laparoscopic urological surgery
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Post on 09-Apr-2017
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Dr. Sreejoy Patnaik
Shanti Omni Super Speciality Hospital Cuttack LAPAROSCOPY IN UROLOGY
History of Lap. UrologyThe first laparoscopic Nephrectomy was performed in 1990 by Clayman
The procedure had an operative time of seven hours and required a 1-unit transfusion and a six-day inpatient hospital stay.
Challenges of Uro lap. surgeryTechnically, more demandingSpecialized teamSlightly more expensive, use of consumablesAdvantages outweigh the challenges
Laparoscopic SurgeryKey hole surgery
Latest development of Urology
Obvious advantages over conventional open surgery
Quicker recovery, discharge, early return to work
Laparoscopic Urological SurgeryRevolutionary development in last 2 decades.
Improves Patients peri-operative quality of life
Provides excellent view due to magnification less tissue trauma & minimal blood loss.
Approaches The 3 three commonly used approaches are
Transperitoneal approachRetroperitoneal approachHand assisted approachEndoscopic Procedures
Transperitoneal approachWider availabilityWorking spaceBetter identification of important landmarksIntestinal Injury ?
Retroperitoneal approachRestricted rapid accessRenal pedicle identification.Reduce the incidence of ileusInjury to the intraperitoneal contents
Hand assisted approachImproved tactile feedbackBridge between open surgeryLap Gelport TMLap Disc TM
ENDOSCOPIC APPROACHESCYSTOSCOPY- TURP/BNI/TURBT/OIUURETEROSCOPY-RIGID URETETROSCOPY URSFLEXIBLE URETEROSCOPY- RIRSPCNL- BY RIGID NEPHROSCPEMINI PERC - RENAL STONES
Laparoscopic Urological ProceduresCommonest procedures performed :-
Ablative Procedures: Urolithiases:Simple nephrectomy PyelolithotomyPartial nephrectomy UreterolithomyRenal cyst marsupilisation CystolithotomyRadical nephrectomy Urachal Cyst excisionRadical cystectomyRadical prostatectomy
Reconstructive Procedures:PyeloplastyLower ureteric reconstructionsBoari flap reconstructionUreteric reimplanation/Psoas hitchIleal ureter implantationOrchipexyDonor nephrectomy
Simple NephrectomyNon functioning KidneyPre renal transplant nephrectomy
Transperitoneal approach Pneumoperitoneum - open technique or closed technique. Ports are inserted in a strategic manner. Preoperative CT Scan) if done helps in determining the location of the kidney and deciding the location of port placement. Other parameters which determine the site of port placement are extent of truncal obesity and body mass index (BMI).
Lateral decubitus positionNear the edge of the tableLower limb is flexed
Left side colon is reflectedIliac bifurcationSuperiorly the splenorenal Renocolic ligamentsIdentify the ureterGonadal vesselsUreter is lifted Psoas landmark
(B) Retroperitoneal approach
Gaur etal15mm incision petit triangleLumbodorsal fasciaBalloon dilator
(C) Hand assist approach
Insert a non dominantHand assist device is inserted Right lower quadrant midway between umbilicus and anteriorsuperior iliac
Laparoscopic Radical NephrectomyT2 & T3a tumors.T1 tumors contraindicated with IVC thrombus
TransperitonealLumbar & adrenal veins are doubly clipped & cut.
Advantage short hospitalLow analgesiaComparableOpen laparoscopic approach is a standard of care in T1 & T2. Renal thrombus is feasible
Laparoscopic partial nephrectomy
Small renal masses Lesions in a solitary kidneyBilateral renal lesionsTechnique- Pneumoperitoneum
- Ports similar to simple nephrectomy
- Ureteric catheter placed per-urethrally - to instill methylene blue- Identify the pelvicalyceal system prior to suturing- Colon reflected and the ureter is lifted off the psoas muscle
- Dissection proceeds to the renal hilum- Renal hilum dissected & satinsky applied - Renal tumor is cut with cautery or harmonic
- Preferred scissors for excising the tumor should be with wide jaws.
- Pelvicalyceal system is closed followed by the cortical defect- An indwelling ureteric catheter or alternatively a double J stent is placed for 48hours.
PyeloplastyPUJ ObstructionRGP prior to positioning the patient5Fr pigtail catheter is inserted into the pelvicalyceal system
30 degree Scope - pelvis is identified bulges outDismembered Anderson hynes Pyeloplasty is preferred crossing vessel is suspectedY-V plasty is preferred
The important steps of this procedure are
PyelotomySpatulation of the ureterPyelotomy is closed a 3-0/4-0 vicrylV stitch as anterior layer easier step to start , followed by posterior layer.
Donor NephrectomyDo no harm to the donor is the dictum
Port placement mirrors that of simple nephrectomyCT angiography plays a pivotal role for strategic port placement.Ureter should be lifted of the psoas in toto as an ureterogonadal packet.Dissection of the artery should be a thermal and should be kept to the minimum.Topical papvarine instillation on the vessel helps in relieving spasmUpper pole should be separated from the spleen securing the adrenal veinGraft should be adequately perfused by intravenous infusion of mannitiol and furosemide prior to retrievalRetrive the graft through a pfannesteil incision
Laparoscopic ureteral reimplanationSupine position a 11mm trocar for camera insertion umbilicusUreter is lifted transected as distally as possibleThe bladder is filled with 200ml salineLateral and anterior peritoneum incised a boari flap is preferredSpatulated ureter and the bladder flap are anastomosed in a tension free manner with 4-0 polygalactin suturesA stent is kept indwelling for 6weeks after the surgery
Laparoscopic stone removalProcedure performed transperitoneal or a retroperitoneal approachPlacement of a stent ureteric catheterUreter lifted of the psoas The ureter is slingedUsing a cold knife the ureter is incisedSpoon may be used for retrieving the stoneStone may be entrapped in a bag for removalUreterotomy is closed with a 3-0 absorbable suture and a drain is placed.
Advanced Laparoscopic Procedures
Laparoscopic ileal interposition
Laparoscopic retroperitoneal lymph node dissections
Laparoscopic radical cystectomy (LRC)Laproendoscopic single site surgery (LESS)
Simple nephrectomyPyeloplastyReconstructive proceduresUreteroneocystostomyLESS donor nephrectomyTechnically feasible procedureSteep learning curve
Robot Assisted Laparoscopic UrologyProstatectomy ,Pyeloplasty, Nephrectomy & Ureter reconstructionsDonor nephrectomyAdrenalectomyAdvantages:Robotic platform Da Vinci SiHigh definition visual magnificationBetter range of motion Additional arm for retractionA unprecedented range of accuracy and dexterityIts increased range of freedomProperty of motion scalingProcedures requiring intracorporeal suturingSmall spaces pelvisThe cost benefit ratio is likely to be a driving force in further development and application of this technology
Laparoscopic NephrectomyBenign, non functioning kidneyRenal cell carcinoma Almost all tumours can be removed laparoscopically
LAP - URETEROLITOTOMY
LAP PARTIAL NEPHRECTOMYVIDEO
LAP RADICAL NEPHRO-URETECTOMYVIDEO
LAP URACHAL CYSTECTOMYVIDEO
Laparoscopic Prostatectomy5 small incisions
Completely mimick all the principles of open surgery
Extraperitoneal approach, avoiding contact with intestine
Laparoscopic Prostatectomy4-5 hours surgery
Less blood loss, minimal blood transfusion requirement
Magnification allowing more accurate dissection and preservation of continence and erection
Hospital stay of 2nights, early removal of urinary catheter.
Laparoscopic radical prostatectomy
Inverted fan shaped manner Endopelvic fascia incisedDorsal vein securedVas deferens &Dissected secured hem-o-lokThe lateral detrussor pillars are secured with clipsThe urethra is dissected be to gain maximum length Posterior reconstruction stich RoccoThe van velthowen technique (bidirectinal running suture) technique with 3-0 monocrylSatisfactory oncologic outcome
Laparoscopic Prostatectomy v/s Robotic prostatectomyAssistance from robot in suturing
High capital and recurring cost
What is new in laparoscopy in urology?Almost all urological procedures can be done laparoscopically
Reproducible, similar if not better results than open surgery
What is the standard of care?
Laparoscopic urological surgeriesProcedureStandard of CareCurrent OpinionLaparoscopic Radical NephrectomyYesProven long term results for tumour upto 7cmLaparoscopic radical nephroureterectomyYesReplaces openLaparoscopic marsupilazation of kidney cystYesReplaces openLaparoscopic adrenalectomyYesReplaces openLaparoscopic pyeloplastyNot yetVery promising, awaiting long term results
Laparoscopic urological surgeriesProcedureStandard of careCurrent opinionLaparoscopic radical prostatectomyNoDivided (laparoscopic, robotic assisted laparoscopic, open)Laparoscopic varicocelectomyNoDivided (open microscope)Laparoscopic extra peritoneal herniorraphyNoPromising, awaiting long term resultsLaparoscopic ureterolithotomyNoAdvanta