Transperitoneal Laparoscopic Technique Research Articles

Laparoscopic management of a congenital H-type rectovaginal fistula in an infant

Congenital H-type rectovaginal fistula with a normal anal opening is a rare malformation. The authors encountered such a case in a 2-month-old girl. Both direct inspection and fluoroscopic examination did not identify the location of the fistula, but passage of contrast media through the vagina was observed. Using a 3-port transperitoneal laparoscopic technique, complete resection of the fistula was successfully performed. Without a protecting colostomy, laparoscopic approach appeared to be safe and feasible in an infant with an H-type rectovaginal fistula and a normal anal opening. Division of pelvic muscle floor and perineal dissection could be successfully avoided.

Laparoscopic repair of retro-caval ureter: report of two cases

Retrocaval ureter is a rare congenital disorder and surgery is necessary when the patient is symptomatic or having significant functional obstructions. The two cases referred to our center with severe hydronephrosis on their right sides. In both cases further evaluation with CT scan showed the diagnosis of retrocaval ureter. The retrocaval segment of the both ureters were isolated and after the excision of the narrow segments, end to end anastomosis have been done with transperitoneal laparoscopic technique. The laparoscopic ureteroureterostomy is a safe, effective and minimally invasive procedure and should be considered as a standard treatment for retrocaval ureter.

Clinical investigation on minimal invasive surgery for Cushing syndrome caused by adrenocortical adenoma: experience of 121 cases in a single center

Objective To explore the efficacy and safety of minimal invasive adrenal sparing surgery for the treatment of Cushing syndrome caused by adrenocortical adenoma. Methods Patients who underwent minimal invasive adrenal surgery for adrenocortical adenoma in our institution from January 2010 to December 2015 were retrospectively analyzed. Preoperative, intraoperative, and postoperative variables were reviewed from the database. The mean patient age at diagnosis was 39 years and male∶female ratio was 10∶111. Of the 121 adenomas, 50 were located in the right adrenal and 71 in the left. The mean tumor size was 2.6 cm.84 cases had hypertension (69.4%), 36 cases had diabetes mellitus (29.8%), and 45 cases had obesity (37.2%). Postoperative follow-up was performed by evaluating adrenal gland function and imaging. Results Mininal invasive partial adrenalectomy was performed in 121 cases and the success rate of operation was 99.2%(120/121). Sixty-two cases received operation through retroperitoneal approach, and 59 cases were through transperitoneal approach. The median operative time was 50 min with a median blood loss of 50 ml. The mean postoperative hospital stay were (5.0±3.2) days.The vascular injury occurred in 2 cases (1 case in each surgical approach), while the abdominal organ injury occurred in 2 cases with 1 case of spleen injury and 1 case of liver injury (both in transperitoneal approach). Postoperative complications were observed in 6 cases: 1 case of deep venous thrombosis, 1 case of wound hematoma, 4 cases of wound infection. Cortisol substitution was given in 2 to 12 months (mean 6.2 months) postoperatively. One year after operation, the remission rate of hypertension, diabetes and obesity was 58.3%(49/84), 30.6%(11/36) and 60.0%(30/45), respectively. Conclusions Minimal invasive adrenal surgery using retroperitoneal and transperitoneal laparoscopic technique can be performed with low morbidity and achieve an excellent outcome.The perioperative hormone therapy may also play an important role. Key words: Cushing syndrome; Partial adrenalectomy; Transperitoneal laparoscopic surgery; Retroperitoneal laparoscopic surgery

Use of a combined retroperitoneoscopic and transperitoneal laparoscopic technique for the management of renal cell carcinoma with level I tumor thrombi

BACKGROUND:To report our initial experiences using a combined retroperitoneoscopic and transperitoneal laparoscopic technique for the management of renal cell carcinoma with level I tumor thrombi.MATERIALS AND METHODS:Two patients underwent this technique for tumors 11- and 13-cm in diameter. After transection of the renal artery with limited mobilization of the kidney using a retroperitoneoscopic approach, additional ports were placed, and the management of the tumor thrombus was performed in the large working space provided by the transperitoneoscopic approach.RESULTS:The technique was feasible in the present 2 cases. The total operative times were 170 and 200 min, respectively. The estimated blood loss was 450 cc in the first case and 200 cc in the second case. No complications were observed in either of the patients.CONCLUSIONS:Based on the initial clinical experience, we have presented a feasible surgical option for the laparoscopic management of renal cell carcinoma with level I thrombi.

PRELIMINARY REPORT: LAPAROSCOPIC RADICAL PROSTATECTOMY IN JAKARTA

Objective: To report initial experience of laparoscopic radical prostatectomy (LRP) in Jakarta and evaluate the functional and oncology outcome. Material & Method: Between June 2007 until September 2008, we had done 9 times LRP surgery. All data is retrospectively taken and divided in three groups, i.e. pre-operative data (patient demography, pre-operative PSA, prostate volume, Gleason Score, clinical and functional staging), intra-operative data (intra-operative complication, conversion to open surgery, bleeding volume, and operating time), and post-operative data (post-operative complication, duration of urine catheter usage, duration of hospitalization, functional and oncology status). Results: Among nine subjects who underwent LRP, five subjects (55,55%) did not converted into open surgery. There are 2 subjects who gain their sexual potency and urine continence in one year post op. Only one subject is proven without biochemical failure in 1 year. Conclusion: We confirmed that radical prostatectomy can be performed with transperitoneal laparoscopic technique by a team that has been experienced in laparoscopic.
 Keywords: Laparoscopic radical prostatectomy, functional result, oncological result.

Early laparoscopic repair for blunt duodenal perforation in an adolescent

Duodenal perforation secondary to blunt abdominal trauma in children is rare and usually associated with delays in diagnosis and surgical intervention. The authors encountered such a case in a 12-year-old boy owing to his falling over the handlebar of a bicycle. Imaging examination showed that there was a perforation over the fourth portion of the duodenum without concomitant injuries. Using a 5-port transperitoneal laparoscopic technique, primary closure of the perforation was successfully performed at 6 hours after the impact. Laparoscopic approach appears to be safe and feasible in hemodynamically stable children with solitary traumatic duodenal perforation if the operation can be performed early in the course of the incident.

Combined Laparoscopic and Percutaneous Management of Calcified Renal Hydatid Cyst—A Novel Nephroscope- and Lithotripter-assisted Technique

To describe the novel technique of percutaneous nephroscope-assisted renal hydatid cyst evacuation and lithotripter-assisted division of the cyst wall for combined laparoscopic and percutaneous management. A calcified hydatid cyst of the kidney is a rare entity and needs special techniques for total laparoscopic management. A 45-year-old woman was treated successfully for a calcified renal hydatid cyst using the transperitoneal laparoscopic technique. A chlorhexidine gluconate and cetrimide mixture was used as the scolicidal solution to sterilize the cyst. The endocyst and daughter cysts were removed completely under vision, after placement of a single 26F nephroscope through a 10-mm port in the cyst, with grasper and lithotripter suction, using chlorhexidine-cetrimide mixture irrigation. Laparoscopic suction did not work well for the viscous contents. The calcified cyst wall did not yield to electrocautery or piecemeal fragmentation, until weakened by division and fragmentation using the pneumatic lithotripter. Partial cyst wall exicision/marsupialisation was complemented with omentoplasty. No intraoperative or early postoperative complications occurred. The patient recovered well with little pain and was discharged early. This technique, in which the principles of percutaneous nephrolithotomy were applied for a special problem, is the first of its type. Calcified renal hydatid cyst evacuation using the novel nephroscope-assisted retrieval of contents and lithotripter-assisted division of the calcified wall is a safe and feasible technique for total minimally invasive management.

Laparoscopic Resection of a Giant Solid Pseudopapillary Neoplasm of Uncinate Process of the Pancreas in a Child

Solid pseudopapillary neoplasm of the pancreas in children is rare, and the most common localization of the tumor is the tail. The authors encountered such a case in a 10-year-old girl with a giant solid pseudopapillary neoplasm at the uncinate process of the pancreas. Imaging examination showed there was a distinct distance between the neoplasm and the main pancreatic duct. Using a 4-port transperitoneal laparoscopic technique, complete resection of the tumor was successfully performed. Laparoscopic approach appears to be safe and feasible in children with solid pseudopapillary neoplasm, and an organ-preservation operation can be successfully performed if there is no communication between the tumor and the pancreatic ductal system.

Laparoscopic treatment of renal hydatid cyst

A 30-year-old woman was treated successfully for renal hydatid cyst disease by using the Transperitoneal Laparoscopic Technique. The peritoneal cavity was protected with the use of betadine-soaked gauze pieces, to avoid spillage. Hypertonic saline was used as the scolicidal solution to sterilize the cyst. The endocyst was removed completely and retrieved in an endobag. There were no intraoperative or early postoperative complications. This appears to be only the second reported case of renal hydatid cyst disease treated with the help of laparoscopy.

Laparoscopic Repair of Vesicovaginal Fistula

Vesicovaginal fistula (VVF) is one of the most devastating surgical complications that can occur in women. The primary cause remains an abdominal hysterectomy. Approach to this condition can be transvaginal or transabdominal. Laparoscopic repair of VVF may be an alternative approach to this treating rare condition. We present seven cases of VVF treated with transperitoneal laparoscopic technique and our results. We retrospectively reviewed the charts of 7 women ranging from 37 to 74 years in age (mean age 52.8 years) at our institution who underwent laparoscopic transperitoneal repair of VVF between February 2004 and March 2006. Etiology of the VVF, surgical technique, operative time, length of hospital stay, and complications were reviewed. Six of the seven VVFs we repaired laparoscopically resulted from gynecologic procedures, and one patient presented with a VVF after a ureterolithotripsy. Mean operative time ranged from 130 to 420 minutes (mean 280 minutes), and mean hospital stay was 7 days. In one patient conversion to open surgery was necessary due to prolonged operative time. Two complications occurred: a urinary tract infection in one patient and an inferior limb compartment syndrome in another. Transvaginal laparoscopic repair of VVF is feasible and safe and provides excellent results. It is a good alternative to the abdominal approach. However, advanced laparoscopic skills are mandatory.

Laparoscopic assisted dismembered pyeloplasty in children: intermediate results

To study the results of an innovative minimally invasive technique of performing dismembered pyeloplasty in children. Using 5 mm camera and 3 mm working ports, the ureteropelvic junction (UPJ) is mobilized by a transperitoneal laparoscopic technique. The UPJ is brought out through a tiny flank incision and a standard dismembered pyeloplasty is performed over a double J stent. Between October 2003 and January 2005, 13 children underwent laparoscopic assisted dismembered pyeloplasty. Indications, operative duration, hospital stay, preoperative and postoperative isotope renogram parameters were analyzed. The children were in the age range of 3 months to 6 years-three were right sided and ten were left sided. Only three were symptomatic while the remaining ten were detected to have UPJ obstruction during evaluation for antenatally detected hydronephrosis. Mean operative duration was 104.2 min (range 80-150 min) with no significant difference in the two patients with crossing vessels. Incision was smaller than 2 cms in all and the average postoperative hospital stay was 3.2 days (range 2-5 days). Follow-up ranging from 28 to 44 months showed reduction in hydronephrosis and improvement in renal function of all the operated units. Isotope renogram in only one patient showed equivocal slopes and prolonged half clearance times though no further surgical intervention was required. This technique has results comparable to that of open pyeloplasty and hence, maybe considered a good option for surgeons making the transition to laparoscopic pyeloplasty.

Laparoscopic resection of a giant retroperitoneal T-shaped duplication of descending colon

The authors encountered an uncommon case of a retroperitoneal T-shaped duplication that presented with a communication with the descending colon, descending downward along the descending colon posterolaterally, passing through the sigmoid mesocolon and across the midline at the level of L5 to S1 vertebrae, ascending behind the ascending mesocolon, and terminating beneath the third portion of the duodenum. Using a 3-port transperitoneal laparoscopic technique, the duplication was completely resected. On reviewing the literature, T-shaped duplication has occurred in only 4 cases; and all arose from the colon and were not associated with other anomalies. Dense adhesions between the blind end and surrounding tissues, a retroperitoneal location, and the U-shaped loop of the duplication appear to support the theory that it was the result of persistent neurenteric canal during the formation of the alimentary tract before the normal midgut-positioning process.

Case Report: Laparoscopic Ureteropyelostomy and Distal Ureterectomy for Management of Duplication with Ectopia

To evaluate the role of laparoscopic ureteropyelostomy and subtotal ureterectomy for management of an ectopic ureter to the prostatic urethra. A 54-year-old man presented with complaints of paravertebral pain and recurrent prostatitis with elevation of the serum prostate specific antigen concentration. Diagnostic evaluation revealed right renal duplication with an ectopic ureter to the prostatic urethra. Using a four-port transperitoneal laparoscopic technique, a laparoscopic ureteropyelostomy and subtotal ureterectomy were performed. Diagnostic follow-up documented successful treatment with the minimally invasive technique. Laparoscopic ureteropyelostomy and subtotal ureterectomy provide effective treatment for this rare condition. The minimally invasive technique may also have clinical applications in the pediatric population.

TRAM flap delay: an extraperitoneal laparoscopic technique

Although the transverse rectus abdominis musculocutaneous (TRAM) flap is the gold standard in autogenous breast reconstruction, it is less reliable in patients at high risk of ischaemic compromise. A preliminary delay procedure involving ligation of the deep inferior epigastric vessels has been shown to augment flap vascularity and improve outcome in those high risk patients undergoing unipedicled TRAM flap reconstruction. Despite previous description of a transperitoneal laparoscopic technique, surgical delay generally continues to be performed as an open procedure. This may reflect apprehension over the transperitoneal approach with its attendant risk of injury to intra-abdominal organs and vessels as well as adhesion formation. In this paper we describe an extraperitoneal laparoscopic technique for TRAM flap delay. Access to the deep inferior epigastric vessels is obtained using an extraperitoneal approach similar to that used for total extraperitoneal laparoscopic inguinal hernia repair and the vessels are easily identified and ligated using a single working port. While further study is required to evaluate the safety and efficacy of this technique, we report this as an alternative to the known open procedure which may be particularly useful for bilateral TRAM flap delay with the potential for reduced operative time, postoperative pain and scarring by avoiding bilateral inguinal incisions.

Hand-assisted transperitoneal laparoscopic living donor nephrectomy

Objective We introduced and evaluated the advantages and disadvantages of the hand-assisted transperitoneal laparoscopic technique for living donor nephrectomy. Materials and methods In December 2001, we started using the technique of hand-assisted transperitoneal laparoscopic living donor nephrectomy (HLDN) in 10 cases. The procedure utilizes a hand-assisted device to increase safety and control of the laparoscopic technique. Results Only left nephrectomy was performed. The mean total operating and the warm ischemia times were 130 minutes and 3.0 minutes, respectively. Average lengths of renal artery and vein were 1.95 cm and 2.8 cm, respectively. There were no intraoperative or postoperative complications. Conclusions HLDN is an easier procedure than the traditional laparoscopic living donor nephrectomy and can greatly mitigate the learning curve. HLDN has shortened warm ischemia time and operating time. It is also good for trocar placement, prevention of torsion of the kidney, control of potential bleeding at the final stage of vascular stapling, and kidney removal. Therefore, HLDN is a promising method for living donor nephrectomy.

Laparoscopic upper pole partial nephrectomy with concomitant en bloc adrenalectomy

Objectives To report our experience with laparoscopic partial nephrectomy for renal tumor with concomitant adrenalectomy. An upper pole renal tumor may contiguously involve the adrenal gland, requiring concomitant adrenalectomy. Although commonly performed in the setting of laparoscopic radical nephrectomy, concomitant adrenalectomy has not been described during laparoscopic partial nephrectomy. Methods Four patients with an upper pole renal tumor and suspected adrenal involvement underwent laparoscopic partial nephrectomy with concomitant ipsilateral adrenalectomy. Preoperative three-dimensional computed tomography revealed the renal tumor to be closely abutting the adrenal gland in 3 patients and a 4-cm adrenal mass in 1 patient. The mean renal tumor size was 3.2 cm (range 1.4 to 6.6). To maintain oncologic principles, our transperitoneal laparoscopic technique excises the adrenal gland en bloc with the renal tumor. As such, adrenalectomy is performed first, followed by partial nephrectomy, incorporating hilar control, tumor excision, and sutured renal reconstruction. Results All four procedures were performed without open conversion or intraoperative complications. The mean renal warm ischemia time was 36 minutes, estimated blood loss 169 mL, total operating time 3.9 hours, and hospital stay 3.2 days. One patient developed a transient urinary leak postoperatively. Pathologic examination of the renal tumor revealed renal cell carcinoma (n = 1), dystrophic calcification with ectopic bone formation (n = 1), adult mesoblastic nephroma (n = 1), and subcapsular heterotopic adrenal cortex with cyst (n = 1), all with negative surgical margins. Pathologic examination of the adrenal gland revealed adenoma in 1 case and a normal adrenal gland without malignant involvement in 3 cases. All patients were disease free at last follow-up (mean 6.2 months, range 2 to 12). Conclusions In patients with an upper pole renal tumor and radiologically suspected adrenal involvement, laparoscopic partial nephrectomy with concomitant adrenalectomy can be performed efficaciously respecting oncologic principles.

LAPAROSCOPIC DISMEMBERED TUBULARIZED FLAP PYELOPLASTY: A NOVEL TECHNIQUE

Laparoscopic dismembered pyeloplasty is now an effective option for ureteropelvic junction obstruction. We describe a novel laparoscopic technique of dismembered tubularized flap pyeloplasty for a difficult recurrent long ureteropelvic junction stricture. A 73-year-old woman with ureteropelvic junction obstruction of a solitary left kidney had undergone failed multiple procedures, including open pyeloplasty, balloon incision endopyelotomy, retrograde balloon dilation and percutaneous endopyelotomy. Using a 4-port transperitoneal laparoscopic technique, the upper ureter was dissected, the scarred ureteropelvic junction stricture was excised and the dismembered ureteropelvic junction was closed with a stitch. A wide base renal pelvic flap was created and tubularized to bridge the 3 cm. upper ureteral defect. Laparoscopic intracorporeal freehand suturing was done to reconstruct the renal pelvis and upper ureter over a Double-J stent (Medical Engineering Corp., New York, New York). Total operative time was 4.5 hours and hospital stay was 4 days. The stent was removed 3 weeks later. At the 2-month followup the patient was asymptomatic. Excretory urography and diuretic renal scan confirmed a widely patent upper ureter with unobstructed drainage. Dismembered renal pelvis tubularized flap pyeloplasty can be successfully performed laparoscopically to bridge a long upper ureteral defect. This approach is feasible even in a ureteropelvic junction in which previous surgery has failed.

Laparoscopic radical prostatectomy: Initial short-term experience

Objectives To determine the feasibility and efficacy of a laparoscopic approach to the radical retropubic prostatectomy (RRP). Methods A transperitoneal laparoscopic technique was developed to perform an RRP. Intra-abdominal access was obtained through five 10-mm trocars. After dissection of the prostate, the urethrovesical anastomosis was created via a transvesical approach. The prostate was removed by extending the umbilical incision. Results Between September 1991 and May 1995, nine laparoscopic RRPs were performed. The operative time averaged 9.4 hours. Only 1 of 9 patients had a positive surgical margin that involved the urethra. Six of 9 patients were completely continent postoperatively. Of the 4 patients who were potent preoperatively, 2 continued to have erections. There were three complications: cholecystitis, thrombophlebitis associated with a pulmonary embolism, and a small bowel hernia into a trocar site. Conclusions Laparoscopic radical prostatectomy is feasible but currently offers no advantage over open surgery with regard to tumor removal, continence, potency, length of stay, convalescence, and cosmetic result.