Retroperitoneal Access Research Articles

Graft-Free surgical retroperitoneal vascular access as bail-out technique for failed percutaneous approach to transcatheter aortic valve replacement

Surgical retroperitoneal access to the iliac artery may provide an alternative route for transcatheter aortic valve replacement (TAVR) in patients with aortic stenosis and prohibitively small common femoral arteries. Consecutive patients undergoing TAVR via the femoral approach were divided into two groups; standard percutaneous access (n=103) and surgical retroperitoneal access (n=15) for patients in whom dilators could not be advanced without resistance. For retroperitoneal access, proximal groin vessels were exposed surgically and direct puncture was performed. The sheath was tunneled from the level of the initial inguinal puncture site in order to achieve coaxial entry of the sheath into the vessel. Baseline characteristics were similar in both groups. Procedural characteristics were insignificantly different between groups; although, procedure time was longer (34 min), while fluoroscopy time and contrast utilization were lower in the retroperitoneal access group. There was no outcome difference between groups. Surgical retroperitoneal access is a reasonable alternative for transcatheter aortic valve replacement in high-risk patients with aortic stenosis who have poor percutaneous access options due to peripheral vascular disease.

Métodos radiológico-quirúrgicos para la identificación de anomalías celiaco-mesentéricas de la arteria hepática ante una duodenopancreatectomía

IntroductionUp to 45% anatomical variations are found in hepatic arterial system. Identifying these anatomical anomalies before or during surgery would prevent additional morbidity in performing a duodenopancreatectomy. They are routinely identified before surgery using CT imaging, but on certain occasions they are not reported and are only discovered during the surgical operation. The initial retroperitoneal access by the superior mesenteric artery (SMA) will avoid a fairly useless intervention if there is superior mesenteric artery invasion, and will identify the anatomical variations originating in the superior mesenteric artery. These anomalies acquire importance in that their unnoticed injury could lead to severe vascular compromise and/or perioperative bleeding. ObjectivesTo analyse celiac-mesenteric anomalies of the hepatic artery before duodenopancreatectomy using the information from multidetector computed tomography (MDCT) using a non-standardised method, a standardised method with multidimensional reconstruction, and maximum intensity projection (MIP), after initial surgical access to the SMA. Patients and methodsA retrospective study of the clinical, histopathological and surgical variables was conducted on patients with an indication for duodenopancreatectomy in our Department from 2008 until April 2010. A study was performed on the reports made after image acquisition by MDCT. A blind, three-dimensional, MIP reconstruction was performed on all the patients to identify arterial anomalies. A description is given of hepatic artery anomalies after initial access to the SMA. ResultsA total of 61 patients were included in the study. The mean age was 65±11 years, with 33 (54%) males and 28 (46%) females. Vascular anomalies, right hepatic artery (RHA) (SMA) substitute (subst), 5 (8%); RHA (SMA) accessory (acc), 4 (7%); left hepatic artery (LHA) (left gastric artery) (LGA) acc 3 (5%); common hepatic artery (CHA) (SMA) subst 3 (5%); RHA (SMA) acc+LHA (LGA) acc2 (3%); CHA (aorta) subst, 1 (2%); RHA+RGA+2 LHA (celiac trunk), 1 (2%); and CHA (SMA)+LHA (LGA) acc. ConclusionOn being able to identify arterial anomalies with a mixture of preoperative radiological and methodological criteria, with three-dimensional reconstruction, MIP, and initially performing a dissection of the superior mesenteric artery could avoid duodenopancreatectomies that may not benefit the patient and compromise bleeding.

Retroperitoneal Total Laparoscopic Live Donor Nephrectomy (RTLLDN): First Three Case in the UK/Europe

Background: Laparoscopic Living donor Nephrectomy is a standard method of donor nephrectomy across in most of the transplant centres. Though trans-peritoneal approach is used widely, retroperitoneal access implies direct approach to the retroperitoneal organs. This offers an intrinsic advantage of minimizing the early and late potential intra-peritoneal complications. Retroperitoneal donor nephrectomy is infrequently performed and there has been no documented European experience in this technique. However, given the potential advantages, few centres in the US have started the transition from trans-peritoneal to retroperitoneal technique. We report the first three cases in the UK performed at our centre. Aim: To report the safety, feasibility and outcomes of the retroperitoneal total laparoscopic live donor nephrectomy. Methods: The donor nephrectomies with retroperitoneal technique were performed in June 2011 and were analysed retrospectively. The donors were evaluated according to BTS guidelines for living donors. The side of the nephrectomy was chosen as per renal vascular anatomy and split GFR Results:Table 1Table: [Results 1: Donor Outcomes]Table: [Results 2: Recipient Outcomes]Recipient Outcomes Conclusion: Our primary experience shows RTLLDN is as safe as other conventional techniques and excellent primary graft functions were obtained.

Management of infected pancreatic necrosis using retroperitoneal necrosectomy with flexible endoscope: 10 years of experience

This study was designed to provide our experience in the management of infected and drained pancreatic necrosis using the retroperitoneal approach. This was a prospective observational study in a tertiary care university hospital. Thirty-two patients with confirmed infected pancreatic necrosis were studied. Superficial necrosectomy was performed with lavage and aspiration of debris. This was achieved though a retroperitoneal approach of the pancreatic area and under the direct vision of a flexible endoscope. The follow-up procedure using retroperitoneal endoscopy did not require taking the patient to the operating room. The main outcome measures were infection control, morbidity, and mortality related to technique, reintervention, and long-term follow-up. No significant morbidity or mortality related to the technique was observed in all of the patients with infected pancreatic necrosis treated with this retroperitoneal approach compared with published data using other approaches. Reinterventions were not required and patients are currently asymptomatic. Retroperitoneal access of the pancreatic area is a good approach for drainage and debridement of infected pancreatic necrosis. Translumbar retroperitoneal endoscopy allows exploration under direct visual guidance avoiding open transabdominal reintervention and the risk of contamination of the abdominal cavity. This technique does not increase morbidity and mortality, can be performed at the patients' bedside as many times as necessary, and has advantages over other retroperitoneal approaches.

Comparison of Complications of Anterolateral and Lateral TransPsoatic Retroperitoneal Approaches to the Th12-L5 Intervertebral Disks. Experience with 208 Patients

Introduction Anterior lumbar interbody fusion using supportive cage is a common surgical method for treating degenerative lumbar spinal diseases. Improved surgical techniques and better results have led to renewed interest in this procedure and to the development of new lateral transPsoatic minimally invasive access to the lumbar disks. The aim of this study was to compare the rate of complications during traditional anterolateral and new lateral transPsoatic retroperitoneal approaches to the intervertebral disks (IVD) at levels Th12-L5. Materials and Methods We reviewed all cases of the IVD anterolateral and lateral surgery at level Th12-L5, treated at the Department of Neurosurgery from January 1996 to June 2011. The ALIF (Anterior Lumbar Interbody Fusion) group consisted of 120 patients: 53 women and 67 men, average age 44 years, range 17 to 76 years; and the XLIF (Extreme Lateral Interbody Fusion) group consisted of 88 patients: 50 women and 38 men, average age 51 years, range 17 to 74 years. They suffered from low back pain (LBP) and usually radiculopathy itself and conservative treatment was not effective for a minimum of 6 months. The diagnosis was established using generally accepted methods including history-taking and physical examination, radiography, and magnetic resonance imaging (MRI) of the lumbosacral (LS) spine. The preoperative diagnosis of ALIF group was degenerative disk disease at 39 levels, failed back surgery syndrome (FBSS) at 27, spondylolisthesis at 27, and posttraumatic disk injury at 35 levels. The preoperative diagnosis of XLIF group was DDD at 39, FBSS at 22, spondylolisthesis at 17, retrolisthesis at 5, and posttraumatic disk injury at 9 levels. The whole surgery, including surgical approach in the lateral decubitus position, was performed by an experienced neurosurgical team. The surgical steps in the minimally invasive anterolateral retroperitoneal approach and lateral retroperitoneal transPsoatic approach from the left side to disks Th12-L5 are described. Intraoperatively during XLIF procedure, the surgeon identified the lumbar nerve roots with stimulator to prevent their injury. All surgical intraoperative and postoperative complications directly related to the spinal surgery were documented. Both study groups were compared to each other. Results In both the groups, we had no serious complications such as death, excessive intra- or postoperative bleeding, thromboembolism, infection, visceral injury, injury of ureter or kidney, ileus, retrograde ejaculation, or sterility. In ALIF group, intra- and postoperative minor complications were found in 35 patients (29%), the main intraoperative complication was the necessity to perform sympathectomy of lumbar sympathetic chain to obtain wide access to the disks in 19 patients (16%). For all of these patients with symptoms of sympathectomy the thermography was done as a sensitive test. The main postoperative complications were numbness of left anterolateral thigh or groin or transient pain of left groin in 16 patients (13%). In XLIF group, we had partial and transient injury of L5 nerve root (just the first patient) during implant insertion at level L4/5 (one patient, 1%), without using an intraoperative neuromonitoring (IOM). Since this major complication, we started using IOM strictly and didnát have more nerve injuries. In XLIF group, intra- and postoperative minor complications were found in 20 patients (23%), mainly transient pain of left groin in 11 patients and sympathectomy in 4 patients. At follow-up, we found no hardware failure on X-ray (implant displacement). Total 198 patients were satisfied with the surgery and reported improvement, 10 patients were neither improved nor worsened. Conclusion Rate of minor complications was similar in both groups, in ALIF group 29% and in XLIF group 23% of treated patients. Only one major complication, nerve root injury, was due to underestimation of XLIF procedure in the beginning. Retroperitoneal access and surgery at levels Th12-L5 disk space is a safe procedure when performed by a knowledgeable and experienced spine team. IOM during XLIF surgery is fully recommended. I confirm having declared any potential conflict of interest for all authors listed on this abstract Yes Disclosure of Interest None declared Crock HV. Anterior lumbar interbody fusion: indications for its use and notes on surgical technique. Clinical Orthopaedics 1982;165:157–163 Faciszewski T, Winter RB, Lonstein JE, Denis F, Johnson L. The surgical and medical perioperative complications of anterior spinal fusion surgery in the thoracic and lumbar spine in adults. Spine 1995;20:1592–1599 Mayer HM. A new microsurgical technique for minimally invasive anterior lumbar interbody fusion. Spine 1997;22:691–700 Mehren C, Mayer HM, Siepe C, Grochulla F, Korge A. The minimally invasive anterolateral approach to L2-5. Oper Orthop Traumatol 2010;22:221–228 Zdeblick TA, David SM. A prospective comparison of surgical approach for anterior L4-L5 fusion. Spine 2000;25:2682–2687

The Anterior Extraperitoneal Replacement of the Intervertebral Disk L5/S1—Safe Solution for Treatment of Degenerative Disk Disease. Experience with 187 Patients

Introduction Despite increased use of anterior spinal surgery, there is little documentation of the specific types and frequencies of complications associated with its use. Review of the spinal surgery literature revealed a dearth of studies that address the morbidity and mortality rates in large samples of patients who had undergone anterior surgery specifically at level L5/S1. The aims of this study were to report prospectively the incidence and specific types of perioperative complications that occur with minimally invasive anterior retroperitoneal spinal surgery performed at level of the L5/S1 intervertebral disk. Materials and Methods We reviewed all cases of anterior surgery at level L5/S1, treated at the Department of Neurosurgery from January 2001 to June 2011. The study group consisted of 187 patients: 111 women and 76 men, average age 45 years, range 24 to 76 years. The preoperative diagnosis was degenerative disk disease in 96 (51%), failed back surgery syndrome (FBSS) in 55 (30%) and spondylolisthesis in 36 patients (19%). They suffered from low back pain (LBP) and radiculopathy itself and conservative treatment was not effective for a minimum of 6 months. The diagnosis was established using generally accepted methods including history-taking and physical examination, radiography and magnetic resonance imaging (MRI) of the lumbosacral (LS) spine. Total 69 (37%) patients had undergone one or more prior abdominal surgeries including appendectomy in 34 (18% of 187 patients), Pfannenstiel incision in 40 (36% of 111 female); and cholecystectomy in 4, gastric surgery and inguinal hernia in 2 each and umbilical hernia in 1. The whole operation, including surgical approach, was performed by an experienced neurosurgical team. ALIF (Anterior Lumbar Interbody Fusion) was performed in 155 patients, including 96 patients with stand-alone fusion, 12 patients with concomitant anterior plating (Oracle plate, Synthes, USA) and 47 patients with additional posterior TP (transpedicular) fixation (USS, Synthes, USA). Arthroplasty (TDR) was done in 32 patients. The surgical steps in the minimally invasive anterior retroperitoneal approach from the right side to disk L5/S1 are described. All surgical intraoperative anatomical anomalies and complications directly related to the anterior spinal surgery were documented. Results Intraoperative pathological-anatomical anomalies were found in 38 patients (20%). We had no serious complications such as death, excessive intra- or postoperative bleeding, thromboembolism, infection, visceral injury, ileus, LS plexus injury, retrograde ejaculation or sterility. Intra- and postoperative minor complications were found in 24 patients (11%), the main intraoperative complication was peritoneal opening without visceral injury in 9 patients (5%), and the main postoperative complication was weakness of the right abdominal wall in 5 patients (2.5%). At follow-up we found no hardware failure on X-ray (implant displacement or pseudoarthrosis). Clinically, no patient was worse after surgery. Total 176 patients were satisfied with the surgery and reported improvement, 11 patients were not improved and we later indicated posterior TP fixation at L5/S1 segment for enhancement of the stability. Conclusion Retroperitoneal access and surgery at level L5/S1 disk space is a safe procedure when performed by a knowledgeable and experienced spine team and can be used with confidence when the nature of a patientás spinal disorder dictates its use. During surgical planning for an anterior approach to the LS spine the surgeon must assess carefully the neuroimaging results, such as MRI, to minimize potentially disastrous vascular complications. I confirm having declared any potential conflict of interest for all authors listed on this abstract Yes Disclosure of Interest None declared Cepellades J, Pellisé F, Rovira A, Grivé E, Pedraza S, Villanueva C. Magnetic resonance anatomic study of iliocava junction and left iliac vein positions related to L5-S1 disc. Spine 2000;25:1695–1700 Cho DS, Kim SJ, Seo EK, Chung IH, Oh ChS. Quantitative anatomical and morphological classification of the ilias vessels anterior to the lumbosacral vertebrae. Journal of Neurosurgery Spine 2005;3:371–374 Ebraheim NA, Xu R, Farooq A, Yeasting RA. The quantitative anatomy of the iliac vessels and their relation to anterior lumbosacral approach. Journal of Spinal Disorder 1996;9:414–417 Faciszewski T, Winter RB, Lonstein JE, Denis F, Johnson L. The surgical and medical perioperative complications of anterior spinal fusion surgery in the thoracic and lumbar spine in adults. Spine 1995;20:1592–1599 Korge A, Siepe C, Mehren C, Mayer HM. Minimally invasive anterior approaches to the lumbosacral junction. Oper Orthop Traumatol 2010;22:582–592 Mayer HM. A new microsurgical technique for minimally invasive anterior lumbar interbody fusion. Spine 1997;22:691–700 McAfee PC, Regan JJ, Geis WP, Fedder IL. Minimally invasive anterior retroperitoneal approach to the lumbar spine. Emphasis on the lateral BAK. Spine 1998;23:1467–1484 Rajaraman V, Vingan R, Roth P, Heary RF, Conklin L, Jacobs GB. Visceral and vascular complications resulting from anterior lumbar interbody fusion. Journal of Neurosurgery (Spine 1) 1999;91:60–64

Simultaneous Laparoscopic Kidney Tumor Resection and Pyelolithotomy Performed with Retroperitoneal Access

Introduction: For more than 50 years surgery has remained the main method of treatment of kidney tumors in every stage of this disease, but the attitude to the management of renal masses underwent a rapid evolution during the last decade.1,2 Owing to a wide application of modern imaging techniques, especially ultrasonography and computed tomography, we have been observing the phenomenon of stage migration. This has caused the increase of a number of incidentally diagnosed renal tumors, many of which are small. Laparoscopic approach to renal tumors has gradually replaced open procedures for the treatment of low-stage renal tumors.3 Case Description: We present the case of a 60-year-old man who suffered from the pain in the left lumbar area. A plain film and intravenous urography showed a stone located in the left renal pelvis. The stone was recurrent because the patient already underwent the percutaneous lithotripsy a few years before. Computed tomography confirmed the presence of the stone and additionally showed the 20-mm tumor located in the lower pole of the same kidney. We assumed the presence of the tumor in the lower pole of the kidney as a contraindication for the next percutaneous nephrolithotripsy (PNL); thus, we suggested to the patient the simultaneous management of both conditions. We applied the retroperitoneal access with three trocars as a routinely used procedure in our center. The working space was created according to Gaur's technique. Two 10-mm and one 5-mm trocars were introduced under finger guidance and located in a shape of triangle with a base on a middle axillary line. In the beginning of the procedure, the Gerotaís fascia was widely opened to obtain the access to the kidney. Then, the kidney was mobilized and the tumor was localized. The cutting line around the tumor was marked with the argon beam coagulation. The tumor was completely enucleated without applying the warm ischemia. For larger masses we routinely obtain vascular control and attempt to take some normal renal tissue around the mass to ensure negative margins. Hemostasis of the lodge was obtained with argon-beam coagulation and Tachosil, which, combined together, entirely stopped the bleeding. To avoid the tumor spillage it was placed in the plastic bag of our own production, and then removed through the skin incision. Subsequently, pyelotomy was performed. The dissection of the renal hilum and the pelvis was constricted because of the presence of scary tissue after previously performed PNL. The stone was removed as a whole, placed in the same bag, and removed in the same way as the tumor. The Double-J catheter was placed intraoperatively along the guidewire to secure the water-tightness and the healing. The renal pelvis was reconstructed with the continuous suture. The hemostasis checkup was done and the drainage was placed. Results: Total operation time was 150 minutes; the blood loss was 200 mL. Postoperative course was uncomplicated. The patient was discharged from hospital on the 5th day after the surgery. Pathology report revealed the renal clear cell carcinoma, Fuhrman grade 2, with negative surgical margins. Conclusions: In our opinion, simultaneous kidney laparoscopic procedures are feasible and may be recommended in selected cases of coexisting disorders such as stones and tumors. No competing financial interests exist. Runtime of video: 9 mins

Surgical complications of the anterior approach to the L5/S1 intervertebral disc

The aims of this study were to describe the incidence and type of perioperative complications that occur with minimally invasive anterior retroperitoneal spinal surgery performed at the level of the L5/S1 intervertebral disc. A retrospective review of 175 patients: 103 women and 72 men, average age 45, who had undergone anterior spinal surgery at level L5/S1 from January 2001 to February 2011. The preoperative diagnoses were: degenerative disc disease in 87 (50%), failed back surgery syndrome in 53 (30%) and spondylolisthesis in 35 patients (20%). The surgical steps in the minimally invasive anterior retroperitoneal approach from the right side to disc L5/S1 are described. All surgical intraoperative anatomical anomalies and complications directly related to the anterior spinal surgery were documented. Intraoperative pathological-anatomical anomalies were found in 34 patients (19%) and intra - and postoperative minor complications in 24 patients (12%) but no serious complications. The main intraoperative complication was peritoneal opening without visceral injury (5%) and the main postoperative complication was weakness of the right abdominal wall (3%). . Retroperitoneal access and surgery at level L5/S1 disc space is a safe procedure when performed by a knowledgeable and experienced spine team. During surgical planning for an anterior approach to the LS spine, the surgeon must carefully assess the neuroimaging results, such as MRI, to minimize potentially disastrous vascular complications.

Reprinted Article “Endovascular Repair with Bifurcated Stent-Grafts under Local Anaesthesia to Improve Outcome of Ruptured Aortoiliac Aneurysms”

Introduction Acute haemodynamic changes and/or loss of abdominal muscle tone can occur during induction of general anaesthesia and may be the Achilles’ tendon in endovascular aneurysm repair (EVAR) of ruptured aortoiliac aneurysms (rAIA). The purpose of this study was to evaluate the use of local anaesthesia (LA) for EVAR to overcome these limitations. Methods Twenty-one consecutive patients with rAIA are included in this study. Twenty patients underwent EVAR under LA, and 1 patient was treated under general anaesthesia. Haemodynamics were stabilised during assessment of EVAR feasibility by CT-scan and during the procedure itself by controlled hypotension (MAP 50-60 mmHg) and moderate fluid resuscitation. Results Median procedure time was 120 min. Haemodynamics remained stable in all but 3 patients who required transfemoral balloon occlusion of the supra-renal aorta. Perioperative intubation was necessary in 5 patients because of respiratory distress (n = 3), or retroperitoneal access (n = 2). Temporary deterioration of renal function occurred in 6 patients, with 2 requiring hemofiltration. CT-scan confirmed sealing of the rAIA in all patients at discharge. 30-day mortality was 9.5% (2 deaths). In the median follow-up of 19 months, there were no deaths, but 3 endovascular re-interventions, 1 crossover femoro-femoral bypass, and 1 open surgical graft repair. Discussion Our series is the first to show that EVAR for rAIA can be safely performed under LA. This approach allows implantation of commercially available bifurcated SG and improves patient outcome.

Retroperitoneal Laparoscopic Live-Donor Nephrectomy: Introduction of Simple Hand-Assisted Technique (Without Hand Port)

Objective Compared with the transperitoneal approach, retroperitoneal laparoscopic live-donor nephrectomy offers a substantial advantage. However, retroperitoneal access is more difficult because of the limited working space. The objective of this study was to report our experience with hand-assisted retroperitoneal laparoscopic live-donor nephrectomy without a hand port. Materials and Methods Intraoperative and immediate postoperative surgical outcomes were reviewed for 23 modified retroperitoneal laparoscopic live-donor nephrectomies performed from May 2009 to January 2010. All kidneys were from living related donors. No prisoners or organs from prisoners were used in this study. Results Retroperitoneal laparoscopic live-donor nephrectomy was successfully completed in all patients, without conversion to open surgery. Mean (range) operative was 114 (98–130) minutes; warm ischemia time was 1.6 (1.3–2.1) minutes; estimated blood loss was 20 (10–50) mL; and postoperative hospital stay was 6.9 (5–10) days. No serious complications such as massive bleeding or bowel injury occurred. In 1 patient, a hematoma of renal fossa developed, which was successfully treated at repeat operation. All kidneys demonstrated good primary function except 1 that exhibited delayed graft function. Conclusions Retroperitoneal laparoscopic live-donor nephrectomy combines the benefits of both hand assistance and the retroperitoneal approach, to minimize the risk of short- and long-term complications associated with the transabdominal approach. The technique could be a cost-effective procedure suitable for use in developing countries.

Minimally Invasive Adrenalectomy: A Multicenter Comparison of Transperitoneal and Retroperitoneal Approaches

Minimally invasive adrenalectomy (MIA) is both feasible and safe with either transperitoneal or retroperitoneal entry. However, only a few studies have rigorously compared these two techniques. The aim of the current study is to compare transperitoneal and retroperitoneal adrenalectomy to detect significant differences in patient selection and perioperative outcomes. Between 1995 and 2009, 171 patients underwent MIA through transperitoneal (n = 127) or retroperitoneal access (n = 44). The respective cohorts were then examined retrospectively through matched and unmatched comparisons. Multivariate analyses of intraoperative blood loss, postoperative morbidity, and length of hospital stay were performed. Surgical indications were benign lesions (70.2%), malignant tumors (11.1%), and pheochromocytomas (18.7%). The postoperative morbidity rate was 15.8 per cent, but mortality was null. The rate of conversion to open surgery was 5.3 per cent. Blood loss and operative time were significantly lower with the transperitoneal approach, whereas time to oral intake was shorter for the retroperitoneal group. Tumor size less than 4.5 cm was associated with less blood loss, shorter hospital stay, and lower postoperative morbidity. Laparoscopic and retroperitoneal routes are both effective and safe for excising adrenal lesions. In the present study, however, laparoscopic adrenalectomy demonstrated shorter operative times with less blood loss. Regardless of this, we remain cautious in recommending one procedure preferentially. Other important measures of clinical outcome such as required pain control, ease of patient recovery, and cost considerations were not included in this analysis. Further randomized trials, with large patient numbers, are therefore desirable for defining an optimal surgical method.

Retroperitoneal Versus Direct Femoral Artery Approach for Thoracic Endovascular Aortic Repair Access: A Case–Control Study

Many individuals who are candidates for thoracic endovascular aortic repair (TEVAR) are found to have iliac artery anatomy and/or disease that preclude transfemoral endovascular access and require retroperitoneal surgical approach through more proximal arteries. This relatively more invasive technique could potentially affect the procedural outcomes. This study compares the retroperitoneal with transfemoral access used for TEVAR in a single center. In this study, 133 consecutive patients (96 men; mean age ± SD: 69.5 ± 14.7 years) who underwent TEVAR between 1994 and 2009 in a single center were retrospectively evaluated. The type of endovascular access was identified in all the patients. The basic demographics, access method, endograft type, 30-day morbidity and mortality rates, as well as procedure recordings including fluoroscopic and procedure duration, estimated blood loss, and duration of hospitalization were compared between the TEVAR procedures performed using a surgical retroperitoneal approach and those using the standard femoral access. Retroperitoneal access was used in 19 (14.3%; 13 women; mean age ± SD: 71 ± 12.2 years) and direct femoral access in 114 (85.7%; 24 women; mean age ± SD: 69 ± 15.4 years) patients. Two of the retroperitoneal accesses were obtained after failure of femoral approach. Techniques that were used included iliac artery conduit (seven patients), aortic artery conduit (eight patients), aortobifemoral artery graft conduit (one patient), and direct sheath introduction through the distal aorta (two patients) or common iliac artery (one patient). Retroperitoneal approach was used more frequently in women (35%) as compared with men (6%) (p = 0.0001). In all, 79% of the retroperitoneal approaches were associated with use of delivery sheath sizes larger than 24F (p = 0.049). TEVAR technical success was 100% with retroperitoneal and 97.3% with femoral access (p > 0.05). Thirty-day mortality rates were 0% and 8.8% and the rates of access artery injury were 5.3% and 4.4% in retroperitoneal and femoral access groups, respectively (p > 0.05). The incidence of retroperitoneal hematoma was significantly higher with retroperitoneal access (21% vs. 2.6%, p = 0.008). Additionally, retroperitoneal access was associated with significant increase in estimated blood loss and duration of hospitalization (p < 0.05). Type of access does not affect TEVAR success and the early mortality rate. Retroperitoneal approach is a valuable alternative technique in cases involving failed or impossible femoral access. However, this approach is associated with higher chances of retroperitoneal bleeding and longer procedural time and duration of hospitalization. Thoracic endografts with smaller delivery systems could minimize the need for this approach in the future.

Retroperitoneoscopic Living Donor Nephrectomy: Experience of 425 Cases at a Single Center

Laparoscopic living donor nephrectomy (LLDN) is a standard method of donor nephrectomy. Most cases of LLDN are transperitoneal. Retroperitoneal access, however, implies a direct approach to the retroperitoneal organs without interfering with any of them. Since 2001, we have been trying to establish the technique of retroperitoneoscopic live donor nephrectomy (RPLDN). To assess the safety, feasibility, and usefulness of RPLDN, we reviewed the experience with this technique at our institution. From July 2001 to March 2009, 425 patients underwent live donor renal transplantation at our institution with allografts procured by RPLDN. Study variables included operative time, time to retrieval of the kidney, blood loss, warm ischemia time, length of hospital stay, number and length of renal vessels, graft function, and complications. Mean follow-up was 53 months. Donor nephrectomy was performed successfully in all patients. The complication rate was 4.9%. In one case, the procedure was changed to open donor nephrectomy because of severe adhesion in the renal hilum from previous surgery. Ureteral complications occurred in four patients, who were successfully treated with retrograde ureteral stent placement. None of the donors needed readmission. Mean warm ischemia time was 4.8 minutes. Creatinine levels returned to normal in all patients, and long-term allograft function was good. Serum creatinine levels at postoperative days 1, 7, and 14 were 3.7 mg/dL, 1.4 mg/dL, and 1.4 mg/dL on average, respectively. Slow graft function was noted in four (1.1%) cases but returned to the normal level within 2 weeks after surgery. One-year donor survival was 99%, and 1-year graft survival was 98.2%. Excellent donor safety and allograft function were obtained with RPLDN. These results suggest that RPLDN could be an option for LLDN.

The challenges with NOTES retroperitoneal access in humans

Animal studies have supported natural orifice transluminal endoscopic surgery (NOTES) retroperitoneal access. NOTES also may offer unique retroperitoneal access in humans. This study was designed to assess the feasibility of endoscopic transgastric and transrectal retroperitoneal access in a cadaver model using prone and supine positioning, and to compare NOTES retroperitoneal examination with endoscopic ultrasound. Using a multidisciplinary team, this institutional review board-approved study evaluated transgastric and transrectal retroperitoneal examination in six cadavers (3 male, 3 female; body mass index range, 25-37 kg/m(2)). Endoscopic ultrasound retroperitoneal examination preceded NOTES access. Transgastric Access: Using a prototype dual channel endoscope, a needle knife gastrotomy was created on the preantral posterior gastric wall. Retroperitoneal examination specifically targeted the pancreas and surrounding structures with the cadaver supine and prone. Transrectal Access: Using the same endoscope, a posterior needle knife rectotomy distal to the upper valve of Houston provided extraluminal access. Retroperitoneal examination proceeded with the cadaver prone and supine. Open dissection followed procedure completion. Access into the retroperitoneum succeeded at all sites. Significant challenges locating identifiable landmarks were faced-mostly transrectal and improved transgastric prone. All cadavers, despite body mass index or sex, had significant retroperitoneal adipose tissue limiting the endoscopic view. Although porcine studies have highlighted successful NOTES retroperitoneal procedures, the abundant human retroperitoneal adipose tissue challenged the translation of porcine research to humans. Additionally, although access to the retroperitoneal space and dissection within this space were accomplished easily, the appearance of cadaveric tissue and lack of blood flow made confident landmark identification impossible. Further study should continue in this area and focus on confident landmark identification for directed dissection. In a cadaveric model, this would best be improved by pre-NOTES anatomic marking or active perfusion of vasculature along with consideration of direct entry into the retroperitoneum from a targeted intraperitoneal site in clinical patients.

The Cold Knife: A New Laparoscopic Instrument for Ureteropelvic Junction Incision

The use of laparoscopic scissors or blades in laparoscopic nondismembered pyeloplasty is quite common; however, the incision made using these tools may cause difficulties for the surgeon. We developed an efficient, safe, reusable, and inexpensive instrument to incise the pelvis and ureter during laparoscopic pyeloplasty. The aim of the present study was to evaluate the new laparoscopic instrument designed for pelvic and ureteric incisions. The cold knife consists of an internal urethrotome that is transformed into an endoscopic instrument that can be inserted easily through a 5-mm-diameter trocar. It has a manual retraction system that enables a stand-by position for added protection when no incisions are being made. The new tool was trialed in laparoscopic Y-V pyeloplasty. Data regarding perioperative parameters and outcomes were collected and analyzed. Eight patients participated in the present study. All patients underwent Y-V pyeloplasty using a three-port retroperitoneal access. Mean operative time was 166.2 minutes (range: 100-300). There were no complications during the procedures. Laparoscopic cold knife for laparoscopic pyeloplasty is a simple, safe, reusable, and inexpensive instrument with a low maintenance cost.

Retroperitoneal Laparoendoscopic Single-Site Surgery: Preliminary Experience in Kidney and Ureteral Indications

The advantages of retroperitoneoscopic technique are well known. We decided to combine this access with the emerging laparoendoscopic single-site surgery (LESS) technique. We present our preliminary data on 11 renoureteral procedures and describe our retroperitoneoscopic LESS technique.As of March 2009, 10 patients were submitted to retroperitoneal LESS and divided into three groups: Group A, 3 patients underwent ureterolithotomy; Group B, 4 patients underwent renal cyst ablation; Group C, 4 patients underwent renal biopsy. Retroperitoneal access was obtained with an optical trocar. After retroperitoneal space blunt dissection, a multichannel port was placed. Standard and bent 5-mm instruments were used; we also used a 5-mm flexible laparoscope as a single procedure in group A. Ten of 11 procedures were completed without conversion; a single case in group A was converted to open surgery.Retroperitoneoscopic LESS is a safe and feasible procedure for renal biopsy and renal cyst ablation, with shorter convalescence time, less postoperative pain, and better cosmetic outcomes. LESS ureterolithotomy was more challenging for the lack of triangulation, resulting in a prolonged convalescence period. In addition, bent laparoscopic instruments are not suitable for retroperitoneal space; the multichannel port leaks carbon dioxide due to the flank position. Therefore LESS pelvic trainer practice is imperative in this case.

Totally videoendoscopic descending thoracic aorta-to-femoral artery bypass

Descending thoracic aorta to femoral artery bypass is an effective and safe procedure for the treatment of aortoiliac occlusive disease when an approach to the abdominal aorta is undesirable. The major limitation of this technique has resulted from the morbidity rate associated with thoracotomy in a relatively high-risk vascular surgery population. As a minimally invasive procedure, videoendoscopy has been shown to improve the patient postoperative course and comfort in the field of general and thoracic surgery. The same benefits could be expected from a videoendoscopic surgery involving the thoracic aorta. In 2003 we reported the first case of a totally videoendoscopic descending thoracic aorta-to-femoral artery bypass procedure. In this article we report our additional experience with and the modifications we have made to this technique.

Modified Ilioinguinal Approach to the Acetabulum and Pelvis from beneath the Inguinal Ligament: A Subinguinal Approach

The ilioinguinal approach is favoured for fractures of the anterior part of the pelvis, but it is associated with some technical difficulties and it is not suitable for some complex fractures. In 2008, a modified ilioinguinal approach was introduced by Farid Yr which afforded visualisation of the inside and outside of the pelvis. The approach involves retroperitoneal access below the inguinal ligament to preserve the integrity of the inguinal canal and allows exposure of anterior and medial wall fractures as well as the anterior hip capsule. Despite the dimensions of the procedure, closure is anatomical because repair of the inguinal canal floor is not required. We report the use of this approach in 17 patients with T-type fractures of the acetabulum, transverse fractures of acetabulum, Tile C1 pelvic fractures, malunion of the pelvis and acetabular dysplasia. The approach is recommended in complex cases of acetabular surgery (including obese or muscular patients) and complicated or old fractures in which a better exposure is required. It is useful in visualisation of the anterior wall and labrum and intra articular structures, and in viewing the internal anatomy of the pelvis and acetabulum. It may be a suitable approach for periacetabular osteotomy.

Surgical Anatomy of the Retroperitoneal Spaces, Part V: Surgical Applications and Complications

Knowledge of the surgical anatomy of the retroperitoneum is crucial for surgery of the retroperitoneal organs. Surgery is essential for treatment of retroperitoneal pathologies. The list of these diseases is extensive and comprises acute and chronic inflammatory processes (abscess, injury, hematoma, idiopathic fibrosis), metastatic neoplasms, and primary neoplasms from fibroadipose tissue, connective tissue, smooth and striated muscle, vascular tissue, somatic and sympathetic nervous tissue, extraadrenal chromaffin tissue, and lymphatic tissue. The retroperitoneum can be approached and explored by several routes, including the transperitoneal route and the extraperitoneal route. The retroperitoneal approach to the iliac fossa is used for ectopic renal transplantation. Safe and reliable primary retroperitoneal access can be performed for laparoscopic exploration. The anatomic complications of retroperitoneal surgery are the complications of the organs located in several compartments of the retroperitoneal space. Complications may arise from incisions to the somatic wall, somatic nerves, blood and lymphatic vessels, lymph nodes, visceral autonomous plexuses, and neighboring splanchna.

Transvaginal Hybrid Natural Orifice Transluminal Endoscopic Surgery Retroperitoneoscopy—The First Human Case Report

Retroperitoneal and transabdominal laparoscopic access to retroperitoneal organs became the golden standard for treatment of most adrenal and renal diseases. Natural orifice surgery is a promising concept in the evolution of minimal access surgery. The possibility of a natural orifice transluminal endoscopic surgery (NOTES) transvaginal retroperitoneal access to diagnose and perform retroperitoneal surgery was developed in our institution, aiming an alternative natural orifice less-invasive approach. Institutional review board approval was obtained from the institution for clinical transvaginal NOTES. A 67-year-old woman (body mass index = 35.6 kg/m(2)) found to have a large renal cyst situated in the lower pole with compression symptoms was subjected to the technique. Transvaginal retroperitoneal access was obtained by direct vision open technique, the space was digitally dissected, and a flexible two-channel colonoscope progressed the dissection to the left kidney. The cyst was dissected using endoscopic instruments, and resection was completed with use of two laparoscopic instruments because of peritoneal tear with loss of retropneumoperitoneum. NOTES transvaginal retroperitoneoscopy was performed, and anatomical landmarks, such as left ureter, inferior mesenteric artery (IMA), vena cava, and aorta, were identified. Insufflation and orientation were hazardous, because of constitutional fat, and operative time was 210 minutes. Postoperative course was complicated by postoperative face and neck enphysema, which disappeared after few days. Observation was maintained for 4 postoperative days, and the patient was discharged without other complications. Follow-up at 30 days was uneventful. This first human procedure using flexible transvaginal retroperitoneoscopy showed feasibility of the access, but inadequate instruments led to technical difficulties for therapeutical purposes. However, the new concept of minimally invasive NOTES retroperitoneoscopy may open new therapeutic indications in clinical practice in the near future.