Minilaparoscopic Urologic Procedures Needlescopic Urologic Procedures

Adrenalectomy

Technique

Left Adrenalectomy. The procedure is performed with the patient in the lateral position with a 45° tilt. A 2 mm Minisite port is utilized to gain initial peritoneal access. The 2 mm trocar serves as a Veress needle and is inserted lateral to the lateral border of rectus abdominus muscle (anterior axillary line) 3 fingerbreadths inferior to the costal margin. Initial peritoneal entry is confirmed utilizing the needlescope. Pneumoperitoneum is then established. Additional ports that are inserted subsequently include a 10 mm port at the umbilicus, a 5-mm port in the midclavicular line 2 fingerbreadths inferior to the costal margin, and a 2 mm port along the lateral border of the rectus at the costal margin. Except for the initial 2 mm port, all ports are placed under direct visual guidance. A 10 mm 45° laparoscope is inserted through the umbilical port. The surgeon operates through the medial 2 mm port and the 5 mm port. The lateral 2 mm port is utilized by the assistant to place traction on the kidney in an inferior and lateral direction, in order to facilitate tissue dissection. Initially, the line of Toldt is incised, and the left colon is reflected medially. The left renal vein is identified. Dissection along the superior margin of the left renal vein facilitates identification of the adrenal vein. The vein is controlled utilizing 5 mm hemoclips and divided. Next, adrenal vessels arising from the renal artery and aorta are individually controlled with hemoclips and divided. The gland is then circumferentially mobilized. A10 mm endocatch bag is inserted through the umbilical port aKarl Storz, Culver City, CA. bMedical Dynamics, Englewood, CO. cOrigin MedSystems, Menlo Park, CA. dU.S. Surgical Corp., Norwalk, CT.

The steps of the procedure are similar to those of a transperitoneal laparo-scopic adrenalectomy. The differences between conventional laparoscopic and needlescopic adrenalectomy include (i) the utilization of a 45° laparoscope at the umbilicus instead of a 30° laparoscope inserted through a more laterally placed port; (ii) the utilization of 2 mm instruments for dissection, and 5 mm hemoclips; and (iii) the need to switch to a needlescope during insertion of secondary ports, specimen extraction, and fascial closure of the umbilical port site.

for specimen entrapment. Insertion of the needlescope through the lateral 2 mm port facilitates this maneuver. Hemostasis is reconfirmed. The fascia underlying the 10 mm port site is closed with a 0 Vicryl suture utilizing a Carter-Thomason closure device.

The steps of the procedure are similar to those of a transperitoneal laparoscopic adrenalectomy. The differences between conventional laparoscopic and needlescopic adrenalectomy include (i) the utilization of a 45° laparoscope at the umbilicus instead of a 30° laparoscope inserted through a more laterally placed port; (ii) the utilization of 2 mm instruments for dissection, utilization of 5 mm hemoclips; and (iii) the need to switch to a needlescope during insertion of secondary ports, specimen extraction, and fascial closure of the umbilical port site.

Right Adrenalectomy. Initial peritoneal access is achieved with a 2 mm port placed in the anterior axillary line 3 fingerbreadths inferior to the costal margin. A 10-mm port is placed at the umbilicus, a 2-mm port is placed lateral to the xiphoid at the costal margin, and a 5-mm port is placed at the lateral border of the rectus 3 finger-breadths inferior to the costal margin. The assistant retracts the liver superiorly with a 2 mm grasper inserted through the medial 2 mm port. The surgeon operates utilizing the lateral 2 mm port and the 5 mm port. Initially, the line of Toldt is incised and the right colon is reflected medially. Following this, the posterior parietal peritoneum inferior to the inferior margin of the liver is incised. The inferior vena cava is then identified. Dissection between the adrenal gland and the inferior vena cava facilitates identification of the adrenal vein, which is controlled with 5 mm hemoclips and divided. The specimen is then circumferentially mobilized, entrapped in an endocatch bag, and extracted through the umbilical port site.

Results

Gill et al. compared needlescopic adrenalectomy (n = 15) to conventional laparoscopic adrenalectomy (n = 21) (3). Within this retrospective review, patients in the needlescopic group were older than patients in the conventional laparoscopic group (60.4 ± 11.3 years vs. 52 ± 12.7 years; p = 0.06). The needlescopic group was associated with shorter operative time (2.8 hours vs. 3.7 hours; p = 0.05), lesser estimated blood loss (61.4 mL vs. 183.1 mL; p = 0.002), and shorter length of stay in the hospital (1.1 days vs. 2.7 days; p < 0.001). The average specimen weight for the needle-scopic group was 41.6 g (range, 6.8-108 g) and was 15.7 g (range, 6.6-55 g) for the laparoscopic group. Convalescence was shorter for the needlescopic group (2.1 ± 1.02 weeks vs. 3.1 ± 1.9 weeks; p < 0.001). Four of the needlescopic cases were converted to conventional laparoscopy for various reasons including: morbid obesity with a body mass index of 34.1 (n = 1); large tumor size (6 cm) (n = 1); and hemorrhage (n = 2). None of the cases required open conversion.

Orchiopexy

Technique

Initially, a 2 mm needle port is inserted at the umbilicus. The normal side is inspected first. The internal ring is identified lateral to the medial umbilical ligament. The vas and testicular vessels are identified entering the ring. Next, the internal ring of the affected side is identified. Blind ending testicular vessels are indicative of anorchia obviating the need for any further intervention. In the rare case with a blind ending vas, identification of the testicular vessels should still be performed as an undescended testis may still be present and may be identified at the termination of the testicular vessels. Alternatively, intra-abdominal testis peeping into the inguinal canal or inguinal testis may be identified. At times, identification of the abdominal testis may require medial reflection of the right colon. Two secondary 2 mm ports are inserted and the line of Toldt is incised, and the right colon is reflected medially. Following identification of intra-abdominal testis therapeutic options include orchiectomy, one-stage or two-stage orchiopexy. For inguinal testis, inguinal exploration may be performed needlescopically or open surgically. The testicular vessels are mobilized, and the gubernaculum is divided. A scrotal incision is then made and the testis is transferred into the scrotum where it is inserted into a subdartos pouch. A stay stitch placed on the testis facilitates its transfer into the scrotum. A hemostat inserted through the scrotal incision grasps the stay suture and the testis is then delivered into the scrotum. Alternatively, a laparoscopic port may be introduced through the scrotal incision to facilitate transfer of the testis. During needlescopic dissection, the internal ring may be enlarged medially in order to achieve a more direct course to the scrotum. If needed, a Stephen Fowler orchiopexy or a two-staged orchiopexy may also be performed.

Results

Gill et al. reported their results following 12 needlescopic procedures for cryptorchidism with nonpalpable testis (4). Following 12 diagnostic needlescopic explorations therapeutic interventions were performed in select cases. These included bilateral orchiopexy (n = 2), orchiectomy (n = 2), and excision of testicular remnant (n = 2). The average operative time was 1.8 hours (range, one to two hours), and the estimated blood loss was 6 mL (range, 0-20 mL).

Bladder Cuff Excision During Laparoscopic Radical Nephroureterectomy

Technique

To begin with, a thorough cystoscopic examination is performed to rule out the presence of any concomitant bladder tumors. Two needlescopic ports are then inserted into the bladder suprapubically. A 2 mm endoloop tie is inserted through one of the ports and is placed over the targeted ureteral orifice. Following this, a ureteric catheter is inserted through the cystoscope. The catheter is inserted through the endoloop tie, into the targeted ureteral orifice. Now, the cystoscope is exchanged for a resectoscope with a Collins knife, and the 2 mm ports are hooked to wall suction to minimize the possibility of extravasation. Glycine is used as the irrigant. A 2 mm grasper is inserted through one of the suprapubic ports in order to retract the ureteral orifice anteromedially. The resectoscope with the Collins knife is then utilized to detach a full thickness bladder cuff. Traction applied by the suprapubically inserted 2 mm grasper facilitates dissection of 3-4 cm of distal ureter in this fashion. The detached ureteral orifice is then occluded with the previously positioned endoloop tie. The bladder is emptied, the 2 mm ports are removed, and a Foley catheter is left indwelling in the bladder. Formal closure of the bladder is not performed. Following this, the patient is positioned in the flank position for a retroperitoneoscopic radical nephrectomy.

Results

The above technique was reported by Gill et al. (5). The procedure was performed in 20 patients undergoing laparoscopic nephroureterectomy. The operative time for this maneuver was 59 minutes (range, 35-120 minutes). In one patient, extravesical extravasation was noted during the case, and the endoscopic procedure was aborted. Postoperative cystograms were obtained by one week. Mild extravasation was noted in one of the 20 patients, which resolved following catheter drainage of the bladder for an additional week.

Lymphocele Drainage

Technique

Pelvic lymphoceles that are symptomatic and recur following percutaneous drainage are best treated by marsupialization into the peritoneal cavity. Laparoscopic lympho-cele drainage entails a three-port transperitoneal approach. Large lymphocele are easily identified laparoscopically and appear as a visible bulge. Surface or intra-abdominal intraoperative ultrasound may be employed to facilitate precise localization of lym-phoceles. The lymphocele wall is excised to facilitate a wide communication between the lymphocele and peritoneum. Lymphoceles that are superficially located, and those that are not associated with significant adhesions can be easily treated utilizing needle-scopic instruments.

Results

Gill and colleagues reported their results following needlescopic lymphocele drainage in three patients (6). The procedures were performed on an outpatient basis. Mean operative time was 118.3 minutes, and estimated blood loss ranged from 10-50 mL.

Renal Cyst Drainage

Technique

Marsupialization of simple renal cysts may be offered to patients with symptomatic renal cysts. For cysts that are anteriorly located, needlescopic techniques may be employed. The procedure is performed through a three- or four-port transperitoneal approach. A 5 mm port is inserted at the umbilicus from the outset of the procedure and a 5 mm laparoscope is inserted through the umbilical port. The other ports are of needlescopic size. The colon is reflected medially, and the Gerota's fascia is incised to expose the cyst. The cyst is drained and the cyst wall is excised. Occasionally, bleeding may be encountered from the residual cyst wall. A 5 mm argon beam coagulator inserted through the 5 mm port is utilized to achieve hemostasis. Next, a 2 mm needlescope is inserted through one of the lateral ports, and the excised cyst wall is extracted through the umbilical port.

Results

Gill and Colleagues reported their experience following three procedures (6). Average operative time was 1.7 hours, and mean estimated blood loss ranged from 10-200 mL. One case was converted to conventional laparoscopy to facilitate better hemostasis. Over a six-month period, one of the three patients developed a recurrent renal cyst, which was subsequently treated utilizing conventional laparoscopic techniques.

Minilaparoscopic Pyeloplasty

Minilaparoscopic pyeloplasty was reported by Tan (7). The procedure is performed utilizing 3 mm instruments inserted through 3.8 mm ports, and a 5 mm laparoscope. The procedure is performed utilizing a transperitoneal approach, and initial peritoneal access is obtained with a 6 mm Hasson cannula, which is inserted through the supraum-bilical skin crease. An Anderson-Hynes dismembered pyeloplasty is performed utilizing a 6-0-polydiaxone suture on a 3/8 circle round body needle. Initially, the posterior layer of the anastomosis is completed in a running fashion. Next, an antegrade ureteral stent is introduced and the suture is continued to complete the anterior layer of the anastomosis. In this manner, a running ureteropelvic anastomosis is performed. No drains are placed, and the fascia underlying the 5 mm port is closed. The bladder is drained with a catheter for a period of 24 hours. The procedure was performed in 18 patients. Average patient age was 17 months (range, 3 months to 15 years). Mean operative time was 1.5 hours. Complications included a trocar injury resulting in a hematoma, and a case of postoperative stent migration, which necessitated ureteroscopic extraction at six weeks. None of the cases were converted to open. During follow-up, 2 of the 18 patients needed to undergo repeat laparoscopic pyeloplasty for persistent ureteropelvic unction obstruction. Both these patients were less than three months of age at the time of the primary laparoscopic procedure.

Minilaparoscopic instruments are ideally suited for handling finer structures and fine sutures, making them optimal for performance of delicate reconstructive laparoscopic procedures.

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