Modified Flank Position Research Articles

Robot-Assisted Laparoscopic Pyeloplasty: Technical Considerations and Outcomes

Since first being described in 1993, laparoscopic pyeloplasty has proven to be less morbid but equally as effective as open pyeloplasty. The technical complexity of the procedure, however, has made it difficult for many surgeons to adopt. The da Vinci robot-assisted laparoscopic pyeloplasty (RP) was introduced to shorten the learning curve. We present our institutional experience with RP. Between October 2005 and September 2006, 29 RPs were performed and prospectively recorded in a database. The patient population consisted of 18 (62%) women and 11 (38%) men with a mean age of 41.2 years (range 17-82 years). Outcomes were retrospectively reviewed. Procedures were performed transperitoneally in a modified flank position using a 4-port template. Mean follow-up was 11 months (range 6-17 months). Eighteen (62%) patients had ureteropelvic junction (UPJ) obstruction on the right, while 11 (38%) patients had obstruction on the left. Nine (31%) patients presented for secondary repair, all because of failed endopyelotomy. Mean operative time was 196 minutes (range 120-420 min), estimated blood loss was 39 mL (range 25-250 mL), and length of hospital stay was 2.2 days. Crossing vessels were encountered in 20 (69%) patients. Procedures in two patients, encountered early in our series, required open conversion. Both were secondary repairs after failed Acucise endopyelotomy. There were two readmissions, one for flank pain and another for pyelonephritis. There were no recurrences based on both subjective and radiologic measures. We demonstrate that RP is a technically feasible management option for UPJ obstruction with success rates comparable to those of conventional laparoscopic and open pyeloplasty.

Laparoscopic transabdominal extraperitoneal repair of lumbar hernia

Lumbar hernias need to be repaired due to the risk of incarceration and strangulation. A laparoscopic intraperitoneal approach in the modified flank position causes the intraperitoneal viscera to be displaced medially away from the hernia. The creation of a wide peritoneal flap around the hernial defect helps in mobilization of the colon, increased length of margin is available for coverage of mesh and more importantly for secure fixation of the mesh under vision to the underlying fascia. Laparoscopic lumbar hernia repair by this technique is a tensionless repair that diffuses total intra-abdominal pressure on each square inch of implanted mesh. The technique follows current principles of hernia repair and appears to confer all benefits of a minimal access approach.

Laparoscopic radical nephrectomy incorporating intraoperative ultrasonography for renal cell carcinoma with renal vein tumor thrombus

The purpose of this study was to describe the technique of laparoscopic right radical nephrectomy incorporating intraoperative, real-time ultrasonography in the management of renal cell carcinoma with level 1 renal vein tumor thrombus. With the patient in a modified flank position, a transperitoneal four-port approach was used to laparoscopically resect an 8.5-cm right renal mass with tumor thrombus extending to, but not into, the inferior vena cava. Early arterial control with gentle traction on the right renal vein provided a short proximal renal venous segment devoid of tumor on laparoscopic inspection. Intraoperative laparoscopic ultrasonography allowed confident identification of the proximal extent of the tumor thrombus. After hilar control, complete resection and intact removal of the renal specimen was performed using standard non-hand-assisted laparoscopic techniques. The actual surgical time was 180 minutes. Surgical resection was successfully performed laparoscopically. No postoperative complications or hospital readmission occurred. Pathologic examination confirmed T3b renal cell carcinoma with negative surgical margins. Laparoscopic right radical nephrectomy incorporating intraoperative, real-time ultrasonography is feasible in the management of renal cell carcinoma with a large-sized level 1 renal vein thrombus. Additional studies are necessary to evaluate its role in urologic oncologic surgery.

Lateral gluteal myonecrosis in a patient undergoing partial nephrectomy in the modified flank position

This is the first report of postoperative rhabdomyolysis occurring in a patient positioned in the “modified flank position,” with the kidney rest positioned under the top of the iliac crest. The patient was treated with aggressive intravenous fluid hydration and hyperbaric oxygen therapy with maintenance of normal renal function and near complete recovery of gluteal muscle function.

Anterior Extraperitoneal Approach to Laparoscopic Retroperitoneal Lymph Node Dissection: A Novel Technique

We describe a novel technique of laparoscopic retroperitoneal lymph node dissection via an anterior extraperitoneal approach. With the patient in a modified flank position an 8 mm. incision is made along the lateral border of the ipsilateral rectus muscle at the umbilical level. Extraperitoneal space creation with finger dissection is initially made at this site and adequately enlarged with a balloon dilator, followed by gas insufflation and placement of 4 laparoscopic trocars. Laparoscopic retroperitoneal lymph node dissection based on a left modified template is then performed in a completely extraperitoneal manner. Surgical time was 330 minutes, blood loss was 150 ml. and 58 lymph nodes were removed. Resumption of physical activity and oral intake was achieved on postoperative day 1. Hospital stay was 36 hours. Postoperative narcotic requirement was 28 mg. morphine sulfate equivalent. There were no intraoperative or postoperative complications. Normal antegrade ejaculation returned postoperatively. This novel surgical technique is technically feasible and associated with satisfactory clinical outcomes in our preliminary study. Further studies are necessary to evaluate its potential as an alternative to the previously reported transperitoneal and retroperitoneoscopic approaches to laparoscopic retroperitoneal lymph node dissection.

RADIO FREQUENCY COAGULATION TO FACILITATE LAPAROSCOPIC PARTIAL NEPHRECTOMY

The advent of cryotherapy and radio frequency ablation technology offers the opportunity to treat renal tumors in a minimally invasive fashion. Drawbacks of these techniques include the possibility of incomplete ablation and the need for aggressive followup imaging. As an alternative laparoscopic partial nephrectomy has been limited by difficult hemostasis in some cases. To overcome this problem we combined these techniques and performed radio frequency coagulation of a renal mass before laparoscopic resection. CASE REPORT A 48-year-old woman presented with left flank pain. Computerized tomography revealed a partially exophytic, enhancing 1.5 cm. left renal mass. All treatment options were discussed and the patient elected laparoscopic partial nephrectomy. She was placed in the modified flank position, and 2, 10 mm. and 2, 5 mm. transperitoneal ports were placed as for standard laparoscopic nephrectomy. The descending colon was reflected and Gerota’s fascia was opened. The middle and lower poles were mobilized, and the tumor was easily identified on the lateral aspect of the kidney (fig. 1, A). Laparoscopic ultrasound confirmed the distinct nature of the mass. Using laparoscopic visualization, the “dry” radio frequency 16 gauge, 7 prong needle electrode probe was percutaneously positioned into the lesion. The prongs were deployed to 1.5 cm. into and through the lesion (fig. 1, B). Radio frequency was delivered at 50 W. and then autoregulated to maintain an average temperature of 100C at this level for 8 minutes according to the recommendation of the manufacturer. Coagulation of the tumor was obvious with visible charring. The tumor and a 0.5 cm. margin of normal parenchyma were excised (fig. 2). Frozen section analysis of the deep margin was negative for tumor. As a safety measure the argon beam coagulator was used to coagulate the cut surface before fibrin glue was applied. There was no appreciable blood loss during tumor excision. The patient was discharged home on postoperative day 1. Radio frequency coagulation did not alter cellular architecture allowing for accurate histological assessment. Final pathological examination revealed grade 2, clear cell renal cell carcinoma with negative margins, including overlying fat. DISCUSSION