Laparoscopic Surgeries Laparoscopic Surgeries Laparoscopic Surgeries

Indications

  • Usual Patients
    • Patients with localized prostatic cancer of low or intermediate risk (cT1a-cT2c, Gleason Score 2-7, PSA10yrs)
  • In very selected cases
    • Patients with low volume, high risk prostate cancer (cT3a or Gleason Score 8-10 or PSA >20ng/ml)
    • Patients with very high risk localized prostate cancer (cT3b-cT4 N0 or any T N1)

Endoscopic Extraperitoneal Radical Prostatectomy (EERPE)

  • Access into extraperitoneal space without entry into peritoneal cavity
  • Minimization of risk of visceral trauma, quicker mobilization of intestines, containment of possible urinary leaks outside peritoneal cavity

Surgical Steps

  1. Positioning of the patient
  2. Dissection and entry into extraperitoneal space
  3. Planning and placement of ports
  4. Balloon inflation of extraperitoneal space (under direct vision)
  5. Dissection of extraperitoneal space and identification of key landmarks
  6. Dissection of anterior surface of prostate and endopelvic fascia
  7. Ligation of deep venous plexus of Santorini
  8. Dissection of prostatic base and bladder neck
  9. Dissection of vas deferens and seminal vesicles
  10. Dissection of posterior prostatic surface
  11. Dissection of prostatic pedicles and preservation of neurovascular bundles
  12. Dissection of prostatic apex and urethral sphincter complex
  13. Entrapment of surgical specimen
  14. Construction of vesicourethral anastomosis
  15. Retrieval of surgical specimen
  16. Exit from extraperitoneal space, removal of trocars and suture of incisions

Transperitoneal laparoscopic prostatectomy

  • Access into peritoneal cavity through all layers of abdominal wall and subsequent exposure of extraperitoneal organs
  • Familiar route for laparoscopic surgeons
  • Careful placement of trocars avoids clashing of instruments, damage to epigastric vessels, and makes suturing easier.
  • In obese patients, trocars may be moved forward by a few centimeters.
  • Before insufflation of the extraperitoneal space, use fingers to swipe adhesions at linea alba
  • Insufflation of the extraperitoneal space requires approximately 60 pumps of the balloon
  • When placing trocars aided by the scope’s vision, always aim to go directly through muscle, and not through other intervening tissue. If there are adhesions, make sure to dissect them
  • If an intrafascial approach is considered, the endopelvic fascia should not be incised, but rather bluntly pushed away. Dissection should happen on the plane of the prostatic capsule
  • Suture of the DVC is easier with a straightened CT1 needle, as the passage under the DVC will be easier to direct.
  • When identifying the bladder neck, tug on the catheter (with a filled balloon). The border between the prostate and the bladder should be readily seen.
  • When dissecting the anterior portion of the bladder neck, aim to dissect directly downwards exactly in the border between the bladder and prostate. This will result in a smaller bladder neck and no prostatic tissue left behind.
  • Identify the ureteral orifices before starting dissection of the posterior bladder neck.
  • If the ductus deferens is not readily seen after dissection of the posterior bladder neck, consider changing the cleavage plane as you may be entering the prostate, Also, beware of through and through injuries to the bladder during this phase.
  • Try to dissect the posterior aspect of the prostate by stripping Denonvilier’s fascia in order to maintain an intrafascial approach
  • When dissecting the seminal vesicles, remember to adequately ligate the vessels on the tips of the vesicles, as they may bleed profusely
  • Do not use any source of energy near the pedicle and the NVB if performing nerve sparing surgery. Use clips and scissors to dissect tissue
  • Use the assistant’s grasper to roll the prostate in more convenient directions for dissection
  • When dissecting the apex, place the assistant’s grasper on the base of the prostate to pull on the prostate in a cranial direction. This will allow for easier apical dissection
  • Protect the rectum under the urethra when dissecting the apex by placing the assistant’s cannula there.
  • The anastomosis may be constructed continuously or with interrupted sutures, as long as sutures are placed with precision. The use of a UR6 needle is recommended
  • Check for water-tightness of the anastomosis by instilling 120ml of saline into the bladder

Indications

Laparoscopic partial nephrectomy is a surgical option for the treatment of patients with relatively small, easily accessible renal tumors. Partial nephrectomy should be considered whenever there is an indication for conservation of the renal function of the affected kidney, such as in cases of:

  • Absence or reduced function of the contralateral kidney
  • Bilateral renal tumors
  • Systemic diseases that may affect renal function in the future
    • Diabetes mellitus – especially if poor glycemic control
    • Hypertension
  • Renal conditions that may affect renal function in the future
    • Extensive stone disease
    • Chronic pyelonephritis
    • Renal artery stenosis
    • Vesicoureteral reflux
  • The ideal indication for partial nephrectomy is a single, <4cm exophytic renal tumor, although larger tumors may also be attempted. The ideal localization is in the lower pole, but masses in all other locations may be removed. Centrally located masses may also be resected, albeit with larger difficulty due to its location closer to the renal vessels. Laparoscopic partial nephrectomy is a challenging intervention, and as such, should be attempted only in centers with significant laparoscopic experience.
  • Surgical access is done in the same fashion as for a radical nephrectomy.
  • Hilar dissection should be performed in all cases (even for small tumors where clamping will not be performed) in order to have immediate access to the renal vessels.
  • A Satinsky clamp is inserted for renal vessel occlusion through an additional trocar inserted for this purpose. Alternatively, bulldog clamps could be inserted for vessels occlusion

 

  • The plane of excision should be decided before renal vessel clamping. The placement of the Satinsky clamp should be performed only when the vessels are adequately prepared and the excision is planned
  • The excision of the tumour is performed with the use of scissors with care to avoid any tumour positive surgical margin
  • The dissection should be performed rapidly since the warm ischemia time should not overcome 30 minutes
  • If the collecting system has been opened during tumor excision, reconstruction with continuous sutures is performed to close the lesion. The reconstruction of the renal parenchyma is performed with continuous suture
  • Additional Hem-o-lok clips are placed on the suture to ensure the tight approximation of the renal parenchyma
  • A bolster of haemostatic gauze is placed underneath the suture in order to provide haemostasis
  • During the suturing of the interstitial layer of the parenchyma, deep bites should be avoided as major vascular compromise to the kidney is possible. Satinsky clamps are removed after the complete suturing of the renal. The use of fibrin glue over the suture line for additional haemostasis is advised
  • Gerota’s fascia is finally closed and specimen contained within the endoscopic bag is retrieved.
  • Warm ischaemia time (WIT) is a concern when planning and performing partial nephrectomy. Warm ischaemia time should be kept to a minimum, in order to minimize the risk of ischemic renal injury. In centers with substantial experience, WIT times for laparoscopic partial nephrectomies are slightly higher to ischaemia times for open surgery, without posing extra risks to renal activity. In cases of small (<4cm) exophytic tumors, enucleation or partial nephrectomy may be performed without vessel clamping. Placement of vessel clamps should only be done when:
  • The vessels are clearly seen and have been adequately dissected
  • The tumor has been visualized and prepared
  • The line of dissection has been visualized
  • Materials for hemostasis (sutures, bolsters,etc) are prepared at the nurse’s table
  • Suturing angles have been visualized in the surgeon’s mind. If an extra trocar is necessary, now is the time to place it.
  • Proper hemostatic control is paramount in partial nephrectomy, independently of vessel clamping status. The tumor bed should be thoroughly visualized for bleeding vessels and breaches into the collecting system that may have to be sutured. The borders of the tumor bed are then sutured together and a hemostatic bolster is placed in the tumor bed for optimal control. Care is taken in this step, as renal tissue may be easily torn by suture placed with excessive tension. A solution our department uses is the use of Lapra-Ty tm suture clips and conventional tissue clips to maintain steady tension while suturing the tumor bed. The oncological outcomes for patients with T1 renal tumors are similar when comparing laparoscopic partial nephrectomy to open surgery. Moreover, partial nephrectomy had been shown to be superior to radical nephrectomy in similar cohorts when comparing overall survival due to a smaller incidence of renal insufficiency and smaller rates of cardiovascular events.

Indications

  • Standard of care for patients with T2 renal tumors (tumor >7 cm, limited to kidney) or smaller tumors not treatable by partial nephrectomy
  • Although significant experience has been accumulated with LRN, the maximum tumor size for LRN remains unclear. In general, the principles of oncologic surgery propose the performance of LRN in tumors up to stage T3bN0M0 . Higher stage disease (T4, renal vein involvement), tumors with diameter up to 14cm (without positive surgical margins) have been reported to be successfully managed by LRN. In fact, the indications of the technique are expanding along with the accumulation of laparoscopic experience.

Surgical steps of transperitoneal access

  • Positioning of patient
  • Lateral decubitus position, table flexed at level of patient’s umbilicus, appropriate padding and support2.Planning and placement of trocars
  • Establish pneumoperitoneum with Hassan or Veress needle technique at lateral margin of rectus muscle, at the level of the umbilicus
  • 12 mm trocar – at the level of the lateral rectus muscle sheath on the anterior axilliary line
  • 10 mm trocar – umbilical
  • 5mm trocars – at the level of the mid-clavicular line under the costal margin3.Entry into peritoneal cavity
  • Inspection of peritoneal contents, division of adhesions4. Exposure of retroperitoneal space (White line of Toldt)
  • Identification of ureter and hilar structures (renal vessels and pelvis)
  • Transection of ureter
  • Dissection and ligation of renal vessels (hemolock clips or EndoGIA stapler)
  • Dissection of renal attachments outside Gerota’s fascia
  • Entrapment of surgical sample
  • Retrieval of surgical sample
  • Removal of trocars, exit from peritoneal cavity, suture of incisions
  • Adequate mobilization of the liver on the right side and full mobilization of the spleen on the left side are essential for proper visualization of the surgical field
  • Mobilization of the colon should be done close to the body wall in order to minimize thermal injuries to the large intestine.
  • For right nephrectomy, the duodenum must be well mobilized
  • The ureter should be used as a guide to the hilar structures and to the lower pole
  • Division of the ureter may be left for the final stages of the operation, as it aids in holding the kidneys in their proper position
  • Division of the lateral attachments of the kidney to the body wall should be done after ligating the vessels, in order to prevent medial “rolling” of the kidney
  • Renal vessels may be ligated and divided en-bloc, with an endoscopic stapler, provided that the vessels are clearly inside the jaws of the device. Arteriovenous fistulas are exceedingly rare complications.
  • The ureter will usually be slightly posterior and lateral to the gonadal vessels
  • On the left side, the gonadal vein is an excellent guide to the renal vein
  • Beware of excessive tension on the right gonadal vein, as it may avulse from the IVC

Indications

  • Usual Patients
    • Patients with muscle-invasive bladder cancer (T2-T4a)
  • Selected patients
    • Patients with high risk, recurrent Tis and/or T1G3 after BCG failure
    • Patients with large papillary tumors refractory to TUR and intravesical treatment
      Salvage cystectomy for patients with tumors refractory to standard therapies
    • Palliative cystectomy for patients with severe complications from tumor extension

Radical Cystectomy

  • Positioning of patient (supine with deep Trendelenburg)
  • Planning and placement of trocars
  • Entry into peritoneal cavity
    • Dissection of prerectal space (seminal vesicles left intact)
    • High peritoneal incision from along the ureters until internal inguinal ring
  • Division of ductus deferens, using a medial retractor
  • Extended pelvic lymph node dissection (ilio-obturator, internal iliac/medial external iliac): both the extent of node dissection and the number of lymph nodes removed has a direct impact on survival for both negative and positive node patients)
  • Division of ureter (once clamped)
  • Merging of peritoneal incisions; division of superior, inferior vesical artery, vesicular arteries
  • Late division of urachus and umbilical ligaments
  • Dissection of Retzius’ space
  • Complete dissection of the endopelvic fascia
  • Dissection along the prostate for preservation of neurovascular bundles (intrafascial: Aphrodite’s veil)
  • Complete dissection of urethra
  • Retrieval of the closed specimen “en bloc”
  • Laparoscopic anastomosis to the urethra in orthotopic bladder replacement

Continent diversion

  • Heterotopic
  • Orthotopic
    • Abol –Enein
    • Studer

Incontinent diversion

  • Cutaneous diversion
  • Ileo-uretero-dermostomy (Bricker, Wallace, etc)

Indications

  • Adrenal benign tumors (functional or non-functional) of relatively small volume (< 5 cm, larger tumors associated with increased risk of malignancy)
  • Aldosteronoma, pheochromocytoma, ganglioneuroma, lipoma
  • Adrenal Hyperplasia
  • Hormonal overproduction
  • The role of LA in the treatment of malignant adrenal tumors is still controversial. Several reports on LA for malignant adrenal tumors have revealed that the procedure is associated with a risk of tumor spillage, peritoneal or port site dissemination resulting in local recurrence. Despite the fact that tumor spillage is not universally accepted, no benefit in matters of oncological outcome has been demonstrated in case of LA versus open approach. Consequently, open adrenalectomy should be currently preferred in cases of pre-operatively diagnosed adrenocortical cancers.
  • A cutoff point of <5-6cm adrenal tumors have been empirically posed by many urologists for laparoscopic resection
  • Adrenal tumor size could pose a relative contraindication for two reasons.
  • Bigger adrenal lesions are associated with higher possibility of a misdiagnosed malignancy.
  • Increased operative time, perioperative blood loss, and conversion to open surgery rate have been reported in the case of large (>5cm) adrenal lesions in comparison to smaller lesions. Nevertheless, operative time, blood loss, hospital stay, and complication rate are always reported to be lower for laparoscopic adrenalectomy in comparison to the conventional open adrenalectomy for large tumors. Moreover, the growing laparoscopic skill and clinical experience resulted in successful laparoscopic management of tumors up to 12 cm in diameter. Thus, the size of benign tumors that are treated by the laparoscopic approach are depending on the clinical experience of the performing surgeon.

Surgical steps of transperitoneal access

  1. Positioning of patient
  • Same position as laparoscopic radical nephrectomy
  1. Trocar placement (similar positions for Right and Left adrenalectomy, inversed sides)
  • Use Veress needle or open Hassan Technique to establish pneumoperitoneum
  • Lateral margin of the rectus muscle in a site cranially to the level of the umbilicus (10mm trocars).
  • Mid- axillary line near the costal margin (12mm trocar)
  • Costal margin towards the xiphoid near the pararectal line (5mm trocar)
  1. Right Laparoscopic Adrenalectomy
  • Elevation of right lobe of the liver using fan retractor inserted via the medial port
  • Incision of the triangular ligament down to the level of the diaphragm
  • Dissection of gland begins medially, between adrenal, IVC and cephalad to the liver
  • Identification and ligation (clipping) of adrenal vein
  • Continuation of dissection, medially, superiorly and inferiorly – clips or electrocoagulation is vessels are encountered
  • Separation of kidney at end of procedure, insertion into retrieval bag and extraction
  1. Left Laparoscopic Adrenalectomy
  • Patient positioning and trocars placement inversed in relation to Right Laparoscopic Adrenalectomy
  • Mobilization of colon’s splenic flexure
  • Division of attachments to spleen and tail of pancreas using electrocautery
  • Identification and ligation of left adrenal vein (flowing into left renal vein).
  • Division of adrenal gland’s attachments
  • Retrieval with specimen bag
  • Control of bleeding is essential in any surgical case, but especially so in laparoscopic surgery where the vision of the operative field may be obscured very quickly by hemorrhage
  • For left adrenalectomy, the spleen should be completely mobilized in order to gain better access to the operative field
  • On the right side, use the vena cava as a guide to finding the the renal and adrenal veins
  • Beware of segmental renal veins to the upper pole, they may be confused for the adrenal vein.
  • The left adrenal vein is usually more easily discerned than the right adrenal vein
  • Although three distinct arterial branches (Superior, Middle and Inferior adrenal arteries) are classically described, there may be a wide range of variations, with an arcade of arteriolar branches commonly seen in the superior surface of the adrenals. These may be ligated with an ultrasonic shears.

Indications

  • De-Roofing of a renal cyst should be undertaken when the size of the cyst causes compressive symptoms to the kidney or other organs. If there is any suspicion of malignancy, de-roofing should not be undertaken.

Surgical steps

  1. Introduction of trocars and creation of pneumoperitoneum (transabdominal access)
  2. Location of Renal cyst
  3. Puncture of the renal cyst wall and aspiration of the contents
  4. Circumferential excision of superior part of the cyst wall
  5. Thorough check for hemostasis
  6. Insertion of drain
  7. Port removal and incision sutur

Indications

  • Relief of uretero-pelvic junction obstruction due to intrinsic anatomic stenosis or crossing vessels. Patients usually present with symptoms related to UPJ obstruction (i.e. recurrent flank pain, recurrent urinary tract infections, pyelonephritis, ipsilateral nephrolithiasis, deterioration of renal function)

Surgical steps of transperitoneal access

  1. Positioning of patient
  2. Planning and placement of trocars
  3. Entry into peritoneal cavity
  4. Exposure of retroperitoneal space (White line of Toldt)
  5. Identification of ureter and hilar structures and obstructed UPJ
  6. Management of UPJ according to characteristics of obstruction (always insertion of double J stent)
  7. Placement of drainage tube
  8. Removal of trocars, exit from peritoneal cavity and suture of incisions
  • Detailed preoperative imaging is necessary for proper diagnosis and for the proper planning of treatment
  • Patients with recurrent pyelonephritis may have extensive perinephric scarring, making dissection and proper anatomical repair very difficult
  • No matter what the repair (V-Y, Hynes Anderson, Culp, etc) the suture line should not be under tension, and be as water tight as possible
  • In order to place the pigtail catheter, use an 18G needle to puncture the abdomen and to direct a guide wire through the pelvis and ureter. Then the pigtail may be pushed over the wire without twisting in the abdominal cavity.
  • If suturing through the established ports is difficult, do not hesitate to place an extra 5 or 3mm port.
  • Placement of a nephrostomy tube before the operation will aid in decompressing the dilated pelvis, and will speed up the identification of the kidney. A decompressed pelvis is easier to manage than a dilated one.

Laparascopic Prostatectomy

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Indications

  • Usual Patients
    • Patients with localized prostatic cancer of low or intermediate risk (cT1a-cT2c, Gleason Score 2-7, PSA10yrs)
  • In very selected cases
    • Patients with low volume, high risk prostate cancer (cT3a or Gleason Score 8-10 or PSA >20ng/ml)
    • Patients with very high risk localized prostate cancer (cT3b-cT4 N0 or any T N1)

Endoscopic Extraperitoneal Radical Prostatectomy (EERPE)

  • Access into extraperitoneal space without entry into peritoneal cavity
  • Minimization of risk of visceral trauma, quicker mobilization of intestines, containment of possible urinary leaks outside peritoneal cavity

Surgical Steps

  1. Positioning of the patient
  2. Dissection and entry into extraperitoneal space
  3. Planning and placement of ports
  4. Balloon inflation of extraperitoneal space (under direct vision)
  5. Dissection of extraperitoneal space and identification of key landmarks
  6. Dissection of anterior surface of prostate and endopelvic fascia
  7. Ligation of deep venous plexus of Santorini
  8. Dissection of prostatic base and bladder neck
  9. Dissection of vas deferens and seminal vesicles
  10. Dissection of posterior prostatic surface
  11. Dissection of prostatic pedicles and preservation of neurovascular bundles
  12. Dissection of prostatic apex and urethral sphincter complex
  13. Entrapment of surgical specimen
  14. Construction of vesicourethral anastomosis
  15. Retrieval of surgical specimen
  16. Exit from extraperitoneal space, removal of trocars and suture of incisions

Transperitoneal laparoscopic prostatectomy

  • Access into peritoneal cavity through all layers of abdominal wall and subsequent exposure of extraperitoneal organs
  • Familiar route for laparoscopic surgeons
  • Careful placement of trocars avoids clashing of instruments, damage to epigastric vessels, and makes suturing easier.
  • In obese patients, trocars may be moved forward by a few centimeters.
  • Before insufflation of the extraperitoneal space, use fingers to swipe adhesions at linea alba
  • Insufflation of the extraperitoneal space requires approximately 60 pumps of the balloon
  • When placing trocars aided by the scope’s vision, always aim to go directly through muscle, and not through other intervening tissue. If there are adhesions, make sure to dissect them
  • If an intrafascial approach is considered, the endopelvic fascia should not be incised, but rather bluntly pushed away. Dissection should happen on the plane of the prostatic capsule
  • Suture of the DVC is easier with a straightened CT1 needle, as the passage under the DVC will be easier to direct.
  • When identifying the bladder neck, tug on the catheter (with a filled balloon). The border between the prostate and the bladder should be readily seen.
  • When dissecting the anterior portion of the bladder neck, aim to dissect directly downwards exactly in the border between the bladder and prostate. This will result in a smaller bladder neck and no prostatic tissue left behind.
  • Identify the ureteral orifices before starting dissection of the posterior bladder neck.
  • If the ductus deferens is not readily seen after dissection of the posterior bladder neck, consider changing the cleavage plane as you may be entering the prostate, Also, beware of through and through injuries to the bladder during this phase.
  • Try to dissect the posterior aspect of the prostate by stripping Denonvilier’s fascia in order to maintain an intrafascial approach
  • When dissecting the seminal vesicles, remember to adequately ligate the vessels on the tips of the vesicles, as they may bleed profusely
  • Do not use any source of energy near the pedicle and the NVB if performing nerve sparing surgery. Use clips and scissors to dissect tissue
  • Use the assistant’s grasper to roll the prostate in more convenient directions for dissection
  • When dissecting the apex, place the assistant’s grasper on the base of the prostate to pull on the prostate in a cranial direction. This will allow for easier apical dissection
  • Protect the rectum under the urethra when dissecting the apex by placing the assistant’s cannula there.
  • The anastomosis may be constructed continuously or with interrupted sutures, as long as sutures are placed with precision. The use of a UR6 needle is recommended
  • Check for water-tightness of the anastomosis by instilling 120ml of saline into the bladder

Indications

Laparoscopic partial nephrectomy is a surgical option for the treatment of patients with relatively small, easily accessible renal tumors. Partial nephrectomy should be considered whenever there is an indication for conservation of the renal function of the affected kidney, such as in cases of:

  • Absence or reduced function of the contralateral kidney
  • Bilateral renal tumors
  • Systemic diseases that may affect renal function in the future
    • Diabetes mellitus – especially if poor glycemic control
    • Hypertension
  • Renal conditions that may affect renal function in the future
    • Extensive stone disease
    • Chronic pyelonephritis
    • Renal artery stenosis
    • Vesicoureteral reflux
  • The ideal indication for partial nephrectomy is a single, <4cm exophytic renal tumor, although larger tumors may also be attempted. The ideal localization is in the lower pole, but masses in all other locations may be removed. Centrally located masses may also be resected, albeit with larger difficulty due to its location closer to the renal vessels. Laparoscopic partial nephrectomy is a challenging intervention, and as such, should be attempted only in centers with significant laparoscopic experience.
  • Surgical access is done in the same fashion as for a radical nephrectomy.
  • Hilar dissection should be performed in all cases (even for small tumors where clamping will not be performed) in order to have immediate access to the renal vessels.
  • A Satinsky clamp is inserted for renal vessel occlusion through an additional trocar inserted for this purpose. Alternatively, bulldog clamps could be inserted for vessels occlusion

 

  • The plane of excision should be decided before renal vessel clamping. The placement of the Satinsky clamp should be performed only when the vessels are adequately prepared and the excision is planned
  • The excision of the tumour is performed with the use of scissors with care to avoid any tumour positive surgical margin
  • The dissection should be performed rapidly since the warm ischemia time should not overcome 30 minutes
  • If the collecting system has been opened during tumor excision, reconstruction with continuous sutures is performed to close the lesion. The reconstruction of the renal parenchyma is performed with continuous suture
  • Additional Hem-o-lok clips are placed on the suture to ensure the tight approximation of the renal parenchyma
  • A bolster of haemostatic gauze is placed underneath the suture in order to provide haemostasis
  • During the suturing of the interstitial layer of the parenchyma, deep bites should be avoided as major vascular compromise to the kidney is possible. Satinsky clamps are removed after the complete suturing of the renal. The use of fibrin glue over the suture line for additional haemostasis is advised
  • Gerota’s fascia is finally closed and specimen contained within the endoscopic bag is retrieved.
  • Warm ischaemia time (WIT) is a concern when planning and performing partial nephrectomy. Warm ischaemia time should be kept to a minimum, in order to minimize the risk of ischemic renal injury. In centers with substantial experience, WIT times for laparoscopic partial nephrectomies are slightly higher to ischaemia times for open surgery, without posing extra risks to renal activity. In cases of small (<4cm) exophytic tumors, enucleation or partial nephrectomy may be performed without vessel clamping. Placement of vessel clamps should only be done when:
  • The vessels are clearly seen and have been adequately dissected
  • The tumor has been visualized and prepared
  • The line of dissection has been visualized
  • Materials for hemostasis (sutures, bolsters,etc) are prepared at the nurse’s table
  • Suturing angles have been visualized in the surgeon’s mind. If an extra trocar is necessary, now is the time to place it.
  • Proper hemostatic control is paramount in partial nephrectomy, independently of vessel clamping status. The tumor bed should be thoroughly visualized for bleeding vessels and breaches into the collecting system that may have to be sutured. The borders of the tumor bed are then sutured together and a hemostatic bolster is placed in the tumor bed for optimal control. Care is taken in this step, as renal tissue may be easily torn by suture placed with excessive tension. A solution our department uses is the use of Lapra-Ty tm suture clips and conventional tissue clips to maintain steady tension while suturing the tumor bed. The oncological outcomes for patients with T1 renal tumors are similar when comparing laparoscopic partial nephrectomy to open surgery. Moreover, partial nephrectomy had been shown to be superior to radical nephrectomy in similar cohorts when comparing overall survival due to a smaller incidence of renal insufficiency and smaller rates of cardiovascular events.

Indications

  • Standard of care for patients with T2 renal tumors (tumor >7 cm, limited to kidney) or smaller tumors not treatable by partial nephrectomy
  • Although significant experience has been accumulated with LRN, the maximum tumor size for LRN remains unclear. In general, the principles of oncologic surgery propose the performance of LRN in tumors up to stage T3bN0M0 . Higher stage disease (T4, renal vein involvement), tumors with diameter up to 14cm (without positive surgical margins) have been reported to be successfully managed by LRN. In fact, the indications of the technique are expanding along with the accumulation of laparoscopic experience.

Surgical steps of transperitoneal access

  • Positioning of patient
  • Lateral decubitus position, table flexed at level of patient’s umbilicus, appropriate padding and support2.Planning and placement of trocars
  • Establish pneumoperitoneum with Hassan or Veress needle technique at lateral margin of rectus muscle, at the level of the umbilicus
  • 12 mm trocar – at the level of the lateral rectus muscle sheath on the anterior axilliary line
  • 10 mm trocar – umbilical
  • 5mm trocars – at the level of the mid-clavicular line under the costal margin3.Entry into peritoneal cavity
  • Inspection of peritoneal contents, division of adhesions4. Exposure of retroperitoneal space (White line of Toldt)
  • Identification of ureter and hilar structures (renal vessels and pelvis)
  • Transection of ureter
  • Dissection and ligation of renal vessels (hemolock clips or EndoGIA stapler)
  • Dissection of renal attachments outside Gerota’s fascia
  • Entrapment of surgical sample
  • Retrieval of surgical sample
  • Removal of trocars, exit from peritoneal cavity, suture of incisions
  • Adequate mobilization of the liver on the right side and full mobilization of the spleen on the left side are essential for proper visualization of the surgical field
  • Mobilization of the colon should be done close to the body wall in order to minimize thermal injuries to the large intestine.
  • For right nephrectomy, the duodenum must be well mobilized
  • The ureter should be used as a guide to the hilar structures and to the lower pole
  • Division of the ureter may be left for the final stages of the operation, as it aids in holding the kidneys in their proper position
  • Division of the lateral attachments of the kidney to the body wall should be done after ligating the vessels, in order to prevent medial “rolling” of the kidney
  • Renal vessels may be ligated and divided en-bloc, with an endoscopic stapler, provided that the vessels are clearly inside the jaws of the device. Arteriovenous fistulas are exceedingly rare complications.
  • The ureter will usually be slightly posterior and lateral to the gonadal vessels
  • On the left side, the gonadal vein is an excellent guide to the renal vein
  • Beware of excessive tension on the right gonadal vein, as it may avulse from the IVC

Indications

  • Usual Patients
    • Patients with muscle-invasive bladder cancer (T2-T4a)
  • Selected patients
    • Patients with high risk, recurrent Tis and/or T1G3 after BCG failure
    • Patients with large papillary tumors refractory to TUR and intravesical treatment
      Salvage cystectomy for patients with tumors refractory to standard therapies
    • Palliative cystectomy for patients with severe complications from tumor extension

Radical Cystectomy

  • Positioning of patient (supine with deep Trendelenburg)
  • Planning and placement of trocars
  • Entry into peritoneal cavity
    • Dissection of prerectal space (seminal vesicles left intact)
    • High peritoneal incision from along the ureters until internal inguinal ring
  • Division of ductus deferens, using a medial retractor
  • Extended pelvic lymph node dissection (ilio-obturator, internal iliac/medial external iliac): both the extent of node dissection and the number of lymph nodes removed has a direct impact on survival for both negative and positive node patients)
  • Division of ureter (once clamped)
  • Merging of peritoneal incisions; division of superior, inferior vesical artery, vesicular arteries
  • Late division of urachus and umbilical ligaments
  • Dissection of Retzius’ space
  • Complete dissection of the endopelvic fascia
  • Dissection along the prostate for preservation of neurovascular bundles (intrafascial: Aphrodite’s veil)
  • Complete dissection of urethra
  • Retrieval of the closed specimen “en bloc”
  • Laparoscopic anastomosis to the urethra in orthotopic bladder replacement

Continent diversion

  • Heterotopic
  • Orthotopic
    • Abol –Enein
    • Studer

Incontinent diversion

  • Cutaneous diversion
  • Ileo-uretero-dermostomy (Bricker, Wallace, etc)

Indications

  • Adrenal benign tumors (functional or non-functional) of relatively small volume (< 5 cm, larger tumors associated with increased risk of malignancy)
  • Aldosteronoma, pheochromocytoma, ganglioneuroma, lipoma
  • Adrenal Hyperplasia
  • Hormonal overproduction
  • The role of LA in the treatment of malignant adrenal tumors is still controversial. Several reports on LA for malignant adrenal tumors have revealed that the procedure is associated with a risk of tumor spillage, peritoneal or port site dissemination resulting in local recurrence. Despite the fact that tumor spillage is not universally accepted, no benefit in matters of oncological outcome has been demonstrated in case of LA versus open approach. Consequently, open adrenalectomy should be currently preferred in cases of pre-operatively diagnosed adrenocortical cancers.
  • A cutoff point of <5-6cm adrenal tumors have been empirically posed by many urologists for laparoscopic resection
  • Adrenal tumor size could pose a relative contraindication for two reasons.
  • Bigger adrenal lesions are associated with higher possibility of a misdiagnosed malignancy.
  • Increased operative time, perioperative blood loss, and conversion to open surgery rate have been reported in the case of large (>5cm) adrenal lesions in comparison to smaller lesions. Nevertheless, operative time, blood loss, hospital stay, and complication rate are always reported to be lower for laparoscopic adrenalectomy in comparison to the conventional open adrenalectomy for large tumors. Moreover, the growing laparoscopic skill and clinical experience resulted in successful laparoscopic management of tumors up to 12 cm in diameter. Thus, the size of benign tumors that are treated by the laparoscopic approach are depending on the clinical experience of the performing surgeon.

Surgical steps of transperitoneal access

  1. Positioning of patient
  • Same position as laparoscopic radical nephrectomy
  1. Trocar placement (similar positions for Right and Left adrenalectomy, inversed sides)
  • Use Veress needle or open Hassan Technique to establish pneumoperitoneum
  • Lateral margin of the rectus muscle in a site cranially to the level of the umbilicus (10mm trocars).
  • Mid- axillary line near the costal margin (12mm trocar)
  • Costal margin towards the xiphoid near the pararectal line (5mm trocar)
  1. Right Laparoscopic Adrenalectomy
  • Elevation of right lobe of the liver using fan retractor inserted via the medial port
  • Incision of the triangular ligament down to the level of the diaphragm
  • Dissection of gland begins medially, between adrenal, IVC and cephalad to the liver
  • Identification and ligation (clipping) of adrenal vein
  • Continuation of dissection, medially, superiorly and inferiorly – clips or electrocoagulation is vessels are encountered
  • Separation of kidney at end of procedure, insertion into retrieval bag and extraction
  1. Left Laparoscopic Adrenalectomy
  • Patient positioning and trocars placement inversed in relation to Right Laparoscopic Adrenalectomy
  • Mobilization of colon’s splenic flexure
  • Division of attachments to spleen and tail of pancreas using electrocautery
  • Identification and ligation of left adrenal vein (flowing into left renal vein).
  • Division of adrenal gland’s attachments
  • Retrieval with specimen bag
  • Control of bleeding is essential in any surgical case, but especially so in laparoscopic surgery where the vision of the operative field may be obscured very quickly by hemorrhage
  • For left adrenalectomy, the spleen should be completely mobilized in order to gain better access to the operative field
  • On the right side, use the vena cava as a guide to finding the the renal and adrenal veins
  • Beware of segmental renal veins to the upper pole, they may be confused for the adrenal vein.
  • The left adrenal vein is usually more easily discerned than the right adrenal vein
  • Although three distinct arterial branches (Superior, Middle and Inferior adrenal arteries) are classically described, there may be a wide range of variations, with an arcade of arteriolar branches commonly seen in the superior surface of the adrenals. These may be ligated with an ultrasonic shears.

Indications

  • De-Roofing of a renal cyst should be undertaken when the size of the cyst causes compressive symptoms to the kidney or other organs. If there is any suspicion of malignancy, de-roofing should not be undertaken.

Surgical steps of transperitoneal access

  1. Positioning of patient
  2. Planning and placement of trocars
  3. Entry into peritoneal cavity
  4. Exposure of retroperitoneal space (White line of Toldt)
  5. Identification of ureter and hilar structures and obstructed UPJ
  6. Management of UPJ according to characteristics of obstruction (always insertion of double J stent)
  7. Placement of drainage tube
  8. Removal of trocars, exit from peritoneal cavity and suture of incisions

Surgical steps

  1. Introduction of trocars and creation of pneumoperitoneum (transabdominal access)
  2. Location of Renal cyst
  3. Puncture of the renal cyst wall and aspiration of the contents
  4. Circumferential excision of superior part of the cyst wall
  5. Thorough check for hemostasis
  6. Insertion of drain
  7. Port removal and incision sutur

Indications

  • Relief of uretero-pelvic junction obstruction due to intrinsic anatomic stenosis or crossing vessels. Patients usually present with symptoms related to UPJ obstruction (i.e. recurrent flank pain, recurrent urinary tract infections, pyelonephritis, ipsilateral nephrolithiasis, deterioration of renal function)

Surgical steps of transperitoneal access

  1. Positioning of patient
  2. Planning and placement of trocars
  3. Entry into peritoneal cavity
  4. Exposure of retroperitoneal space (White line of Toldt)
  5. Identification of ureter and hilar structures and obstructed UPJ
  6. Management of UPJ according to characteristics of obstruction (always insertion of double J stent)
  7. Placement of drainage tube
  8. Removal of trocars, exit from peritoneal cavity and suture of incisions
  • Detailed preoperative imaging is necessary for proper diagnosis and for the proper planning of treatment
  • Patients with recurrent pyelonephritis may have extensive perinephric scarring, making dissection and proper anatomical repair very difficult
  • No matter what the repair (V-Y, Hynes Anderson, Culp, etc) the suture line should not be under tension, and be as water tight as possible
  • In order to place the pigtail catheter, use an 18G needle to puncture the abdomen and to direct a guide wire through the pelvis and ureter. Then the pigtail may be pushed over the wire without twisting in the abdominal cavity.
  • If suturing through the established ports is difficult, do not hesitate to place an extra 5 or 3mm port.
  • Placement of a nephrostomy tube before the operation will aid in decompressing the dilated pelvis, and will speed up the identification of the kidney. A decompressed pelvis is easier to manage than a dilated one.

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