Retroperitoneal Group Research Articles

Should stage IIIC ovarian cancer be further stratified by intraperitoneal vs. retroperitoneal only disease?: A Gynecologic Oncology Group study

ObjectiveTo examine whether clinical outcomes varied with intraperitoneal (IP) and/or retroperitoneal (RP) involvement in stage IIIC epithelial ovarian cancer (EOC) patients with microscopic residual disease after cytoreduction. MethodsRetrospective review was performed for EOC patients enrolled in Gynecologic Oncology Group (GOG)-182 who underwent primary cytoreduction to microscopic residual disease. Patients were divided into 3 groups: stage IIIC by lymphadenopathy with <2cm IP spread (RP); >2cm IP spread and negative nodes (IP/RP−); and >2cm IP dissemination and positive lymphadenopathy (IP/RP+). Product-limit and multivariate proportional hazards modeling were used. ResultsAnalyses included 417 stage IIIC women who underwent primary cytoreduction with lymphadenectomy to microscopic residual. There were 203, 123, and 91 in the RP, IP/RP−, and IP/RP+ groups, respectively. IP/RP+ and IP/RP− were associated with worse progression-free survival (PFS) (Hazard Ratio (HR) 1.68, 95% confidence interval (CI) 1.23–2.30; HR 1.38, 95% CI 1.04–1.84) vs. RP only. IP/RP+ was associated with worse overall survival (OS) (HR 1.79, 95% CI 1.24–2.57) while IP/RP− trended towards worse OS (HR 1.21, 95% CI 0.85–1.73) vs. RP only. Median PFS for IP/RP+ and IP/RP− groups was 21 and 29months, respectively, vs. 48months in the RP group (p=0.0007) and median OS of 63 and 79months vs. “not reached,” respectively (p=0.0038). ConclusionsAmong EOC patients surgically cytoreduced to microscopic residual disease, those upstaged to IIIC by retroperitoneal involvement demonstrated significant improvement in PFS and OS compared to patients with intraperitoneal tumor, suggesting that these women may represent a unique subset of FIGO stage IIIC patients.

Comparison of retroperitoneal and transperitoneal approach for reconstruction of abdominal aortic aneurysm in patients with previous laparotomy

Although the standard surgical approach for repair of infrarenal abdominal aortic aneurysm (AAA) has been the transperitoneal approach, several reports have suggested the usefulness of retroperitoneal aortic reconstruction. However, the superiority of the retroperitoneal compared with transperitoneal approach is still controversial. To compare the efficacy of the retroperitoneal with that of the transperitoneal approach in elective AAA resection, 19 consecutive cases with previous laparotomies were randomly reviewed. From January 1990 through December 1992, 94 consecutive patients underwent elective reconstructions of an infrarenal AAA. Among them, 75 patients had had no previous surgery of any kind. In all of them, the transperitoneal approach was used (Group I). Nineteen other patients who had various laparotomies were randomly divided into two groups. The transperitoneal approach was used in 10 patients (Group II), and the retroperitoneal approach was used in 9 patients (Group III). Thus, the patients were separated into three groups and the intra- and postoperative parameters were compared. Surgical data including operative time, intraoperative blood loss, and aortic cross-clamping time did not differ significantly between the transperitoneal approach in the patients without laparotomy (Group I) and the retroperitoneal approach (Group II). In addition, the postoperative recovery including the initiation of alimentation and postoperative hospitalization also did not differ significantly between the two groups. However, there was a significant difference in the operative time and the blood loss between the retroperitoneal approach (Group II) and transperitoneal approach (Group III) in the patients with previous laparotomy. In addition, the postoperative parameters including the initiation of oral intake was sooner and hospitalization was significantly shorter in the retroperitoneal group (Group II) than in the transperitoneal group (Group III) with previous laparotomy. There was no incidence of postoperative adhesive ileus in the patients with the retroperitoneal approach (Group II). The results demonstrated no important advantage for the retroperitoneal approach compared with routine transperitoneal approach in the patients without previous laparotomy. However, in the patients with previous laparotomies, the retroperitoneal approach is a preferable alternative to the transperitoneal route.

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.

Comparison of different radical resection of renal pelvis carcinoma

Objective To investigate the surgical technique and clinical effectiveness of retroperitoneal laparoscopic nephroureterectomy with transurethral bladder-cuff excision and open nephroureterectomy in pelvis carcinoma. Methods We retrospectively analysed the records of all 62 patients who underwent retroperitoneal laparoscopic or open nephroureterectomy in Tianjin Dagang Hospital or the Second Affiliated Hospital of Tianjin Medical University from July 2001 to July 2009. Variables analyse were compared including operative time, blood loss, turning to open operation, complications, length of stay, tumor recurrence and metastasis. Groups were compared using Student's t-test, and a probability (P) value of less than 0.05 was taken to indicate statistical significance. Results The respective mean operative duration [(47.34±39.16) vs (118.17±44.65) ml], length of hospital stay [(9.15±2.19) vs (11.64±3.71) d], time to ambulation [(3.58±0.79) vs (5.67±1.24) d]and blood loss [(70.64±27.33) vs (118.17±44.65) ml]in retroperitoneal laparoscopic nephroureterectomy with transurethral bladder-cuff excision group was significantly reduce to open nephroureterectomy group (t = 3.3167, 2.0587, 8.0494, 5.1777, P ＜0.05). There was no significantly difference between two groups in complication of during operation and post operation [4.8 % (2/42) vs 5.0 %(1/20), 0 vs 0, respectively](P ＞0.05). 4 cases were failed and conversed to open surgery in retroperitoneal laparoscopic nephroureterectomy group. During the follow up period range from 8-48 months, there was no significantly difference between two groups in tumor recurrence and metastasis [4.8 % (2/42) vs 5.0 % (1/20),2.4 % (1/42) vs 5.0 % (1/20), respectively](P ＞0.05). Conclusion Retroperitoneal laparoscopy in upper urinary tract transitional carcinoma uses a small incision, incurs less blood loss, and allows for a more rapid recovery, suggesting it is a safe and effective method for treating patients with renal and pelvis cancer. Key words: Kidney neoplasms; Kidney pelvis; Laparoscopy; Nephrectomy

Comparison of the application of retroperitoneal laparoscopy and open surgery in ureteropelvic junction obstruction

Objective To review and analyze the application of retroperitoneal laparoscopy and open surgery in ureteropelvic junction obstruction, sum up clinical expeirence, and improve the skills of retropeirtoneal laparoscopic surgery. Methods Retroperitoneal laparoscopic surgery was carired out in 22 csaes of ureteropelvic junction obstruction(retroperitoneal laparoscopy group). Open surgery was carried out in 21 cases(Open surgery group). The two groups were compared in operation time, blood loss postoperative discharge time and postoperative hospital stay respectively. Results Ureteropelvic junction obstruction group was significantly less than open surgery group in intraoperative bleeding time,postoperative bleeding time and average length of stay. Operation time in ureteropelvic junction obstruction group was slightly longer than that in open surgery group [(32.0 ± 10.0) ml vs (70.0 ± 11.9) ml, (31.0 ±5.7)h vs(52.0 ±6.9)h,(7.0 ± 1.6) d vs(14.0 ± 1.4) d, (113.0 ±7.6) min vs(72.0 ± 6.8) min] (t = 7.06,8. 14,11.37,11.36, all P ＜ 0.05). Conclusions Retroperitoneal laparoscopic technology was in the treatment of ureteropelvic junction obstruction for its direct way, had non interference and pollution to laparoscopic internal organs,less damage,less pain, rapid recovery and short hospitla stay. With on going training and constantly updating technical skills and equipments, retroperitoneal laparoscopic technology will shotren the operation time, and will substitute open surgery. Key words: Ureteral obstruction; Laparoscopy; Retroperitoneal space

Comparison of effect between retroperitoneal laparoscopic living donor nephrectomy and open surgery

Objective To study the advantage of retroperitoneal laparoscopic living donor nephrectomy through comparative study on postoperative care between retroperitoneal laparoscopic living donor nephrectomy and open surgery. Methods During the period from August 2007 to December 2009, living donor nephrectomy were divided into 25 cases of retroperitoneal laparoscopic surgery and 20 cases of open surgery. The nursing characteristics were compared. Results The operation and recovery of all patients are successful. The drainage tube indwelling days, urinary catheter indwelling days, postoperative bed time, days of absolute diet and hospitalization in retroperitoneal laparoscopic surgery group were significantly shorter than those in open surgery group(P <0. 01). Conclusions Retroperitoneal laparoscopic living donor nephrectomy has the advantages of minimally invasive, rapid recovery and fewer hospital days, Worth being popularized in clinical otolaryngology application Key words: Retroperitoneal laparoscopic liviny donor nephrectomy; Open surgery; Nursing

Retroperitoneal and Transperitoneal Robot-Assisted Pyeloplasty in Adults: Techniques and Results

BackgroundThe surgical management of ureteropelvic junction obstruction (UPJO) has dramatically evolved over the past 20 yr due to the development of new technology. ObjectiveOur aim was to report the feasibility and efficacy of robot-assisted pyeloplasty (RAP) performed by either the retroperitoneal or the transperitoneal approach. Design, setting, and participantsA stage 2 investigative study was conducted including development (stage 2a) and exploration (stage 2b) of transperitoneal and retroperitoneal RAP performed in 55 patients at an urban tertiary university department of urology. Surgical procedureRetroperitoneal RAP was performed with the patient in full flank position using a 12-mm Hasson-style optical port at the tip of the 12th rib, plus two operative 8-mm robotic trocars and an assistant 5-mm port. The stenotic ureteropelvic junction was excised, the ureter was spatulated, and a dismembered pyeloplasty was performed in all cases. Transperitoneal RAP was performed with the patients in the 60° flank position. The optical port is in the umbilical area, plus two 8-mm operative robotic ports and one 5-mm assistant port. The pyeloplasty technique is similar to the retroperitoneoscopic approach. In both groups, the stent can be positioned in an anterograde or retrograde fashion. MeasurementsSuccess consisted of no evidence of obstruction on computed tomography urography or mercaptoacetyltriglycine-3 diuretic renal scan, no postoperative symptoms, and no further treatment. Results and limitationsThirty-six patients underwent retroperitoneoscopic RAP and 19 transperitoneal RAP for UPJO. All the procedures were completed with robotic assistance. The overall objective success (measured by diuretic renal scan and/or imaging techniques) was 96% with two cases of recurrence (both in the retroperitoneal group). The main limitation was the short follow-up, although all patients reached at least a 6-mo follow-up. ConclusionsRAP performed either retroperitoneally or transperitoneally was revealed as a feasible and reproducible surgical option for the treatment of UPJO, offering a subjective optimal plasty reconfiguration at short follow-up.

Retroperitoneal versus Transperitoneal Laparoscopic Pyeloplasty: Our Experience

Objective: Laparoscopic pyeloplasty, which has been quoted to have a success rate equivalent to open pyeloplasty for ureteropelvic junction obstruction (UPJO), can be performed transperitoneally and retroperitoneally. The aim of the present study is to report our experience with these 2 routes of laparoscopic pyeloplasty and to further improve our understanding of the merits and demerits of these 2 routes. Patients and Methods: A total of 47 laparoscopic pyeloplasties were performed at our center from June 2000 to August 2009. Twelve pyeloplasties were performed transperitoneally and 35 retroperitoneally. Results: In the retroperitoneal group, we had a success rate of 91.5% after a mean follow-up of 22 months, and in the transperitoneal group, we had a success rate of 91.7% after a mean follow-up of 48 months. The mean operative time was 156 min in the retroperitoneal group and 195 min in the transperitoneal group. Conclusion: This study shows a success rate comparable with open pyeloplasty and favors the retroperitoneal route with a shorter operative time, less dissection needed, a higher sensitivity of detecting crossing vessels, a decreased risk in visceral injury and an early start of oral feeds.

Retroperitoneal Repair of Abdominal Aortic Aneurysms Offers Postoperative Benefits to Male Patients in the Veterans Affairs Health System

Transperitoneal (TP) and retroperitoneal (RP) approaches have equal efficacy in elective open abdominal aortic aneurysm (AAA) repair. The effect of open operative approach on patient-specific outcomes after AAA repair was tested. Consecutive patients undergoing open AAA repair at the Veterans Affairs Tennessee Valley Healthcare System between January 2000 and August 2008 were retrospectively reviewed. Analysis was performed to examine the effects of demographic and clinical covariates on postoperative outcomes. A total of 106 patients were identified: 54 with TP approach and 52 with RP approach. Demographics and preoperative comorbidities were equivalent (p > or = 0.10), with the exception of chronic obstructive pulmonary disease which was more prevalent in the TP group (61 vs. 40%). Operative times were longer in the TP group (4.6 vs. 3.5 hours; p < 0.01); however, significantly more TP patients had reconstruction with a bifurcated graft (72 vs. 2%; p < 0.01). Postoperative nasogastric tube decompression times were shorter in the RP group (1 vs. 3 days; p < 0.01), and RP approach led to a quicker return to preoperative diet (4 vs. 6 days; p = 0.05). Patients undergoing RP repair developed fewer incisional hernias (2 vs. 15%; p = 0.03). RP approach to AAA repair offers patients faster return of bowel function and is associated with fewer incisional hernias.

Laparoscopic Transperitoneal and Retroperitoneal Nephrectomies in Children: A Change of Practice

Laparoscopic nephrectomies (LNs) may be performed in children with benign renal disease by the transperitoneal (TP) or retroperitoneal (RP) approach. The aim of this study was to present our early results from using both the laparoscopic transperitoneal and retroperitoneal approach, highlighting the change in the approach to a better, simpler procedure performed by experienced surgeons. Between February 2002 and June 2006, 30 LNs were performed, with the first 10 patients by TP (group 1) and the remaining patients by RP (group 2). Two patients were not included. Demographic data were compared: mean age (88 vs. 66.6 months), gender (30% female vs. 70% male), and laterality (60% left-handed vs. 40% right-handed). Other factors were assessed, as well: Operating time was compared, as was morbidity, analgesics requirement, postoperative hospital stay, and time to resume oral intake. LN was performed in 28 of the 30 cases. One case in each group was converted. Both groups were similar regarding operating time (TP: 92.2 minutes vs. RP: 121.1), hospital stay (36.5 hours vs. 28.8), postoperative analgesia (2.1 doses of dipyrone and 1.2 doses of nalbuphine vs. 2.3 and 1.4). RP was associated with significantly faster postoperative analgesia tolerance than that of the TP approach (7.8 hours vs. 14.4; P < 0.05). Two (22.2%) patients in group 1 presented with vomiting, whereas no patients in group 2 had postoperative vomiting (P < 0.05). No further postoperative complications appeared. In our hands, both laparoscopic TP and RP approaches are equally safe and effective, but the operating time was slightly shorter (not significant) and postoperative recovery significantly longer for TP. LN may be performed by both approaches, obtaining equal efficacy. TP may be associated with minimal paralytic ileus within the first 12-24 hours, meanwhile RP is related with better surgical skill and postoperative tolerance.

Laparoscopic Decortication of Large Renal Cysts: A Comparison Between the Transperitoneal and Retroperitoneal Approaches

We compared the operative outcomes and follow-up results of laparoscopic decortication of large, simple renal cysts, performed by the transperitoneal (TP) and retroperitoneal (RP) approaches, and identified selection criteria for each approach. Between 2000 and 2007, 53 patients with renal cysts underwent laparoscopic decortication via the TP (n = 25) and RP approaches (n = 28), according to the location of the cysts. Operative and follow-up data were collected retrospectively, and the approaches were compared with regard to intra- and postoperative parameters, complications, and success rate. Among the 53 patients, 48 (90.5%) had their cysts completely removed, and in 5 (9.5%), the cyst size was reduced to less than one half of the initial cyst volume. Thirty-three patients (84.6%) had their symptoms completely relieved within 3 months, while 6 patients (15.3%) had continued mild pain. There were no significant differences in the symptomatic response and radiologic findings between the two approaches. The RP approach had the advantages of reduced operation time, time to oral intake and ambulation, as well as analgesic use. One patient in the RP group required laparoscopy to control postoperative bleeding. Based on the cyst location, as the major selection criteria, both approaches were comparable with regard to symptomatic improvement and radiologic findings. The retroperitoneal approach had the advantages of reduced operation time, time to oral intake and ambulation, as well as analgesic use. Therefore, we prefer to perform laparoscopic decortication by the retroperitoneal approach without mobilization of the bowel.

SURGICAL APPROACHES TO REVASCULARISATION OF AORTO-ILIACAL SEGMENT

Introduction: The retroperitoneal approach for abdominal aortic and iliac reconstruction classically had been reserved for select patients with either high-risk comorbid disease or specific anatomic problems that preclude the transabdominal approach. With increasing appreciation of the physiologic, anatomic, and technical advantages of the retroperitoneal approach, the authors have expanded its use for repair of all types of aorto-iliac artery disease as well as infected aortic grafts. The objective of this article is to determine whether retroperitoneal approach for aorto-iliac surgery has greater physiologic and technical advantages than transperitoneal approach. Patients and Methods: From January 2002 to May 2006, 344 retroperitoneal aortoiliac reconstructions were performed and 2 for infected aortic grafts. On the other hand we also performed 283 transperitoneal aortic and aorto-iliac reconstructions. From total number of operated patients for aorto-iliac disease, 99 patients fulfilled criteria for entrance in the study. Beside identical operative indication (aorto-iliac disease), patients were matched according to comorbidities, age, gender, and bad habits such as smoking and alcohol abuse. Results: The mean age was 61 years with 70 men and 29 women. Overall mortality was 1% for all cases: 2% for trnasperitoneal and 0% for retroperitoneal approach. Major complications occurred in 11% of all procedures, 8% in retroperitoneal and 14% in transperitoneal approach. Over the past 4.5 years, the average length of hospital stay for uncomplicated aorto-iliac reconstructions was 5.9 days in retroperitoneal group and 6.3 days in transperitoneal group, intensive care unit stay was 1.2 days in retroperitoneal and 2.5 days in transperitoneal group, and diet was resumed by postoperative day 1 in retroperitoneal versus postoperative day 3 in transperitoneal group. Two-year graft patency was 99% for retroperitoneal and 96% for transperitoneal approach. Discussion: The retroperitoneal approach offers greater physiologic advantages than transperitoneal approach, associated with minimal disturbance of gastrointestinal and respiratory function, thereby reducing the length of intensive care unit and hospital stay.

Evolution of the Technique of Laparoscopic Live Donor Nephrectomy at a Single Center: Experience with More than 350 Cases

Aim: To present our experience with laparoscopic live donor nephrectomy (LLDN), evolution of the technique and analysis with respect to the cost-effective modifications. Materials and Methods: This is a retrospective review of all the LLDNs performed at our institute from January 2001 to November 2006. Few of the cost-effective modifications to the procedure include use of metallic autoclavable ports and instruments, Hem-o-lock clips for ureter, renal artery and vein, and extraction of the graft manually without use of a specimen retrieval bag. Results: From January 2001 to December 2001, 42 laparoscopy-assisted LLDNs, and since December 2001 380 LLDNs were performed, which includes 342 cases of transperitoneal and 38 cases of retroperitoneal LLDN. The mean operative time was 180 ± 45 and 192 ± 35 min, mean blood loss was 85 ± 50 and 115 ± 50 ml, warm ischemia time was 4.5 ± 2 and 3.5 ± 1.5 min in transperitoneal and retroperitoneal LLDNs, respectively. The total number of conversions was 14, with 12 in the transperitoneal group and 2 in the retroperitoneal group. Mean hospital stay was 3.14 ± 1.5 days. Recipient mean serum creatinine at days 1, 3 and 7 was 2.56 ± 0.91, 1.63 ± 0.46 and 1.72 ± 0.25, respectively. The total cost incurred by the patient at our institute for LLDN including stay in the hospital was USD 500 ± 150. Conclusion: LLDN provides all the benefits of minimally invasive therapy to the donors while preserving allograft function in the recipients. Few technical modifications can make the procedure more cost-effective for routine use.

Cosmetic and functional outcomes following paramedian and anterolateral retroperitoneal access in anterior lumbar spine surgery

In this paper, the authors review the functional and cosmetic outcomes and complications in 300 patients who underwent treatment for lumbar spine disease via either an anterior paramedian or conventional anterolateral retroperitoneal approach. Seven surgeons performed anterior lumbar surgeries in 300 patients between August 2004 and December 2006. One hundred and eighty patients were treated with an anterior paramedian approach, and 120 patients with an anterolateral retroperitoneal approach. An access surgeon was used in 220 cases (74%). Postoperative evaluation in all patients consisted of clinic visits, assessment with the modified Scoliosis Research Society-30 instrument, as well as a specific questionnaire relating to wound appearance and patient satisfaction with the wound. At a mean follow-up of 31 months (range 12-47 months), the mean Scoliosis Research Society-30 score (out of 25) was 21.2 in the patients who had undergone the anterior paramedian approach and 19.4 in those who had undergone the anterolateral retroperitoneal approach (p = 0.005). The largest differences in quality of life measures were observed in the areas of pain control (p = 0.001), self-image (p = 0.004), and functional activity (p = 0.003), with the anterior paramedian group having higher scores in all 3 categories. Abdominal bulging in the vicinity of the surgical site was the most common wound complication observed and was reported by 22 patients in the anterolateral retroperitoneal group (18%), and 2 patients (1.1%) in the anterior paramedian group. Exposures of >or= 3 levels with the anterolateral approach were associated with abdominal bulging (p = 0.04), while 1- or 2-level exposures were not (p > 0.05). Overall satisfaction with incisional appearance was higher in patients with an anterior paramedian incision (p = 0.001) and with approaches performed by an access surgeon (p = 0.004). Patients who undergo an anterior paramedian approach to the lumbar spine have a higher quality of life and better cosmetic outcomes than patients undergoing an anterolateral retroperitoneal approach.

Laparoscopic adrenalectomy for adrenal tumors by transperltoneal or retroperltoneal approaches:a report of 41 cases

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

The retroperitoneal approach combined with epidural anesthesia reduces morbidity in elective infrarenal aortic aneurysm repair

In elective open infrarenal aortic aneurysm repair the surgical approach and the use of epidural anesthesia (EDA) may determine patients' outcome. Hence we analyzed our results after elective open aneurysm repair in the light of the surgical approach and the use of EDA. Retrospective analysis of a prospective data base. From December 2005 to April 2008, 125 patients with infrarenal aortic aneurysm underwent elective open repair. Patients were divided into four groups: retro- and transperitoneal approach with and without epidural anesthesia (RP+/-EDA and TP+/-EDA). In terms of age, sex, aneurysm diameter, ASA score and clamping time all groups were comparable. In the retroperitoneal groups significantly more tube grafts were implanted (63 vs. 27; P=0.001). The rate of surgical complications did not differ between the groups. The RP+EDA group had the lowest rate of postoperative assisted mechanical ventilation (5.1% vs. 35.7%; P=0.002) and medical complications (17.9% vs. 42.8%; P=0.032). Concerning frequency of surgical complications, the retroperitoneal incision was comparable to the transperitoneal approach in infrarenal aortic reconstruction. Supplementation with EDA resulted in a decreased rate of postoperative assisted mechanical ventilation and in lower morbidity rates.

Comparison of Transperitoneal and Retroperitoneal Approaches in Abdominal Aortic Surgery

Background: The transperitoneal approach (TP) to the aorta is the most widely accepted surgical approach in aortic surgery as it is simple, fast and provides excellent exposure of the intra-abdominal cavity and vascular structures. In recent years, there has been an increasing interest in the retroperitoneal (RP) approach to the aorta since it has been described as having a better outcome, i.e., preserving pulmonary function and gastro-intestinal physiology, reducing the intra-operative blood loss, minimising patient discomfort or pain, decreasing the incidence of wound complications and shortening ICU and hospital stay. The aim of this study is to compare the transperitoneal and retroperitoneal approaches in aortic surgery for aorto-iliac occlusive disease (AIOD).Methods: From December 2003 to June 2006, a total of 153 consecutive patients who had undergone aortic surgery for AIOD, were studied retrospectively. The TP approach was used in 85 patients and the RP approach in 68 patients. Demographic features, intra-operative and postoperative data were analysed and compared according to the approach used.Results: The mean operating time (83.6 ± 23 vs. 104.4 ± 30 min, p < 0.001) and mean aortic cross-clamp time (18.4 ± 3 vs. 15.2 ± 3 min, p < 0.0412) were significantly longer in the RP group. Peri-operative blood loss (700 ± 350 vs. 650 ± 330 ml, p < 0.683) and mortality rate < 30 day (1/1.2% vs. 0/0.0%, p < 0.896) were similar between the groups. The operative 30 day mortality rate was 0.7% (1 of 153) overall. The RP group had an earlier return of bowel functions (17.1 ± 3 vs. 24.2 ± 5 hrs, p < 0.001), earlier resumption of diet (26.4 ± 4 vs. 31.4 ± 5 hrs, p < 0.001), shorter period of intubation (3.5 ± 2 vs. 6.5 ± 3 hrs, p < 0.001), ICU stay (1.5 ± 1 vs. 4.2 ± 1 hrs, p < 0.001) and hospital stay (4.0 ± 1 vs. 5.9 ± 1 days, p < 0.001). Mean effort-pain scores were significantly lower in the RP group (3.8 ± 1 vs. 5.3 ± 1, p < 0.001). Incidence of pulmonary complications (4.4%, 3 of 68 vs. 7.3%, 8 of 85, p < 0.001), paralytic ileus (1.5%, 1 of 68 vs. 3.5%. 3 of 85, p < 0.001) were also lower in the RP group. Wound complications were more common in the TP group (4.7%, 4 of 85 vs. 10.3%, 7 of 86, p < 0.001). Most cases in both groups were related to incisional hernia or evisceration.Conclusion: This report presents our experience with the use of TP and RP approaches in a patient population merely consisting of AIOD. The RP approach was associated with a significantly lower incidence of postoperative pulmonary complications, rapid recovery of gastro-intestinal functions, shorter ICU and hospital stay, less peri-operative blood loss and lower mean effort-pain scores. We conclude that the RP approach is a safe and feasible technique that exposes patients to less postoperative complications.

Transperitoneal versus Retroperitoneal Suprarenal Cross-Clamping for Repair of Abdominal Aortic Aneurysm with a Hostile Infrarenal Aortic Neck

Infrarenal abdominal aortic aneurysms (AAAs) with a hostile infrarenal aortic neck unfit for endovascular aneurysm repair (EVAR) are more likely to require open repair with suprarenal aortic cross-clamping. We compared the results of the transperitoneal versus retroperitoneal approaches for repair of infrarenal AAA requiring suprarenal cross-clamping and the relative frequency of such techniques after incorporating EVAR into our clinical practice. From January 1998 through September 2005, 478 elective infrarenal aortic aneurysms were repaired. There were 160 (33%) open repairs (71% transperitoneal and 29% retroperitoneal) and 318 (67%) endovascular repairs. In 38 cases (24%) suprarenal cross-clamping was performed (47% transperitoneal and 53% retroperitoneal incisions) for a hostile infrarenal neck. A hostile aortic neck was defined as severe angulation (>60 degrees ), short neck (<15 mm), extensive calcification, or circumferential thrombus. The median age was 70 years; 47% were men; 16% had diabetes mellitus, 29% pulmonary disease, 53% coronary artery disease, and 11% renal insufficiency. The median aneurysm size was 6.0 cm. A retrospective analysis was performed to compare 30-day postoperative outcomes between the trans- and retroperitoneal patient cohorts. The results were determined for two time periods to assess whether open repair with suprarenal cross- clamping was being performed more frequently as a result of increased utilization of EVAR in the contemporary period. After 2002, EVAR increased from 60% to 71% (p = 0.04) while open repair declined from 40% to 29% (p = 0.01). The retroperitoneal approach doubled from 19% to 39%, while the transperitoneal approach decreased from 81% to 61% (p = 0.02). Suprarenal cross-clamping increased by 11% after 2002. There was no significant difference in age, sex, aneurysm size, or comorbidities between the trans- and retroperitoneal groups with suprarenal cross-clamping. The 30-day mortality was 2/38 (5%) and occurred only in the transperitoneal group. The transperitoneal approach was associated with significantly greater blood loss and longer suprarenal cross-clamp times (2,400 vs. 1,800 mL and 38.0 vs. 29.5 min; p = 0.03), but there were no significant differences in 30-day postoperative complications. In our 7 years' experience, there has been a gradual increase in the utilization of EVAR for infrarenal AAAs. At the same time, more infrarenal AAAs with hostile aortic necks requiring suprarenal aortic cross-clamping were encountered. In such instances, the retroperitoneal approach is safer, with less perioperative blood loss and shorter suprarenal cross-clamp time. This is likely attributed to better exposure of the suprarenal abdominal aorta, allowing a more secure proximal anastomosis.

Retroperitoneoscopic versus open dismembered pyeloplasty for ureteroplevic junction obstruction in children

Purpose New techniques should be compared with the gold standard of classical open surgery to confirm their true effectiveness and potential advantages. Material and methods In a retrospective review between 1999 and 2005, 45 patients with a mean age of 22 months (range 1 to 168) who underwent lumbotomy pyeloplasty were compared to 45 patients with a mean age of 71 months (range 4 to 172) who underwent a retroperitoneoscopic pyeloplasty. All the patients were operated by the same two surgerons (JSV-HS) well trained in laparoscopic techniques. We analysed operative time, hospital stay, results. Results The respective indication for each technique has changed during this 7 years period : for the first 20 patients open surgery was used in 80% of cases and for the last 20 patients minimally invasive surgery was used in 90% of case. Operative time was longer for the retroperitoneal laparoscopic group (155 min versus 98) ; mean hospital stay was nearly similar (4,5 days versus 5,5). No intraoperative complications occured in either group. The incidence of post operative complication, mainly urine leakage, was 11% in the open group (of which 4 cases needed another general anaesthetic for ureteralcatheter placement) and 17% in the laparoscopic group (of which 6 patients needed a new general anesthesia). Mean follow up was 41 months and 16 months in the open and laparoscopy group, respectively ; 2 patients in the open group and 1 patient in the laparoscopic group needed to be reoperated later for restenosis (success rate 95,5% versus 97,7%). Conclusions Retroperitoneoscopic dismembered pyeloplasty in children remains a difficult operation even after a learning curve ; however this technique is as safe and effective as open pyeloplasty ; it is feasable after 3 months of age ; the main advantage in our study is cosmetic ; the other potential advantages (less pain, fast recovery) seem more clear in adolescents.

Transperitoneal and Retroperitoneal Laparoscopic Heminephrectomy—What Approach for Which Patient?

We report our experience with laparoscopic heminephrectomy using the transperitoneal and retroperitoneal approaches in 48 pediatric patients. A total of 48 laparoscopic heminephrectomies were performed in 35 girls and 13 boys 45 days to 17 years old (mean 4.08 years) between September 1998 and March 2005. The procedures consisted of 44 upper pole heminephrectomies with partial or total ureterectomies and 4 lower pole heminephroureterectomies. Surgeries were performed using a transperitoneal approach in 32 patients (67%) and a retroperitoneal approach in 16 (33%). Followup ranged from 0.75 to 7.25 years (mean 3.53). In the retroperitoneal group 2 procedures required conversion, 1 to open heminephrectomy and 1 to a transperitoneal laparoscopic approach. Complications were seen in 5 of 48 patients (10%). Complications in the retroperitoneal group were seen in 2 patients. One patient had a postoperative urinary leak that resolved spontaneously. Another patient had development of a urinoma that was treated conservatively. Complications in the transperitoneal group were seen in 3 patients. One patient required an intraoperative chest tube due to pneumothorax, 1 had recurrent urinary tract infection that required excision of a short ureteral remnant and 1, 6-month-old boy had development of postoperative hypertension. Four of the 5 complications (80%) were seen in patients younger than 1 year. Transperitoneal and retroperitoneal laparoscopic heminephrectomy can be performed for benign disease in children with minimal morbidity, improved cosmesis and short hospital stay. Complication rate does not depend on the surgical approach, but rather on the age of the patient.