Laparoscopic Transperitoneal Research Articles

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 transperitoneal pyelopyelostomy and ureteroureterostomy of retrocaval ureter: Report of two cases and review of the literature

We report two cases of retrocaval ureter that were successfully treated by a laparoscopic transperitoneal approach. Presentation of both these cases was with flank pain. Ureteroureterostomy using an intracorporeal suture technique was performed for one, and pyelopyelostomy for the other case. Operative time was 120 min and 110 min, respectively. Pyelopyelostomy was technically easier to perform than ureteroureterostomy that required an extra fourth port insertion to facilitate dissection. With increasing experience with the intracorporeal suturing laparoscopic technique of either pyelopyelostomy or ureteroureterostomy should be the first choice for retrocaval ureter.

Laparoscopic ureteric reimplantation of a single-system ectopic ureter in a girl: A rarity

A 14-year-old girl presented with continuous dribbling of urine along with normal voiding pattern since childhood. Cystourethroscopy showed absence of right ureteric opening, and vaginoscopy showed right ureter opening into vaginal vault. Radiological images showed small right kidney with normal excretory function with single-system ectopic ureter. Patient underwent laparoscopic transperitoneal extravesical ureteric reimplantation. At 3 months’ follow-up, intravenous urography (IVU) and micturating cystourethrogram (MCU) showed no obstruction and reflux.

Stadification ganglionnaire des cancers du col utérin avancé

Lymph node staging in patients with locally advanced cervical cancer is the most important prognostic factor and also leads to adjuvant treatment choice. Because of the lymphadenectomy associated morbidity and delay in the beginning of adjuvant therapy, noninvasive approaches were developed during the last decennia. Recently, positron emission tomography employing a glucose analogue (FDG-PET) has been shown to be more sensitive and more specific than magnetic resonance imaging or than computed tomography usually used in diagnosis of pelvic and para-aortic lymph node metastases. Even if recent studies have reported promising results, surgical pelvic and para-aortic staging remains actually the most accurate procedure for evaluating lymph node metastases. This procedure should be accomplished by transperitoneal or extraperitoneal laparoscopy, with the benefits of minimal morbidity, shorter length of hospital stay and no significant increase of complications comparing to laparotomy approach. Laparoscopy also allows an early start of adjuvant treatment, this delay constituting an important prognostic factor for patients with locally advanced cancer. However, the survival benefit of lymph node dissection is still controversial and should be proved in randomised studies.

Robot assisted laparoscopic transperitoneal para-aortic lymphadenectomy in the management of advanced cervical carcinoma

Objectives Adequate staging of advanced cervical cancer is essential in order to optimally treat the patient. FIGO clinical staging, imaging techniques such as CT scan, MRI and PET sometimes underestimate the extension of tumors. The presence of para-aortic lymph node metastases in advanced cervical cancer identifies patients with poor prognosis who need to be treated aggressively. Laparoscopic para-aortic lymph node dissection is now proposed as a diagnostic tool in many guidelines. We evaluated the feasibility and safety of a robot assisted laparoscopic transperitoneal approach to para-aortic lymph node dissection. Study design Eight patients with advanced cervical carcinoma who were eligible for primary pelvic radiotherapy combined with concurrent cisplatin chemotherapy or pelvic exenteration underwent a pre-treatment robot assisted transperitoneal laparoscopic para-aortic lymphadenectomy. Results We isolated from 1 to 38 para-aortic nodes per patient and had one para-aortic node positive patient who was treated with extended doses of pelvic radiotherapy. We did not encounter any major complications and post-operative morbidity was low. Conclusions Robot assisted transperitoneal laparoscopic para-aortic lymphadenectomy is feasible and provides the surgeon with greater precision than classical laparoscopy. Larger prospective multicentric trials are needed to validate the generalised usefulness of this technique.

The optimum approach for pre‐transplant bilateral nephrectomy in small kidneys: dorsal lumbotomy vs laparoscopy

To evaluate the outcomes of bilateral pretransplant nephrectomy (BPN) for small kidneys, using a bilateral dorsal lumbotomy (BDL) or transperitoneal laparoscopy (TL) approach. Fifty-eight patients with end-stage renal disease and small kidneys underwent BPN for various indications, most commonly uncontrolled hypertension. There were 38 patients in the BDL group (group 1) and 20 in the TL group (group 2). The variables before and during surgery, and the outcomes afterward, were compared between the groups. The mean age of the patients and male/female ratio were comparable in both groups. The mean size of the kidneys removed were 7.4 and 8.2 cm, respectively, in groups 1 and 2. The mean (range) operative duration was longer in group 2, at 210 (160-240) min, than in group 1, at 112 (90-150) min (P < 0.001). The postoperative analgesic requirement for pain, blood transfusion rate, wound and pulmonary complications were similar between the groups. Bowel function recovered earlier in group 1 than group 2 (19 vs 37 h, P < 0.001). The total cost for the nephrectomy in group 2 was 3.5 times that of group 1. The mean interval between nephrectomy and transplantation was similar in both groups. BDL appears to be better than TL for BPN in small kidneys because the surgery is quicker, and there is earlier bowel recovery and lower costs.

Laparoscopic transperitoneal partial nephrectomy in children under 2 years old: A single-centre experience

To report our experience with laparoscopic transperitoneal (TP) heminephrectomy for duplicated pyeloureteral systems in children under 2 years old. We retrospectively reviewed the intraoperative evolution and patient outcome of 10 laparoscopic partial ureteronephrectomies (7 upper and 3 lower pole nephrectomies) using a TP approach, performed over 4 years. Mean age at surgery was 9.1 months (range 3.5-20.4), with seven children younger than 1 year. Average follow up based on clinical examinations and renal ultrasounds was 13.9 months (range 1.2-38.5). The average operative time was 123 min (range 90-195). There was no need for conversion and no intraoperative complications. Mean postoperative hospital stay was 2.9 days. A perirenal collection with spontaneous regression occurred in one case. The main postoperative complication consisted of a diminution in renal function with pyelic dilation in a 4-month-old child, due to inadequate positioning of the remaining moiety. This child remains asymptomatic 3 years after surgery. We recommend a TP approach for laparoscopic heminephrectomy due to the improved vascular exposure and control, diminished need for renal mobilization, and greater working space that can be obtained, especially in toddlers with a higher morbidity rate caused by the lack of retroperitoneal space.

Technique of Laparoscopic-Endoscopic Single-Site Surgery Radical Nephrectomy

Laparoscopic-endoscopic single-site surgery (LESS) represents the closest surgical technique to scar-free surgery. To assess the feasibility of LESS radical nephrectomy (LESS-RN). Ten patients with body mass index (BMI) < or = 30 underwent LESS-RN for renal tumour by two experienced laparoscopists. TriPort (Olympus Winter & Ibe, Hamburg, Germany) was inserted through a transumbilical incision. A combination of standard laparoscopic instruments and flexible grasper and scissors was used. A 5-mm 30 degrees camera was also used. The standard laparoscopic transperitoneal nephrectomy technique was performed. Patient demographics, operative details, and final pathology were prospectively recorded. Postoperative evaluation of pain and use of analgesic medication were recorded. Ten cases were successfully accomplished (two right-sided tumours and eight left-sided tumours; tumour diameter ranges: 4-8 cm). The mean patient age was 63.5 yr (22-77 yr), and median BMI was 23.56 (18.2-26.6). The mean operative time was 146.4 min (120-180 min), and the mean blood loss was 202 ml (50-900 ml). Pathological examination observed organ-confined T1 renal cell carcinoma in nine cases and pT3b tumour in one case. One bleeding complication occurred. Limitations regarding the intraoperative instrument ergonomics and the requirement for ambidexterity of the surgeon were noted. LESS-RN proved to be safe and feasible. Further clinical investigation in comparison to the established techniques should take place to evaluate the outcome of LESS-RN.

Névralgies obturatrices : prise en charge et résultats préliminaires de la neurolyse laparoscopique

Obturator neuralgia is a pain which is ill-defined and particularly less well-known to practitioners. Here we report on the etiologies, the treatment and the results of conservative laparoscopic treatment by neurolysis of the obturator nerve in cases of obturator neuralgia. Thirteen patients (15 nerves) who had obturator neuralgia have been treated in our service since 2005. The etiologies were idiopathic (four cases), following surgery for an inguinal hernia (two cases), trauma of the pelvis (one case), a TVT strip (three cases) and a TOT strip (three cases). The diagnosis was based on the pain, which was neuropathic, of the antero-internal side of the thigh. It was confirmed under block anesthetic by tomodensitometry using a posterior approach. The treatment consisted of laparoscopic neurolysis. The patients suffered pain measured at a rate of 8/10 on the visual analogical scale before the operation. In each case, neurolysis was carried out by transperitoneal laparoscopy by dissecting the nerve and sectionning the scarring fibrosis where the prothesis was in contact. In the idiopathic cases, the liberation of the nerve was carried out by a section of the internal obturator muscle and of the obtured membrane, allowing for the blocked canal to be widened. Seventeen months later, a rate of improvement of at least 50% of pain was found in 77% of cases (10/13), of whom pain had totally disappeared in 54% of cases (7/13). There was no improvement at all for 23% of cases (3/13). The mini-invasive conservative treatment of obturator neuralgia by laparascopic neurolysis of the obturator nerve, after confirmed diagnosis by selective infiltration allowed for a rate of 75% of improvement to be obtained after a period of 17 months.

UPJ obstruction and lower pole crossing vessels: further experience with the laparoscopic vascular hitch

Purpose The transposition of lower pole crossing vessels has been reported as an alternative technique to dismembered pyeloplasty for the treatment of ureterovascular ureteropelvic junction (UPJ) obstruction. We report a multi-institutional experience with laparoscopic transposition in children with intermediate follow-up. Material and Methods Candidate patients were selected on the basis of clinical history, renal ultrasonography, MAG-3 renal scan, and magnetic-resonance angiography. Selection criteria included presence lower-pole crossing vessels with moderate hydronephrosis, poor renal drainage, and intraoperative normal ureter with UPJ peristalsis. All children were followed clinically with renal ultrasonography and postoperative MAG-3 renal scan. Success was defined by symptoms resolution with improvement in hydronephrosis and drainage. Results 36 children (21 boys- 15 girls) presenting with flank pain, hydronephrosis SFU grade 1 or 2, impaired drainage on MAG-3 and crossing vessels at a mean age of 11.5 years (range 3.5-16) were selected. Operations were performed through transperitoneal laparoscopy (n = 33) or robotic assisted (n = 3). The mean operative time was 95 min. (47-137), and length of hospital stay was 2 nights (1-3). With a follow-up of 20 months (3-42), outcome was successful in 34/36 patients (94%), with resolution of symptoms in all, improved hydronephrosis and better drainage. There were 2 failures in children showing recurrent pain and worsened hydronephrosis, who initially required ureteral stent placement. One boy had intrinsic UPJ stenosis and was treated by dismembered pyeloplasty. In the remaining child, adhesions around the renal pelvis had caused kinking of the proximal ureter and extrinsic UPJ obstruction, and subsequently underwent Mikulitz UPJ incision and plasty. Conclusions At intermediate follow-up, the laparoscopic vascular hitch procedure has been successful in treating a selected group of children with obstructive crossing vessels, and represents a safe and reliable alternative to standard dismembered pyeloplasty.

Technique of Laparoscopic Transperitoneal Lower Pole Heminephroureterectomy

Laparoscopic transperitoneal nephrectomy is technically feasible in most cases of benign renal disease. To date, there have been isolated reports of laparoscopic transperitoneal heminephroureterectomy of principally the upper moiety of a duplex system. Rarely reported are lower moiety nephroureterectomies. The aim of this IPEG submission is to present a 3-minute video demonstrating the technical details of a transperitoneal laparoscopic, right, lower moiety, heminephroureterectomy in a 3-year-old. METHODS/TECHNIQUES: A child with marginally functioning (<5%) lower moiety of a right duplex system was subjected to a transperitoneal heminephroureterectomy. The patient was placed in a left lateral position and an umbilical camera and two working ports (right iliac fossa, epigastric), all 5 mm, were utilized. The ascending colon was reflected to the left and the underlying lower moiety ureter identified and isolated. With traction on the ureter, the pelvis was brought into view and control of blood supply to the lower moiety was achieved by using a combination of ultrasonic scalpel and hook diathermy. A critical step at this stage was definition of the superior limit of the pelvis, which corresponded to the level of vascular demarcation. The renal parenchyma was transected at this point by using the ultrasonic scalpel, which ensured reasonable hemostasis. Complete hemostasis was assured by approximating the divided kidney with a series of three interrupted intracorporeal sutures. The subtending ureter was dissected close to the bladder base, where it was ligated and divided. A drain was placed percutaneously in the renal bed and the specimen retrieved via an extended umbilical incision. The patient was started on fluids on recovery with oral feeds introduced the next morning. The drain was removed prior to discharge on day 2. At 6 months post-resection, the patient remains well. Laparoscopic transperitoneal lower pole heminephroureterectomy is technically feasible for benign renal disease in children. The combination of ultrasonic scalpel and intracorporeal suturing is adequate to control bleeding of the transected kidney. Dissection of the ureter distally to bladder neck is easily achieved without change in port position. Recovery is robust with minimal requirement for analgesia. The wider space, better view, and ability to access all of the urinary tract make this a tenable alternative to other laparoscopic approaches.

Laparoscopic Management of Endopelvic Etiologies of Pudendal Pain in 134 Consecutive Patients

The feasibility of the laparoscopic transperitoneal approach to the pelvic somatic nerves was determined for the diagnosis and treatment of anogenital pain caused by pudendal and/or sacral nerve root lesions. The records of 134 consecutive patients who underwent laparoscopy for refractory anogenital pain were retrospectively reviewed. All neurosurgical procedures, such as neurolysis/decompression of the pudendal nerve and the sacral nerve roots or neuroelectrode implantation to the sacral plexus for postoperative neuromodulation, were done via the laparoscopic transperitoneal approach to the pelvic nerves. A total of 18 patients had Alcock's canal syndrome and decompression was successful in 15. Due to failed decompression 3 patients underwent secondary sacral laparoscopic neuroprosthesis implantation with a decrease of at least 50% on the pain visual analog scale. Sacral plexus lesions or radiculopathies, most commonly postoperative lesions and retroperitoneal endometriosis, were found in 109 patients who underwent laparoscopic neurolysis of the sacral plexus. The final outcome depended on the etiology. Of patients with postoperative nerve damage 62% had a decrease in the mean +/- SD preoperative visual analog scale score of from 8.9 +/- 2.9 (range 7 to 10) to 2.4 +/- 2.3 points (range 0 to 4) at the time of article submission at a mean followup of 17 months (range 3 to 39). Because of failed decompression, 8 patients underwent secondary sacral laparoscopic neuroprosthesis implantation and a decrease in the pain visual analog scale score was achieved in 5. Of patients with an endometriosis lesion of the sacral plexus 78% had a decrease in the mean preoperative visual analog scale score of 8.7 +/- 1.9 (range 8 to 10) to 1.1 +/- 0.7 points (range 0 to 2) at the time of article submission at a mean followup of 21 months (range 2 to 42). All 6 patients with vascular entrapment of pelvic nerves achieved complete relief. The last 7 patients underwent primary sacral laparoscopic neuroprosthesis implantation with at least a 50% decrease in the pain visual analog scale score in 4. Our findings emphasize that in patients with seemingly inexplicable anogenital pain, especially after failed treatment for Alcock's canal syndrome, laparoscopic exploration of the pelvic nerves must be done for further diagnosis and therapy before prematurely labeling the patients as refractory to treatment.

Laparoscopic repair of large flank hernia staged with laparoscopic sleeve gastrectomy in the morbidly obese

Laparoscopy is the preferred operative approach for the repair of abdominal wall hernias. The large amount of intra-abdominal fat that accompanies morbid obesity obscures the anatomy, making flank hernia repairs in this population technically challenging, more so in the presence of previous flank surgery and multiple intra-abdominal adhesions. Laparoscopic repair of flank and lumbar hernias with mesh have also become standard practice [ 1 Palanivelu C. Rangarajan M. John S.J. Laparoscopic transperitoneal repair of lumbar incisional hernias: a combined suture and “double-mesh” technique. Hernia. 2008; 12: 27-31 Crossref PubMed Scopus (18) Google Scholar , 2 Iannitti D.A. Biffl W.L. Laparoscopic repair of traumatic lumbar hernia. Hernia. 2007; 11: 537-540 Crossref PubMed Scopus (12) Google Scholar , 3 Madan A.K. Ternovits C.A. Speck K.E. Laparoscopic lumbar hernia repair. Am Surg. 2006; 72: 318-321 PubMed Google Scholar ]. Compared with open hernia repair approaches, laparoscopy typically offers fewer complications, a decreased length of hospital stay, less pain, and overall improved outcomes. However, incisional hernia recurrence rates are still high in the morbidly obese [ 4 Raftopoulos I. Courcoulas A.P. Outcome of laparoscopic ventral hernia repair in morbidly obese patients with a body mass index exceeding 35 kg/m2. Surg Endosc. 2007; 21: 2293-2297 Crossref PubMed Scopus (56) Google Scholar , 5 Tsereteli Z. Pryor B.A. Heniford B.T. et al. Laparoscopic ventral hernia repair (LVHR) in morbidly obese patients. Hernia. 2008; 12: 233-238 Crossref PubMed Scopus (71) Google Scholar , 6 Novitsky Y.W. Cobb W.S. Kercher K.W. et al. Laparoscopic ventral hernia repair in obese patients: a new standard of care. Arch Surg. 2006; 141: 57-61 Crossref PubMed Scopus (92) Google Scholar ]. It is thus essential to identify methods to decrease the recurrence rates and minimize morbidity during operative repair. Surgically induced weight loss before flank hernia repair appears to be a sound alternative to decrease recurrences and the associated morbidity. Laparoscopic sleeve gastrectomy has shown optimal short-term outcomes and is technically suited for the morbidly obese with large flank hernias and intra-abdominal adhesions. The weight loss provided by the sleeve gastrectomy as a first stage might facilitate flank hernia repair during a second procedure, by decreasing the amount of intra-abdominal fat, reducing the operative morbidity and intra-abdominal pressure and resulting in minimization of hernia recurrence. The case and operative technique of a laparoscopic flank hernia repair preceded by laparoscopic sleeve gastrectomy is described in a morbidly obese patient.

Laparoscopic ureteroneocystostomy for management of lower ureteric strictures

Aim: We assessed the results of laparoscopic transperitoneal ureteroneocystostomy with or without a psoas hitch for management of lower ureteral strictures. Materials and Methods: Between October 2005 and August 2008, 16 patients with lower ureteric strictures underwent laparoscopic ureteroneocystostomy with or without a psoas hitch. Etiology of strictures was gynecological surgery in 11, surgery for stone disease in 3, ureterovaginal fistula in 1 and primary obstructive megaureter in 1. Transperitoneal 3- or 4-port laparoscopic ureteroneocystostomy was performed with or without psoas hitch. Results: All operations were successfully completed without any need for conversion to open. Mean operative time was 171.56 min (range 130 to 260 min), mean blood loss was 93.44 cc (range 30 to 200 cc) and total hospital stay was 3.73 days (range 3 to 6 days). Mean time to resume oral intake was 12.5 h (range 8 to 22 h). Mean follow-up period was 21.83 months (range 6-39 months). Postoperative follow-up investigations revealed successful outcome in all 16 patients, success being defined as relief of symptoms and radiological improvement, irrespective of the refluxing status. Non-refluxing status was achieved in 15 out of 16 patients as determined by micturition cystography. Conclusions: Laparoscopic ureteroneocystostomy is a safe and effective procedure, with inherent advantages of laparoscopic surgery.

The laparoscopic transperitoneal approach for irreducible inguinal hernias: Perioperative outcome in four patients

BACKGROUND:Incarceration and strangulation are the most feared complications of inguinal hernia. Till date, incarcerated hernias have traditionally been treated by conventional open repair. Reports are now available for the feasibility of laparoscopic repair of incarcerated inguinal hernia. Here, we described our experience with the transperitoneal approach for incarcerated hernias.MATERIALS AND METHODS:Between January 2008 and May 2008, four patients were presented with a history of irreducible hernia, abdominal distention and vomiting. All the patients had right-sided inguinal hernia. Reductions of the hernia contents were not possible in any patient. The patients were treated on emergency basis with laparoscopic transabdominal preperitoneal hernia repair. Retrospective analyses of all the patients were done.RESULTS:Reduction of the bowel was achieved in all but one patient, who required the division of the internal ring on lateral side. Transperitoneal mesh repair was performed. No major complications were encountered. One patient developed seroma formation that was treated conservatively.CONCLUSION:Laparoscopic transperitoneal approach has the advantage of observation of the hernia content for a longer period of time. The division of the internal ring can be done under direct vision. Other intra-abdominal pathology and opposite side hernia can be diagnosed and treated at the same time..

Renal ischemia time in laparoscopic surgery: an experimental study in a porcine model

Laparoscopic nephron sparing surgery is becoming more common, only limited by experience of the surgeon and the renal ischemia time. It is currently unknown if laparoscopic surgery alters the accepted 30 min threshold for renal ischemia. The purpose of this study was to define the normothermic ischemic threshold in the laparoscopic setting. Twenty-four domestic female pigs underwent a laparoscopic transperitoneal procedure after randomization to one of five treatment groups: 30, 60, 75, 90, and 120 min of unilateral renal ischemia. One animal was used as a control specimen and was not exposed to any surgery or pneumoperitoneum. The contralateral kidney in each animal was used as an individual control for the corresponding time of pneumoperitoneum. The animals were euthanized after 3 weeks, when both renal units were harvested and data were analyzed. Three animals died secondary to complications from their procedure and were replaced. There was no association between urine volume and ischemic time, but urine creatinine and creatinine clearance decreased significantly as ischemic time increased. The control animal and 30 min ischemic group had similar results. Functional renal parameters decreased in those animals exposed to greater than 75 min of ischemia. The histologic analysis did not show any significant differences among the experimental groups. Renal function begins to deteriorate between 75 and 90 min of renal vascular occlusion in this two-renal unit laparoscopic porcine model.

The Sacral LION Procedure for Recovery of Bladder/Rectum/Sexual Functions in Paraplegic Patients after Explantation of a Previous Finetech-Brindley Controller

Study Objective To report on our technique of sacral laparoscopic implantation of aneuroprosthesis-LION procedure–for recovery of bladder/intestinal/sexual function in paralyzed patients after spinal cord injury. Design Prospective case series report. Setting Academic community teaching hospital. Patients Eight consecutive complete T-paralyzed patients after explantation of a previous dorsal implanted Brindley-Finetech controller with a sacral deafferentation. Interventions Laparoscopic transperitoneal exposure of the sacral plexuse and bilateral implantation of Brindley-Finetech electrodes to the sacral nerve roots S2 to S4. Measurements and Main Results Feasibility, complications, and outcome of the procedures. In 6 patients, recovery of electrically induced micturition and defecation could be obtained and in 2 men recovery of electrically induced erection. In 2 other patients, exposure and intraoperative stimulation of the sacral nerve roots showed irreversible destruction of the motoric vesical and rectal nerves. In one, the bilateral implantation of neuromodulation electrodes permitted complete control of the spasticity of the lower limbs and to the autonomic dysreflexia. Conclusion The laparoscopic transperitoneal approach offers minimally invasive access for implantation of electrodes to the sacral nerve roots in paralyzed patients for recovery of pelvic visceral functions after failure of a previous implanted dorsal Brindley-Finetech controller with sacral deafferentation.

Laparoscopic Transperitoneal Right Adrenalectomy for ‘Large’ Tumors

Objectives: We compared two different approaches to right laparoscopic transperitoneal adrenalectomy for large tumors (>5 cm): the anterior transperitoneal (AT) and lateral transperitoneal (LT) approaches. Methods: 40 patients with a right large adrenal mass >5 cm underwent right adrenalectomy: 20 patients underwent the AT procedure and 20 patients the LT procedure. Preoperative characteristics were similar for both groups: mean tumor size for the AT and LT groups was 6.52 cm (range 5.2–8.5) and 6.59 cm (range 5.4–8.1), respectively. Mean patient’s age was 53 years (23–75 in the AT group and 20–77 in the LT group). AT and LT approaches were compared in terms of operative time, intraoperative blood loss, time to first oral intake and postoperative convalescence. Results: No difference was found between two groups in terms of estimated blood (100 ml for the AT group and 105.3 ml for the LT group), time to first oral intake (2.0 days for both groups) and convalescence (3.5 and 3 days, respectively). The mean operative times of the AT and LT procedures were 75.25 and 84.75 min, respectively: this difference was statistically significant at the Student’s t test (p = 0.0423). Conclusions: Both approaches proved to be safe and minimally invasive. We believe that the shorter operative time of AT procedures was related to the better visibility of familiar anatomic landmarks, easier access to the vessels and a larger operative field. For these reasons, we prefer the AT approach in the management of large adrenal masses.

Feasibility of Microlaparoscopy for Surgical Procedures of Advanced Complexity in Children

Abstract Purpose: We conducted a prospective study to determine the value and the feasibility of the microlaparoscopic approach for surgical procedures of advanced complexity in children. We report our experience with these small instruments. We also report the preliminary results of a recently developed 2.4 mm prototype scope, specifically developed for the present study. This study includes 15 children (aged two weeks to 11 years; median, 2.8 years). Eighteen procedures with advanced complexity were carried out: Nissen fundoplication, thoracoscopic congenital diaphragmatic hernia repair in a newborn, hiatoplasty with repair of an upside-down-stomach, laparoscopically assisted pull-through for Hirschsprung's disease in a newborn, laparoscopic transperitoneal pyeloplasty and laparoscopy for acute abdominal illness. No complications occurred due to the exclusive use of 2 mm instruments. All microlaparoscopy procedures were performed successfully except one fundoplication that was converted to an open procedure due to anatomical deformities. The average operative times for the 5 mm and 2 mm groups were similar compared across a similar age and type-of-intervention population. The microlaparoscopic approach for surgical procedures of advanced complexity in pediatric surgery is feasible, safe, and effective in conditions where they are indicated and are practical in terms of the surgeon's experience and the facilities. The advantages of microlaparoscopy are obvious: minimum access trauma, "nearly scarless" healing, less risk of damage to abdominal organs, the possibility of fewer adhesions and less postoperative pain. We suggest the further consideration of the use of the microlaparoscope for advanced laparoscopic procedures in children.

VID.13: Laparoscopic Retroperitoneal Lymphadenectomy for Stage I Non-Seminomatous Germ Cell Cancer: Better Results with the Same Template as Open Surgery?

Laparoscopic transperitoneal lymphadenectomy is a minimally invasive procedure and a feasible option to open retroperitoneal lymph node dissection. Our purpose was to demonstrate that endoscopic technique can duplicate the open procedure.