Index

Adhesions, 381 cavity, hand incision, 789 extraperitoneal drain, 7 fascia, anterior, 971 hysterectomy, 411 surgery, 242, 971 preparation for, 188 viscera, inspection of, 5 wall, 432 anatomy, 432 injury, risk of, 1036 layers, 68, 435 lifting method, 813, 818 metastases, 817 neuralgias, body mass index, 930-931 parietal peritoneum of, 433 relaxation, 456 vasculature, by transillumination, 1036 Abdominal wall lift (AWL), 813, 818 cardiovascular and respiratory effects, 976 mechanical, 976...

Laparoscopic Radical Simple Nephrectomy Models

The following patient parameters were recorded during the retrospective chart review (392 patients) age, sex, surgeon, radical versus simple, unilateral versus bilateral, Our goal was to design algorithms to predict the duration of hospital stay after laparoscopic renal surgery based on preoperative patient parameters. planned adrenalectomy, planned lymph node dissection, gastro-esophageal reflux disease, hypertension, smoking, diabetes mellitus, hyperlipidemia, chronic obstructive pulmonary...

Laparoscopic Partial Nephrectomy Models

The following patient parameters were recorded during the retrospective chart review (334 patients) age, sex, surgeon, body mass index, American society in anesthasiology grade, hypertension, prior pancreatitis, prior abdominal surgery, prior deep venous thrombus, peripheral vascular disease, smoking, coronary astery disease, gastic erophageal refull disease, anxiety, hyperlipidemia, depression, renal stone disease, constipation, liver cirrhosis, hepatitis C, hematuria (micro or gross), chronic...

Laparoscopic Partial Nephrectomy Greater or Lesser Than One Day Duration of Hospital Stay Predictor

Univariate logistic regression analysis in the design group for duration of hospital stay greater or lesser than one day identified 24 patient characteristics as significant predictors for a duration of hospital stay of greater than one day as listed in Table 6. As there were only 28 patients in the design group who had a duration of hospital stay of less than or equal to one day, the statistical significance of some of these parameters may be overstated. Multiple logistic regression analysis...

Noncontinent Urinary Diversions Ileal Conduit

Ileal conduit urinary diversion is commonly employed and has few short-term complications. Initial isolated reports and clinical series describing laparoscopic ileal conduit urinary diversion took advantage of the fact that radical cystectomy specimens are often removed through laparotomy incisions, and therefore used open-assisted or mini-laparotomy techniques. Kozminski and Partamian performed the first laparoscopic-assisted ileal conduit diversion in 1992. Their procedure did not include a...

Abdominal Insufflation Exposure

CO2 is the primary gas used to create a pneumoperitoneum for laparoscopy in nonpregnant and pregnant patients. Gaseous carbon dioxide exchange occurs with intraperitoneal insufflation. There has been much concern in the past over the effects of CO2 pneumoperitoneum on the fetus. While studies have demonstrated that fetal acidosis does occur in animal models during CO2 pneumoperitoneum, there have been no long-term adverse effects noted (56-58). Furthermore, there is no evidence to support...

Adjacent Organ Injury

As in any laparoscopic renal procedure, injury to surrounding structures such as the bowel, spleen, liver, pancreas, pleura, and adrenals can occur. Use of a preoperative bowel preparation especially in more challenging cases such as autosomal dominant polycystic kidney disease can decompress the bowel, improve visualization, and reduce the chance of iatrogenic injury from laparoscopic instrumentation. During mobilization of the colon and small bowel, the use of elec-trocautery should be...

Age

Aging of the general population and the attendant increase in End stage renal disease has widened the gap between available cadaver kidneys and demand. It appears that there is the development of an organ social security system in which younger donors TABLE 4 Contraindications for Live Kidney Donation Abbreviation CT, computed tomography. There is no difference in recipient graft function when received from obese donors. However, the future health and well-being of obese donors is a real...

Aldosteronomas

Primary hyperaldosteronism (Conn's syndrome) is a rare etiology of hypertension (< 1 ). Other clinical manifestations of Conn's syndrome arise from an increased total body sodium content and a deficit in total body potassium. Symptoms include urinary urgency or frequency, nocturia, muscle weakness, paresthesias, or visual disturbances (4,11). Computed tomography scan or magnetic resonance imaging can detect adrenal adenomas as small as 1 cm in size. Laboratory manifestations include...

Alternative Sites for Introducing the Veress Needle

For a previously operated abdomen with a midline incision, the Veress needle should be placed in the upper left quadrant of the abdomen just lateral to the rectus sheath. Transrectus insertion of the Veress needle is discouraged because of risk of injury to the inferior epigastric vessels. The Veress needle at the upper quadrant region needs to be passed more deeply into the abdomen in order to enter the peritoneal cavity because all layers of the abdominal wall are present here and the risk of...

Anatomic Overview 1 Brachial Plexus

The most common peripheral nerves or neural structures at risk for surgery-related injury in the upper extremity are the brachial plexus and the ulnar and median nerves, whereas in the lower extremity, the femoral, obturator, and peroneal nerves are at risk. The brachial plexus (Fig. 1) is derived from the ventral rami of C5 through T1 and gives rise to most nerves supplying the arm. The plexus begins in the neck and proceeds into the axilla as it passes under the clavicle and over the first...

Anderson Hynes Dismembered Pyeloplasty

Anderson-Hynes dismembered pyeloplasty is preferred when pelvic reduction may be necessary, a renal calculus is present, or a crossing vessel is encountered (Fig. 3). A dismembered pyeloplasty may have superior efficacy compared with the other nondismembered techniques. In the largest head-to-head comparison of laparoscopic dismembered (n 25) and nondismembered pyeloplasties (n 15), Klingler et al. showed superior efficacy for dismembered (96 ) versus nondismembered (73.3 ) pyeloplasty. Once...

Apical Dissection

Following division of the Santorini plexus, both neurovascular bundles are exposed lateral to the rectum by blunt dissection. The approach to the apex of the prostate is determined by a decision to proceed with nerve-sparing or with the nonnerve-sparing technique. The criteria for carrying out nerve-sparing technique are listed in Table 3. After transection of the dorsal vein complex, the anterior striated sphincteric urethral complex is demonstrated. The fibers of this complex at the apex are...

Ascites

Presence of ascites is considered a contraindication to laparoscopic surgery because of the increased risk of port site metastasis. Neoplasic ascites is usually secondary to primary hepatic neoplasms, metastases to liver or peritoneum, lymphomas, leukemias, or myeloid metaplasia. The differential diagnosis of ascites is shown in Table 3 (19). The diagnosis of ascites is obtained by paracentesis and fluid analysis. Peritoneal effusion, like pleural effusion, can be subdivided as exudative or...

Basic Principles Of Immunology

We are all exposed to a large variety of infectious agents that would cause pathological damage if left unchecked. In majority of normal individuals, these infections are of limited duration and leave little damage because of the human defense mechanisms in the form of the immune system. The human immune system has two major functional divisions the innate and adaptive systems. Both act in concert, with innate immunity forming the first line of defense. Breaching of innate defenses leads to...

Basic Principles Of Tissue Engineering

The source of donor tissue can be heterologous, allogenic, or autologous autologous is preferred as this method avoids tissue rejection by the immune system and immunosuppressive drugs can be avoided. When autologous cells are used, a biopsy is obtained from the host and the cells are dissociated and expanded, and later returned to the same host as new tissue that is not immunogenic. Tissue engineering entails the use of donor tissue that is dissociated into individual cells. The cells are...

Bladder Diverticulectomy With Stone Removal

The presence of stone(s) in a bladder diverticulum can be a cause of recurrent urinary tract infection, or outflow of obstruction and may require diverticulectomy. In a large diverticulum, with history of infection or in a location close to ureter, bilateral ureteral catheterization or double J stenting is preferred. The dissection is started from the most prominent part of the diverticulum, proceeding toward the diverticulum neck. However, sometimes it is difficult to expose the diverticulum....

Bleeding

Bleeding during laparoscopic renal cyst ablation can occur during many steps of the operation including (i) mobilization and dissection of the kidney, (ii) cyst wall excision and fulguration, and (iii) dissection around the renal hilum. Dissection of Gerota's fascia and perinephric fat and mobilization of the kidney, especially along the hilum and adrenal gland, can lead to bleeding. In cases of simple, solitary renal cyst, only limited dissection of Gerota's and perirenal fat should be...

Blind or Seldinger Technique

In the blind or modified Seldinger technique, a needle is inserted into the abdomen, a guidewire placed, a tract dilated, and the catheter inserted through a split-sheath all maneuvers are performed without visualization of the peritoneal cavity (11). The deep cuff usually remains outside the outer rectus sheath after implantation. The blind technique is not widely used in the United States. The bedside blind insertion technique is associated with a significant risk of visceral damage and high...

Blunt Trauma

Computed tomography scan is the mode of choice in evaluating the hemodynamically stable patient with blunt trauma. Certain circumstances have been described in which computed tomography scan results cannot completely rule out abdominal organ injury. For example, patients with pelvic fractures or retroperitoneal hematomas, who already have abdominal tenderness (thereby limiting clinical evaluation), are at increased risk for missed blunt hollow organ injury. Similarly, such occult findings may...

Bowel Preparation

In cases of symptomatic simple renal cysts, no specific bowel preparation is required prior to surgery. However in patients with autosomal dominant polycystic kidney disease, the typically large-sized kidneys can at times occupy the majority of the peritoneal cavity. Therefore, use of a preoperative bowel preparation (e.g., citrate of magnesium) is advised to decompress the bowel and provide more working space during laparoscopy. Patients should partake of only clear liquids 24 hours prior to...

Circumferential Specimen Mobilization

After control of the adrenal vasculature has been secured, sequential blunt and sharp dissection of the remaining attachments frees up the adrenal gland. Inferior phrenic vessels are often encountered along the undersurface of the diaphragm. During specimen mobilization, one should be careful not to create an unintentional perito-neotomy. Although a peritoneotomy does not significantly compromise operative FIGURE 8 Retroperitoneoscopic right adrenalectomy. Dissection between adrenal gland and...

Clinical Applications In Urology

Limited clinical applications have been reported in urology for partial nephrectomy, radical prostatectomy and retroperitoneal lymphadenectomy using the hydro-jet technique. The majority of these procedures were completed using open technique. In a clinical study, 24 patients underwent open renal sparing surgery for various indications including renal tumors (21). The dissection was performed without hilar control. The dissection time was 14 to 40 minutes with no significant blood loss. A...

Clinical Implications

This could potentially eliminate the use of bowel (and its attendant morbidity) in urinary tract reconstruction. Potentially, such a bladder substitute could have mucosal, myogenic, and neurogenic attributes that approximate those of a functionally intact urinary bladder. Our proposal represents a concerted effort at establishing and developing this novel field of visceral tissue expansion. The search for the ideal tissue substitute for bladder augmentation is ongoing. Currently, intestinal...

Clinical Presentation And Evaluation

Chyluria has an unpredictable course associated with remission and exacerbation. The disease usually affects young adults presenting with complaints of passage of whitish urine, white clots, or hematuria (hematochyluria). Sometimes chylous clots can lead to obstruction in the urinary tract, leading to clot colic (flank pain), retention of urine, or even anuria. Although not life threatening, the disease can be debilitating. Chyluria can lead to considerable weakness and weight loss secondary to...

Coagulation

Pregnancy is considered a hypercoagulable state increasing the risk of thromboembolic phenomena due to increased venous stasis, vessel wall injury, and changes in the coagulation cascade. The effects of estrogen cause increased synthesis of clotting factors, particularly factors VII, VIII, X, and XII (28). Intra-abdominal vascular stasis secondary to inferior vena cava compression from the uterus also increases the risk of deep venous thrombosis during pregnancy with an incidence of...

Collecting System Injury

Injury to the collecting system can occur during aggressive biopsy and fulguration of the base of the cyst wall or during attempts at cyst wall excision of a peripelvic or autosomal dominant polycystic kidney disease cysts. When biopsy of the cyst base is indicated, only superficial samples should be taken especially in the case of peripelvic cysts or cysts located close to the collecting system. Reference to preoperative radiologic films may be helpful in assessing the depth of the cyst and...

Common Gynecologic Laparoscopic Procedures Adnexal Mass and Adnexal Torsion

The incidence of adnexal masses during pregnancy is 2 (123). Adnexal torsion, which is more common during pregnancy, occurs in about one in 1800 pregnancies (34,124). Most adnexal masses discovered during the first trimester of pregnancy are functional cysts and resolve spontaneously by the second trimester (18). Persistent masses are most commonly functional cysts or mature cystic teratomas, with the incidence of malignancy reported at 2 to 6 (125). Presenting symptoms of adnexal torsion...

Comparative Analysis of Open and Laparascopic Approaches

In order to define the clinical outcomes of a laparascopic approach to bladder reconstruction, we compared prospectively, our initial experience in laparoscopic augmentation cystoplasty with continent catheterizable ileal stoma to a similar cohort of patients who underwent an open approach. Eighteen consecutive cases of augmentation colocysto-plasty with continent catheterizable ileal stoma were performed at our Institute nine patients underwent the open approach (eight women and one man mean...

Complications

Few studies differentiate between major and minor complications. The complication rates range from 0 to greater than 20 (Table 4) (5,33,38,57). Major complications seen with laparoscopic Burch include bladder injury, ureteral damage or kinking, abscess or seroma formation in the space of Retzius, failed procedure requiring additional surgery, de novo detrusor instability, new onset intrinsic sphincter deficiency, urinary retention, voiding dysfunction, and a possible increase in posterior...

Complications Of Handassisted Laparoscopy Specific Complications

Hedican et al. reported a multi-institutional complications report including 196 patients undergoing various hand-assisted laparoscopy renal procedures (56). Procedures included 57 radical nephrectomies, 50 donor nephrectomies, 38 nephrouretectomies, 24 partial nephrectomies, 2 simple nephrectomies, and 2 other renal procedures. The data showed that 28 patients (14 ) had minor complications, including urinary retention in 11 and prolonged ileus in four. Of the patients, 9.2 suffered major...

Computed Tomography Protocol For Laparoscopic Surgical Planning

Three-phase computed tomography protocols are the state-of-the-art for imaging the kidneys and provide all the necessary information for surgical planning for laparoscopic surgery (Fig. 1) (3-5). These scans should be performed on a multidetector helical scanner, which allows efficient use of intravenous contrast and facilitates creating thin-slice datasets for smooth two-dimensional and three-dimensional reformations. The first scan phase is a noncontrast computed tomography scanning of the...

Conclusion

Urologic laparoscopic reconstructive surgery is rapidly expanding at numerous centers around the world. The ability to reconstruct every urologic organ by laparoscopic methods have been reported. The technology to accomplish these dextrous maneuvers is changing rapidly with logarithmic rises in the number of cases. Suturing technology and techniques are the leading methods that are fostering these reconstructions, but the skills and talents of innovators in this field cannot be denied....

Continent Catheterizable Stomal Reservoirs

When continent catheterizable stomal reservoirs is desired, preoperative preparation and patient selection parallels that of their open counterparts. First and foremost, patients must be motivated and intact cognitively and physically, without restrictions imposed by neurologic injury or neurodegenerative disorders that would impair coordination necessary for clean intermittent catheterization. Many of the reports of appendicovesicostomy urinary diversion are found in the pediatric population,...

Costs of Training Ethical Considerations of Certification

Following initial reports of laparoscopic cholecystectomy, surgical practice in the United States has undergone substantial change. There has been a torrential outpouring of interest to learn new endoscopic techniques. The costs absorbed by practitioners to attend courses were hefty and few academic centers availed themselves of the early training experience (156). Some groups started small businesses of training surgeons, as the demand was so acute and the courses themselves proved financially...

Current Indications And Contraindications Of Laparoscopic Adrenalectomy

Laparoscopic adrenalectomy has become the gold standard approach for the treatment of select patients with aldosteroma, pheochromocytoma, Cushing's disease, nonfunc-tioning adenoma, and rarely, adrenal cyst or myelolipoma. Laparoscopic radical adrenalectomy for primary or metastatic malignancy, has been reported (4). Unacceptable cardiopulmonary risk, uncorrected coagulopathy, abdominal sepsis, and bowel obstruction represent general contraindications for laparoscopy. Laparoscopic adrenalectomy...

Current Status Of Laparoscopic Approach

It has long been documented that grafts from living kidney donors show superior function and survival when compared to those from cadaver donors. Open donor nephrec-tomy has been performed successfully for nearly five decades with low rates of complications and graft loss. Donor nephrectomy is a unique surgery because the outcomes and complications affect both the donor and the recipient. Mis-steps that occur during the harvest may ultimately affect the donor and graft function. The initial...

Cushings Syndrome

Cushing's syndrome comprises the symptom complex resulting from excess circulating glucocorticoids, regardless of etiology (3). Non-adrenal causes of hypercortisolism include pituitary adenomas, ectopic corticotrophin production, and exogenous steroid use. The urologist is most often confronted with an adrenal lesion as the etiology of Cushing's syndrome. Cushing's syndrome manifests with a variety of well recognized clinical features, including hypertension, truncal obesity, moon facies, easy...

Delayed Complications

There is a growing amount of literature on the risk of postoperative laparoscopic hernia formation following trocar removal (95-99). The standard custom has been to close the fascia in all trocar sites 10 mm in diameter or above. The literature would suggest that although the risk of port site herniation is uncommon below the 10 mm cutoff it is by no means certain. In fact, children and obese patients are significantly at risk of herniation from the 5 mm trocars and smaller (100). The estimated...

Detailed Laparoscopic Technique Equipment and Hand Assist Devices

Gelport Device

The operating room is assembled in a similar manner as for any laparascopic procedure. Equipment used in hand-assisted cases versus pure laparascopic cases is similar as well. Two important instruments exclusive to hand-assisted surgery include a ringless laparotomy pad and the hand-assist device. A clean, rolled up laparotomy pad with the ring removed is placed into the abdomen through the hand incision. The laparotomy pad is used to help retract and dry tissues. Drier tissues are easier to...

Diagnosis

Adrenal lesions historically were diagnosed secondary to clinical manifestations of endocrinopathies. However, widespread use of abdominal ultrasound, computed tomography scanning, and magnetic resonance imaging has led to the not infrequent finding of the incidental adrenal mass. Figures 1 and 2 show typical examples of adrenal lesions diagnosed on computed tomography and magnetic resonance imaging. The differential diagnosis of an incidental adrenal mass is extensive and includes the benign...

Digital Imagingvideo Documentationand Editing

Over the last few years, digital imaging has slowly revolutionized the field of video endoscopy. Images captured initially in the analog format could later be converted digitally using a digital camera or scanner. However, the introduction of digital still cameras has taken image documentation and editing to a new level. Currently, the newest surgical video systems have integrated digital image capture system, allowing immediate capturing of still images from endoscopic procedures (Fig. 5) (3)....

Discussion

As stated by Hoznek et al., in open retropubic radical prostatectomy, the pubic bone impairs the visibility and the access to the urethral stump making the placement of the sutures difficult. In addition, the surgeon must tie the knots in a blind field and must rely on tactile sensation only. Therefore, there is a risk of inadequate suture knot positioning. Moreover, if the knot is pulled too strongly it may tear out of the urethra, whereas if it is too loose, the vesical neck and the urethral...

Effect on Delayed Type Hypersensitivity and T Lymphocytes

Delayed-type hypersensitivity responses can indirectly reflect changes in T-lymphocyte populations in patients undergoing surgical procedures. Although it seems that delayed-type hypersensitivity is better preserved after laparoscopic than open surgery, it is still not clear which components of the cascade are responsible for this preservation of cellular immunological response (1,13). Gutt et al. assessed cell-mediated immune function by measuring the size of skin pustules induced by...

Elevated Intracranial Pressure and Cerebral Ischemia

In a small study of pigs insufflated with CO2 at a pressure of 15 mmHg, the intracranial pressure increased by 5 mmHg (169). In two myelomeningocele patients with ventriculoperitoneal shunts, the intracranial pressure increased more than 15 mmHg above baseline during a CO2 pneumoperitoneum of 10 mmHg pressure only (170). In another study of 18 patients with ventriculoperitoneal shunts undergoing 19 laparo-scopic procedures, however, bradycardia and hypertension, which would be expected if the...

Endoscopic Camera Systems and Charged Coupled Device

The current generation of endoscopic cameras employs the charge coupled device chip. The digital image is captured on a charge coupled device using either a digital still or a digital video camera. Photoreceptors, within the charge coupled device , rapidly assess the different light intensities that make up the endoscopic image. The charge coupled device generates pixels by converting unique light intensities within an image into corresponding electronic signals, which are then transmitted to a...

Enterovesical Anastomosis

Although different approaches can be used for intracorporeal suturing of the bowel segment to the bladder as shown in Figure 6, we prefer to begin by running the preplaced suture on the posterior wall of the reconfigured bowel patch to the apical aspect of the bladder flap in a medial to lateral direction on each side. Completion of the posterior wall of the reconfigured bowel segment from an intravesical approach beginning medially (point A) and finishing laterally (points B and C,...

Equipment And Technique

Gasless laparoscopy creates a working space in the abdominal cavity by lifting the abdominal wall instead of using carbon dioxide. To lift the abdominal wall, the following three methods are available subcutaneous wire lifting in which a thin steel wire is passed subcutaneously to lift the abdominal wall peritoneal planar lifting in which by a retractor is inserted into the abdominal cavity to lift the whole abdominal wall and abdominal wall lifting in which the abdominal wall is lifted by a...

Expansion of Laparoscopic Approach

Pain, extended hospitalization, time away from work, and long-term disability are barriers to potential donors. The laparoscopic approach provides potential donors with a minimally invasive alternative to open donor nephrectomy. Laparoscopic donor nephrectomy has definitely decreased hospitalization. The average hospital stay for 2339 standard transperitoneal donors reported has been 2.9 days. There is a clear difference between the United States and the rest of the world, where pressure for...

Experimental Data

The porcine model was used by Pompeo et al. to describe transthoracic (TT) left adrenalectomy in 1997 (13). After inserting four 10-mm laparoscopic trocars into the left pleural cavity, left pneumothorax was created insufflating CO2 at a mean pressure of 10 mmHg. A 6-cm phrenotomy was performed starting from the lateral side of the aorta and retroperitoneal space entry was achieved. Carbon dioxide-induced positive intrapleural pressure facilitated this maneuver. After Gerota's fascia opening...

Frequency Of Laparoscopic Vascular Injury

TABLE 1 Laparoscopic Vascular Injuries from Urologic Series TABLE 1 Laparoscopic Vascular Injuries from Urologic Series 4-Dissection injury 2-Stapler misfire 2-Clip dislodgment 4-Dissection injury 3-Access injury 2-Stapler misfire 1-Clip dislodgement and three were related to problems with access. Five of the seven dissection injuries resulted in emergent open conversion. In nonurologic laparoscopy, vascular injury appears to be less frequent and is usually associated with access-related...

Future Directions Hydrojet Technology

Future directions include potentially bloodless renal parenchymal incision without hilar clamping with the use of hydro-jet technology. This technology employs a high-pressure water jet to perform selective tissue dissection in a relatively bloodless manner. Spared intrarenal vessels may then be controlled with clips or bipolar coagulation, and the renal collecting system suture repaired (130). Basting et al. (131) reported the initial clinical experience using water jet resection in 24...

Future Robotic Surgery Systems

As previously mentioned, one of the major points of criticism of robotic telemanipula-tors is the lack of haptic feedback from the operating instruments. While some surgeons using the current systems on a regular basis feel that this is partly compensated for by the superior three-dimensional visual feedback, others differ. Future robotic systems are likely to include improved haptic feedback data. The enormous size of the systems compromises their proper positioning, thus either...

Gasless Vs Pneumoperitoneum Basic Research

Many basic studies have compared gasless laparoscopic surgery and laparoscopic surgery using pneumoperitoneum in terms of invasiveness and effects on the patient. Gasless surgery without carbon dioxide pneumoperitoneum is not associated with compression of the inferior vena cava and intestinal vessels, elevation of the diaphragm, and absorption of carbon dioxide gas into the blood. Therefore, the gasless laparoscopic surgery is superior with regard to the effects on hemodynamics and respiratory...

Gastrointestinal Effects of Pneumoperitoneum

Halevy et al., in a series comparing open and laparoscopic cholecystectomy, have demonstrated that laparoscopic surgery results in significantly less disruption of normal gastrointestinal motility when compared to open surgery (18). The mechanism(s) of decreased ileus with laparoscopic surgery remain(s) unclear. Another concern with abdominal laparoscopy has been gastroesophageal reflux. Despite the increased intra-abdominal pressures associated with insufflation, there has been no increased...

Hand Assisted Laparoscopic Adrenalectomy

This technique, described by Bennett and Ray, is reported to be associated with short operative times and has the advantage of introducing tactile feedback in locating the adrenal gland. This technique utilizes the Handport f, which is placed in the upper midline for left-sided lesions and via an oblique right lower subcostal incision for right-sided procedures. The procedure then follows the same dissection as for open surgery with Kocherization of the duodenum on the right prior to control of...

Hand Assisted Techniques

Collins Knife Incision Ureteral Orifice

Hand-assisted laparoscopic nephroureterectomy has been advocated by some (19-22), because it provides the surgeon with tactile sensation and an incision adequate for intact specimen removal. Herein, we present two hand-assisted laparoscopic nephroureterectomy techniques. Gonzalez et al. described making a midline, periumbilical incision, which was used as the hand-assisted port (20). Prior to the dissection of the kidney, two large clips were placed on the proximal ureter to prevent any...

Hemostatic Aids And Impact Of Floseal

The specific technical challenge of laparoscopic partial nephrectomy lies in achieving a bloodless operative field for precise tumor excision and pelvicalyceal repair followed by renal hemostasis in a time-sensitive manner, with the least possible compromise of renal function. Achieving prompt and durable hemostasis is of paramount importance. Several techniques of parenchymal hemostasis during laparoscopic partial nephrectomy have been reported with varying success, including cauterization of...

High Intensity Focused Ultrasound

As an ultrasound wave propagates though biologic tissues, or any medium that is not ideally viscoelastic, it is progressively absorbed and the energy is converted to heat. If the ultrasound beam is brought to a tight focus at a selected depth within the body, the high energy density produced in this region results in temperatures exceeding the threshold level of protein denaturation. As a consequence coagulative necrosis occurs. The energy drops sharply outside the focal zone so that overlying...

Hilar Clamping Vs Nonclamping

Guilloneau et al. (119) compared 12 patients undergoing laparoscopic partial nephrec-tomy with renal hilar clamping versus 16 patients undergoing laparoscopic partial nephrectomy without hilar control. The non-clamping group experienced significantly greater blood loss (708 vs. 270 mL p 0.014) and longer operative time (3 vs. 2 hours p 0.004) compared to laparoscopic partial nephrectomy with hilar clamping. Postoperative serum creatinine levels were not significantly different (1.3 vs. 1.45 mg...

History Gynecologic And General Surgery Literature

Vertical midline laparotomy is argued as the gold standard for ovarian malignancy, because large prospective randomized clinical trials comparing laparoscopy are absent from the contemporary gynecologic literature (13). Despite this argument, the ubiquity and benefits of laparoscopy has driven minimally invasive management for many gynecologic malignancies (14). Using laparoscopy for the treatment of uterine carcinoma with bulky adenopathy appears to have a higher gynecologic risk of port site...

History Of Laparoscopy An Odyssey Of Innovations

Rays Tmj Disorder

Ordorica Division of Urology, University of South Florida, Tampa, Florida, U.S.A. Department of Urology, University of California Davis School of Medicine, Sacramento, California, U.S.A. Urologists once only peered into the new frontier of laparoscopy. Today we are now embracing it and thriving within it, bringing its benefits to our patients. Even as we witness its growth and realize its potential, it is instructive to peer into the past. The principal mark...

Idiopathic Retroperitoneal Fibrosis

Idiopathic retroperitoneal fibrosis is a chronic inflammatory process that comes to uro-logic attention when extrinsic compression and encasement of the ureter by surrounding retroperitoneal tissues cause ureteral obstruction. The progressive nature of the inflammatory process can lead to flank pain and renal deterioration. Radiographic findings on intravenous pyelogram or retrograde pyelogram may include medial deviation of the involved ureter and the absence of intraluminal obstruction....

Image Interpretation And Threedimensional Volume Rendering

Computed tomography and magnetic resonance images are reviewed to characterize all lesions for lesion size and location and to determine the number of arteries and veins whether it is local, regional, or distant lymphadenopathy the presence of renal vein tumor extension and if it is a local or regional metastatic disease. Tumor size, renal vein, and inferior vena cava tumor thrombus, and lym-phadenopathy are all criteria used for staging. If the patient is a nephron-sparing surgery candidate,...

Increased Intra Abdominal Pressure

Insufflation of gas elevates the intra-abdominal pressure. Increase in intra-abdominal pressure is the most prominent of the physiologic insults of laparoscopy and can have dramatic effects with only small changes. Increased intra-abdominal pressure compresses the splanchnic circulation (Fig. 1) (18), in both capillaries and capacitance vessels, and in both the venous and arterial systems (14,15,19-22). An intra-abdominal pressure of 20 mmHg or more diminishes blood flow to all abdominal and...

Indications

Laparoscopic simple nephrectomy is indicated in benign renal diseases where complete loss of the renal unit has occurred or is desired. Such conditions include but are not limited to Obstructive or reflux nephropathy, Chronic inflammatory infection conditions including xanthogranulomatous and tuberculosis pyelonephritis (these are technically challenging), Posttransplantation hypertension. Simple nephrectomy is most commonly performed for symptomatic (pain, hypertension, and infections) and...

Indications And Contraindications

The indications for laparoscopic partial nephrectomy have been expanded beyond small, exophytic, and peripheral renal tumors to include patients with more involved tumors placed deep in the kidney, abutting the collecting system or renal sinus, completely intraparenchymal, adjacent to the renal hilum, or tumor in a solitary kidney. Laparoscopic partial nephrectomy for such complex tumors is performed only when nephron sparing surgery is indicated. Contraindications for laparoscopic partial...

Indications Of Laparoscopic Radical Prostatectomy

The indications for the radical laparoscopic prostatectomy are the same as that for the open procedures including treatment of men with localized prostate carcinoma and a life expectancy of 10 years or more. TABLE 1 History and Technical Modifications of Laparoscopic Radical Prostatectomy Schuessler et al. (1) Kavoussi et al. (4) The first reported case underwent laparoscopic radical prostatectomy Laparoscopic approach to seminal vesicles for its diseases and perineal radical prostatectomy with...

Informed Consent Legalese

The jargon utilized by the legal system can be overwhelming. Some basic definitions are warranted for review (141). A plaintiff is the person who alleges malpractice. The defendant is the laparoscopic urologic surgeon, an assistant, and possibly the hospital where the surgery was performed. A complication is some difficulty, problem, or change in the patient's health that is unintended. Negligence is the failure to exercise the degree of care considered reasonable under the circumstances,...

Instrumentation and Skills

Closed environmental constraints aside, there are two other significant barriers limiting rapid mastery of intracorporeal suturing skills and instrumentation skills. Instrumentation initially relied upon adaptation of grasping instruments for the purpose of laparoscopic suturing. Limitations of general-purpose graspers are their inability to grasp and maintain the torque needed for driving needles through tissue. To overcome this problem, several manufacturers developed pin-vise-like needle...

Insufflation and Trocar Placement

The peritoneal cavity is insufflated through a Veress needle to establish a pneu-moperitoneum of 15 mmHg. A 5-mm incision is made just lateral to the umbilicus to accommodate the Veress needle. The needle is inserted directly perpendicular to the skin surface, with the distal tip stabilized by the surgeon's hand to prevent past-pointing during placement. The position of the needle tip is confirmed by the saline drop test. If the saline passes through the needle without resistance, the...

Introduction And Background

Laparoscopic adrenalectomy was initially performed, in 1991, for a case of adrenal hematoma (1). Gagner et al. first reported the procedure for neoplasia in October 1992 (2) however, Go et al. had begun a series of laparoscopic adrenalectomies in patients with primary aldosteronism in January 1992 (3), followed by Suzuki et al., who had also commenced a series in February the same year (4). Laparoscopic adrenalectomy has become the standard surgical approach for most surgically correctable...

Introduction

The use of bioadhesive technology in laparoscopic urologic surgery dates back to the mid-1990s (1) however, Bergel first used dry plasma to establish hemostasis in 1909 (2). Fibrin patches to establish hemostasis during cerebral surgery (3) and to manage bleeding from battlefield parenchymal organ injuries were introduced subsequently. The adhesive properties of fibrin sealant were first recognized experimentally and then clinically in 1942, when investigators performed microsurgical peripheral...

James O LEsperance

Department of Urology, Naval Medical Center, San Diego, California, U.S.A. Glenn M. Preminger Division of Urologic Surgery, Comprehensive Kidney Stone Center, Duke University Medical Center, Durham, North Carolina, U.S.A. DIGITAL IMAGING Analog vs. Digital Imaging Endoscopic Camera Systems and Charged VIDEO ENDOSCOPY (AKA CHIP ON A STICK) Future Developments in Endoscopic Imaging DIGITAL IMAGING, VIDEO DOCUMENTATION, AND EDITING IMAGE DISPLAY SYSTEMS AND HIGHDEFINITION VIDEO SYSTEMS...

Kidney Therapeutic Cloning and Stem Cells

Approximately 70,000 people in the United States are on a transplant wait list due to renal disease. The two currently available options for such patients are dialysis and renal allotransplantation. Both options are life-sustaining, but both are associated with significant morbidity and mortality. Dialysis is often poorly tolerated, and transplantation is burdened with severe donor shortages as well as the complications that accompany immuno-suppression. This has motivated researchers to...

Laparoscopic Anatomy Upper Abdomen

Section of Laparoscopic and Robotic Surgery, Glickman Urological Institute, Cleveland Clinic Foundation, Cleveland, Ohio, U.S.A. Because every urologist has studied gross anatomy and basic surgical abdominal anatomy during general surgery and urology training, this chapter details urologic laparoscopic abdominal anatomy. A clear and confident understanding of surgical anatomy and anatomic interrelationships is a prerequisite for performing laparoscopic surgery. The surgeon must understand the...

Laparoscopic Aortorenal Bypass

Physiologically significant renal artery stenosis, mostly due to atherosclerosis, has been known to cause hypertension and deterioration of renal function (1-3). Percutaneous transluminal balloon angioplasty and intravascular stenting have evolved as the first-line therapy in recent years however, they have provided inferior long-term patency (4). Surgical revascularization remains the gold-standard definitive treatment of renal artery stenosis as well as the salvage treatment of failed...

Laparoscopic Ice Slush Renal Hypothermia

Based on prevailing open surgical principles, the technique of laparoscopic ice slush for renal hypothermia was first described by Gill et al. (3) from the Cleveland Clinic Foundation. They reported their technique in 12 patients, with a mean tumor size of 3.2 cm (range, 1.5-5). Mean depth of invasion into the parenchyma was 1.5 cm (range, 0.7-2.5). Of these, two patients had a solitary kidney. A transperitoneal approach was used. A 5 French open ended ureteral catheter was inserted...

Laparoscopic Ileal Ureter Replacement Introduction and Indications

Ileal ureter replacement was first described by Shoemaker in 1906, and has proved to be a reliable procedure for urinary reconstruction (7). Replacement of the ureter with ileum is performed in certain clinical indications where a long segment or the entire length of the ureter needs to be replaced. The only other alternative in these cases is the more complicated renal autotransplantation (8,9). Indications for ileal ureter replacement include long or multiple ureteric strictures...

Laparoscopic Intracorporeal Suturing And Knotting Intracorporeal Suturing Difficulties

Laparoscopic urologic reconstruction continues to require intracorporeal suturing skills. Intracorporeal suturing and knotting represent the most difficult surgical techniques that the advanced laparoscopic surgeon can acquire. Reasons for the difficulty in performing intracorporeal suturing are multifactorial (Table 3). The closed operating environment represents the primary hindrance to mastering these techniques. Fixed portals of entrance limit the approach to the targeted suture site. The...

Laparoscopic Marsupialization Of Lymphocele

Scales, Jr., and David M. Albala Division of Urology, Duke University Medical Center, Durham, North Carolina, U.S.A. The exposure to the peritoneal surface results in the absorption of lymphatic fluid and forms the basis of surgical therapy for lymphocele treatment through either an open or laparoscopic approach.

Laparoscopic Partial Adrenalectomy For Recurrent Pheochromocytomas

The author reported the first case of laparoscopic partial adrenalectomy for recurrent pheochromocytoma in the literature (52). Walz et al. demonstrated successful laparo-scopic surgical treatment of three locally recurrent pheochromocytomas following open transperitoneal surgery, including one case of partial resection (50). They noted limited scarring around the recurrent tumors allowing clear and rapid identification of landmarks and neoplasm, and recommended endoscopic surgery for recurrent...

Laparoscopic Partial Nephrectomy

Laparoscopic partial nephrectomy is an emerging minimally invasive nephron-spar-ing alternative to open partial nephrectomy. However, before laparoscopic partial nephrectomy can be recommended for widespread use, reproducible technical, perioperative, pathologic, functional, and oncologic outcomes comparable to open partial nephrectomy must be confirmed. Advances in laparoscopic skills and technology have allowed efficacious achievement of renal hilar vascular control, renal hypothermia (if...

Laparoscopic Prostatectomy

Radical prostatectomy is the most common therapy for patients with prostate cancer and accounts for approximately half of the 1.7 billion cost of prostate cancer treatment (30). In evaluating the cost of radical retropubic prostatectomy as compared to laparo-scopic and robot-assisted prostatectomy, we found that radical retropubic prostatectomy was the least expensive approach with a cost advantage of 487 and 1726 over laparoscopic radical prostatectomy and robot-assisted prostatectomy,...

Laparoscopic Radiofrequency Ablation Technique

The laparoscopic approach to radiofrequency ablation of a small renal mass is indicated for anterior, medial, and some lateral renal tumors where the ureter, colon, or small bowel are within 1 cm of the tumor and risk injury. In addition, the path for percutaneous radiofrequency needle placement for a posterior renal tumor is occasionally impeded by a large spleen, liver lobe, or lung parenchyma. In these cases, if radiofrequency ablation is intended, a laparoscopic approach is indicated. The...

Laparoscopic Repair Of Renal Artery Aneurysm

Renal artery aneurysms may cause renal function deterioration and renovascular hypertension. Furthermore, large aneurysms (> 2 cm) have the increased risk of rupture. When indications for intervention are present, the conventional open surgical renal revascularization is the gold-standard treatment, which is known to be associated with significant postoperative morbidity. Gill et al. from the Cleveland Clinic reported their initial experience with repair of renal artery aneurysm performed...

Laparoscopic Suturing Time Line

Thou shouldst draw together for him his gash with stitching, quotes the Edwin Smith surgical papyrus. Suturing has existed since prehistorical times. Ancient suture materials included flax, hair, linen, pig bristles, grasses, cotton, silk, and gut from animals. Ant mandibles were used as needles to draw the sutures through wounds. By the 18th century, wire had begun to be used in holding together tissues. Currently, in the United States, the U.S. Pharmacopeia sets the standards that are used by...

Laparoscopic Technique

The patient is placed in the supine position on the operative table, prepped and draped in a standard sterile fashion. A Foley catheter is placed along with a nasogastric tube to Percutaneous needle aspiration has been described as an initial attempt to manage symptomatic lymphoceles. However, high recurrence rates are reported ranging from 42 to 100 (17-19). Small lymphoceles (< 100 mL) lying near the renal hilum, or lateroposterior, lateroinferior, or inferomedial lymphoceles are the most...

Laparoscopic Training

Surgical education has struggled with the methods to objectively scrutinize surgical performance of house staff for many years. The methods of formal education have had some limited application, but as the complexity of modern laparoscopic surgery has manifested itself, departments across the country and around the world have begun to evaluate how to assess competency, skill development, teaching methodologies, and communication skills (67). The complexity of this task has resulted in a...

Laparoscopic Assisted Laparoscopic Radical Cystectomy

In 2002, Gaboardi et al. (16) introduced the laparoscopic-assisted technique of laparoscopic radical cystectomy with ileal neobladder, in which extracorporeal restoring of intestinal TABLE2 m Operative Outcomes of Reconstructive Urinary Diversion TABLE2 m Operative Outcomes of Reconstructive Urinary Diversion In their six cases experience of laparoscopic-assisted laparoscopic radical cystectomy with orthotopic ileal neobladder, operative time was reported, 360 to 510 minutes (mean, 425)...

Laparoscopy and Litigation

Laparoscopic cholecystectomy was widely adopted in 1990. Just four years later, litigation centering around bile duct injury for the laparoscopic technique surpassed similar litigation for open cholecystectomy by more than 20-fold (19). Kern suggests that this was in part due to the great deal of negative press surrounding laparoscopic injuries during cholecystectomy. In 1992, the New York Times reported, Surgeons who rushed to use a new technique to remove gallbladders without adequate...

Laparoscopy And Systemic Immunity

Laparoscopic surgery causes less tissue trauma than open surgery and is likely to be associated with better preservation of systemic immune function and contribute to quicker recovery (1,8,9). In general, immunological function is depressed after open surgery, with adverse altera- tions in cytokine levels and changes in the function of cellular components of the systemic immune response (10-12). On the contrary, the body's response to laparoscopy is one of lesser immune activation as opposed to...

Laterality of Nephrectomy

Since the inception of living, related kidney donation, the better kidney has always remained with the donor (77). Historically, the percentage of right kidney donors in the open experience ranges from 26 to 37 (78). Common indications for right-sided donor nephrectomy include multiple left renal arteries or veins, right renal cysts, smaller right kidney, or possibly solitary right-sided nephrolithiasis (79-81). Right renal vein length is significantly shorter than left donor vein length....

Local Recurrences Port Site And Ureteral Stump

Port site metastasis is a rare event. Biologic, pathophysiologic, and technical factors can facilitate its occurrence, particularly in diseases such as transitional cell carcinoma that TABLE5 Results of Studies Comparing Laparoscopic and Open Nephroureterectomy for Upper Urinary Tract Transitional Cell Carcinoma TABLE5 Results of Studies Comparing Laparoscopic and Open Nephroureterectomy for Upper Urinary Tract Transitional Cell Carcinoma aSurvival rate calculated from data in the publication....

Mathematical Models to Predict Duration of Stay After Laparoscopic Nephrectomy Radical Simple or Partial

Laparoscopic nephrectomy (radical, simple or partial) is a minimally invasive procedure that is offered to patients for the treatment of renal malignancy or chronic renal dis-ease In our current medical climate, efficient use of resources in the postoperative care of patients undergoing these procedures is of prime importance Duration of hospital stay plays a critical role in determining the cost of individual surgical procedures (23) Minimally invasive procedures offer significant cost savings...

Mechanical Tissue Tripsy

By forcing water through a small nozzle under high pressure at 10-50 kg cm2 parenchymatous tissue can be removed, whereas vessels > 200 m in diameter remain undamaged (2). This tissue skeletonization by water-jet facilitates subsequent hemostasis by elec-trocautery or suturing and is being utilized clinically, such as for partial hepatectomy or nephrectomy. Structures up to diameter of 500 m can be dissected by using probes generated to longitudinal and transverse oscillation of 200-300 m by...

Mechanism Of Action

Radiofrequency ablation uses monopolar alternating electric current delivered directly into the target tissue, where the native impedance of the tissue leads to heat generation. Where heating is sufficient, lethal temperatures are produced and the tissue is ablated. Specifically, a radiofrequency electrode is positioned into the target tissue and a grounding pad placed on the body. A computer-controlled generator applies alternating electrical current with a frequency within the radio segment...

Mechanism of Injury

Laparoscopic surgery always carries the risk of inadvertent injuries that usually occur during the learning curve of various procedures. The exceptions to this rule, and some of the most feared injuries facing the laparoscopic urologist are those to vascular structures or bowel. These injuries are fortunately infrequent. The best method of managing these injuries is avoiding them. This is best accomplished by a thorough understanding of the equipment utilized during laparoscopy, high-risk...

Natural History Of Small Renal Tumors

Small renal neoplasms are generally removed soon after diagnosis. Therefore, their natural history has been historically poorly understood. In the landmark report of surveillance of kidney tumors, Bosniak et al. retrospectively reviewed the imaging of 40 incidentally detected, less than 3.5 cm renal masses that had been followed for a mean of 3.25 years. Twenty-six tumors were eventually removed after an average of 3.8 years and 84.6 of them were histologically renal cell carcinomas. Variable...

New Innovations In Laparoscopic Prostate Surgery

As the technique of laparoscopic radical prostatectomy has become standardized and widespread, several centers have begun to use these techniques for salvage laparo-scopic radical prostatectomy, and to perform sural nerve grafting during laparoscopic radical prostatectomy. In an early experience from France, Vallancien et al. (58) reported on laparoscopic radical prostatectomy performed as salvage therapy for seven patients. All had previously undergone radiotherapy (external beam radiation in...