent pain. They uniformly noticed improved preoperative pulmonary and gastrointestinal symptoms Hand assisted laparoscopic nephrectomy in patients with autosomal dominant polycystic kidney disease makes bilateral nephrectomy a reasonable option. The bilateral procedure may be performed as rapidly as laparoscopic only, unilateral nephrectomy in these cases. The advantages of the hand assisted approach include using tactile sensation to facilitate dissection, rapid blunt finger dissection, hand retraction and the application of immediate tamponade when needed. This procedure provides the benefits of minimal intraoperative blood loss, minimal postoperative pain, brief hospital stay and rapid convalescence in this group of patients at high risk.

LAPAROSCOPIC PARTIAL NEPHRECTOMY WITH A MICROWAVE TISSUE COAGULATOR FOR SMALL RENAL TUMOR

LAPAROSCOPIC PARTIAL NEPHRECTOMY WITH A MICROWAVE TISSUE COAGULATOR FOR SMALL RENAL TUMOR

LAPAROSCOPIC RADICAL NEPHROURETERECTOMY FOR UPPER TRACT TRANSITIONAL CELL CARCINOMA: THE CLEVELAND CLINIC EXPERIENCE

We report our single institutional experience with retroperitoneal laparoscopic radical nephroureterectomy in patients with upper tract transitional cell carcinoma and compare results to those achieved by the open technique. A total of 77 patients underwent radical nephroureterectomy for pathologically confirmed upper tract transitional cell carcinoma. Of these patients 42 underwent laparoscopic nephroureterectomy from September 1997 through January 2000 and 35 underwent open surgery. All specimens were extracted intact. Of the laparoscopic group the juxtavesical ureter and bladder cuff were excised by our novel transvesical needlescopic technique in 27 and radical nephrectomy was performed retroperitoneoscopically in all 42. Data were compared retrospectively with 35 patients undergoing open radical nephroureterectomy from February 1991 through December 1999. Laparoscopy was superior in regard to surgical time (3.7 versus 4.7 hours, p = 0.003), blood loss (242 versus 696 cc, p <0. 0001), specimen weight (559 versus 388 gm., p = 0.04), resumption of oral intake (1.6 versus 3.2 days, p = 0.0004), narcotic analgesia requirements (26 versus 228 mg., p <0.0001), hospital stay (2.3 versus 6.6 days, p <0.0001), normal activities (4.7 versus 8.2 weeks, p = 0.002) and convalescence (8 versus 14.1 weeks, p = 0.007). Complications occurred in 5 patients (12%) in the laparoscopic group, including open conversions in 2, and in 10 (29%) in the open group (p = 0.07). Followup was shorter in the laparoscopic group (11.1 versus 34.4 months, p <0.0001). The 2 groups were similar in regard to bladder recurrence (23% versus 37%, p = 0.42), local retroperitoneal or port site recurrence (0% versus 0%) and metastatic disease (8.6% versus 13%, p = 1.00). Mortality occurred in 2 patients (6%) in the laparoscopic group and 9 (30%) in the open group. Cancer specific survival (97% versus 87%) and crude survival (97% versus 94%) were similar between both groups (p = 0.59). In patients with upper tract transitional cell carcinoma who are candidates for radical nephroureterectomy the retroperitoneal laparoscopic approach satisfactorily duplicates established technical principles of traditional open oncological surgery, while significantly decreasing morbidity from this major procedure. Short-term oncological and survival data of the laparoscopic technique are comparable to open surgery. Although long-term followup data are not yet available, it appears that laparoscopic radical nephroureterectomy may supplant open surgery as the standard of care in patients with muscle invasive or high grade upper tract transitional cell carcinoma.

NEPHRON SPARING SURGERY FOR SUSPECTED MALIGNANCY: OPEN SURGERY COMPARED TO LAPAROSCOPY WITH SELECTIVE USE OF HAND ASSISTANCE

Laparoscopic nephron sparing surgery has been reported rarely, likely due to technical difficulty when using only laparoscopic instrumentation. Hand assisted techniques may facilitate the procedure in select cases while maintaining the benefits of minimally invasive surgery. We prospectively compared the laparoscopic with selective hand assistance and open surgical approaches to nephron sparing surgery for suspected malignancy. We compared our initial 10 laparoscopic nephron sparing procedures for suspected malignancy, including 8 with hand assistance, in 9 patients (11 tumors) with 11 consecutive open surgical procedures for similar indications. Standard laparoscopic technique was used in cases of an exophytic mass with shallow penetration into the parenchyma. Otherwise hand assistance was used. Recovery data were obtained prospectively using self-administered questionnaires. Although mean operative time was 24% greater in the laparoscopic group, recovery was more favorable than in the open surgical group, as evidenced by 62% less parenteral narcotic use, 43% shorter hospital stay, 64% more rapid return to normal nonstrenuous activity, and improved pain and physical health scores 2 and 6 weeks postoperatively. In each group mean lesion diameter was 2.4 cm., 8 of 11 neoplasms were malignant and no margins were positive for malignancy. There were no conversions to open surgery and no major complications in the laparoscopic group. Laparoscopic nephron sparing surgery appears to have an advantage over open surgery in terms of patient recovery. Facilitation by hand assistance may make laparoscopic nephron sparing surgery a more widely available, minimally invasive alternative to open surgery for small, favorably located renal tumors.

PROSPECTIVE, CASE MATCHED COMPARISON OF HAND ASSISTED LAPAROSCOPIC AND OPEN SURGICAL LIVE DONOR NEPHRECTOMY

The technical difficulty of standard laparoscopic live donor nephrectomy has limited its application. Hand assistance, which takes advantage of the incision necessary for organ removal, facilitates laparoscopy without significant impact on patient recovery. We prospectively compared open surgical and hand assisted laparoscopic donor nephrectomy. Our first 10 laparoscopic live donor nephrectomies were matched with 40 open donor nephrectomies by gender, age and body mass index. Data were obtained by pain scales, SF-12 survey instruments, questionnaires and chart abstraction. Operative time was longer for the laparoscopic approach (mean 95 versus 215 minutes). However, laparoscopic group patients had a shorter hospital stay compared to those undergoing open surgery (mean 2.9 versus 1.8 days), returned sooner to nonstrenuous activity (mean 19.0 versus 9.9 days) and reported less pain 6 weeks postoperatively (mean 2.3 versus 0.6) (p </=0.03 for all). There were no differences between groups in terms of donor complications, allograft function and ureteral complications. Mean hospital cost was 23% greater in the laparoscopic group (p = 0.005) but global cost, which accounted for estimated loss of income from work during the recovery period, was only 15% greater (p = 0.10). Mean operative time was significantly improved for our second compared to our first 5 laparoscopic group patients (177 versus 254 minutes). Laparoscopic live donor nephrectomy appears to be a safe and effective alternative to open donor nephrectomy. Indexes of patient recovery suggest patient morbidity similar to that reported following standard laparoscopic donor nephrectomy and significantly less than after open nephrectomy. Improvement in operative time in the first 10 cases suggests that hand assistance "shortens" the learning curve, which might encourage more surgeons to offer laparoscopic live donor nephrectomy.

RETROPERITONEOSCOPIC NEPHROURETERECTOMY FOR RENAL PELVIC TUMORS WITH A SINGLE ILIAC INCISION

Retroperitoneal laparoscopy, by providing direct access to the retroperitoneal cavity, is a useful approach to urological surgery. We applied this technique to nephroureterectomy in patients with tumors of the renal pelvis. Between January 1995 and March 1997 we performed 4 retroperitoneal laparoscopic nephroureterectomies in patients with tumors of the renal pelvis. The patients were placed in the lateral decubitus position. Five trocars were used. Balloon dilation was not contributory. Radical nephrectomy was performed and the kidney was left in the retroperitoneal space. Via an iliac incision ureterectomy with a bladder cuff was performed and the specimen was removed (kidney and ureter) en bloc via this incision without opening the urinary tract. One right and 3 left nephroureterectomies were performed with an average operating time of 220 minutes (range 160 to 300). Average kidney size was 110 mm. (range 100 to 120). Average hospital stay was 5.7 days (range 5 to 7). Blood loss was minimal and postoperative analgesic requirements were moderate. Conversion to open surgery was never necessary. The morbidity rate was zero. The pathological stages were pT2 G2, pT3 G2, pT3G3 and pT3 G2-G3 N+. A local recurrence was observed in a patient with a pT3 G3 tumor. Nephroureterectomy can be performed by retroperitoneal laparoscopy. The perioperative morbidity and hospital stay are reduced. Further followup is required to evaluate long-term results in terms of cancer outcome.

HAND ASSISTED LAPAROSCOPIC NEPHRECTOMY: COMPARISON TO STANDARD LAPAROSCOPIC NEPHRECTOMY

Purpose We report our initial experience with hand assisted laparoscopic nephrectomy, and compare it to our results of standard laparoscopic nephrectomy. Materials and Methods The results of 21 hand assisted and standard laparoscopic nephrectomies (15 simple and 4 radical nephrectomies, and 2 nephroureterectomies) were reviewed. Hand assisted laparoscopic nephrectomy was performed with a hand placed intra-abdominally using the Pneumo Sleeve, * * Dexterity, Inc., Blue Bell, Pennsylvania. in addition to standard laparoscopic instruments manipulated through laparoscopic ports. Standard laparoscopic nephrectomy was performed using laparoscopic instruments alone. Perioperative data were recorded and questionnaires, including visual analog pain scales, were administered prospectively to 17 of 21 cases. Results The average operative time for 13 hand assisted laparoscopic nephrectomies was 240 minutes, which was significantly less than the 325-minute average for 8 standard laparoscopic nephrectomies (p = 0.04). Major complications tended to be more frequent in the standard group (38 versus 8%, p = 0.10). Hospital stay, return to normal activity and corrected 2-week abdominal/flank pain score in the hand assisted group (3.1 days, 14 days and 0.8, respectively) were not significantly different from the standard group (3.0 days, 10 days and 0.2, respectively). Conclusions Compared to standard laparoscopic techniques, hand assistance appears to facilitate the operative speed and safety of laparoscopic nephrectomy without sacrificing the benefits of minimally invasive surgery. Hand assistance may make laparoscopic nephrectomy more appealing to urologists without advanced laparoscopic experience, may facilitate the laparoscopic management of demanding pathological conditions and is particularly useful when intact specimens are required. Hand assistance, by improving manipulative ability and tactile sense, is helpful for select cases of laparoscopic nephrectomy.

Transurethral Resection of the Intramural Ureter as the First Step of Nephroureterectomy

Nephroureterectomy is the standard surgical approach for upper urinary tract carcinoma. In 1952 a modified technique was described based on a prior endoscopic disconnection of the intramural ureter as an initial step for subsequent nephroureterectomy via a single lumbar incision. Since October 1989 we performed 31 nephroureterectomies with this technique in 26 men and 5 women (average age 64.5 years). Of the patients 9 had prior bladder carcinoma. The predominant pathological diagnosis of the nephroureterectomy specimens was high grade infiltrating tumor. There were no intraoperative complications except for 1 case of intra-abdominal extravasation detected in the immediate postoperative period and treated conservatively. With an average followup of 20 months, tumor has not recurred at either the resected trigonal area or the retroperitoneum. We believe that our experience assesses the feasibility of this technique to improve and simplify nephroureterectomy, thus, decreasing the morbidity rate and operating time while maintaining the same oncological radicality.