Technical Tips To Aid Laparoscopic Lymphatic Disconnection

■ Acquaintance to the variations in number and course of renal vessels helps in avoiding vascular catastrophe. During hilar stripping, one should carefully look for the posterior segmental branch of renal artery, which is the most constant division and makes its way out of the renal artery before it enters the renal hilum and proceeds posterior to the renal pelvis to supply a large posterior segment of the kidney. It may be mistaken for a dilated lymphatic vessel and get inadvertently clipped (12).

■ Occasionally, the right renal artery may arch anterior to the inferior vena cava. In that way it will be located more anteriorly to the right renal vein. In retroperitoneoscopic approach, such anteriorly located right renal artery may be best approached through the plane created between the anterior surface of the kidney and peritoneal reflection medially. In such a situation, conversion of retroperitoneal to transperitoneal approach may be a more judicious step.

■ During ureterolympholysis, staying in proper dissection plane, i.e., outside the ureteral adventitia that contains the plexus of ureteral blood supply that courses longitudinally along the ureter, helps in preserving the ureteral blood supply.

■ To ensure complete lymphatic dissection, a few drops of methylene blue can be applied to the renal hilum via a specially designed laparoscopic syringe to aid in the visualization of the remaining lymphatic vessels (Fig. 8) (11).

FIGURE8 ■ Diagrammatic representation after completion of nephrolympholysis, stripping of hilar vessels, and ureterolympholysis.

FIGURE8 ■ Diagrammatic representation after completion of nephrolympholysis, stripping of hilar vessels, and ureterolympholysis.

TABLE3 ■ Causes of Failure after Laparoscopic Lymphatic Disconnection

Early failure

Late failure

Incomplete stripping

Recanalization of lymphatic

Release of chyle from contralateral

fistulae to the operated kidney

unit

Fistula in the lower part of the ureter

and bladder

Collateral release of chyle due to

increased lymphatic pressure

Source: From Refs. 19 and 22.

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