LAPAROSCOPIC REPAIR OF RENAL ARTERY ANEURYSM

Robotic Renal Artery Aneurysm Repair

BACKGROUND

Renal artery aneurysm (RAA) is a rare condition, traditionally managed with endovascular or open surgical techniques.

OBJECTIVE

To report our experience with robotic RAA repair.

DESIGN, SETTING, AND PARTICIPANTS

Nine consecutive patients underwent intracorporeal robotic surgery for 10 RAAs.

SURGICAL PROCEDURE

Two patients underwent concomitant robotic partial nephrectomy. One patient had RAA in a solitary kidney. Median RAA diameter was 2.2 (1.8-3)cm. Intracorporeal transarterial hypothermic renal perfusion was performed in five patients. Robotic techniques included tailored aneurysmectomy and repair (n=5), excision with end-to-end anastomosis (n=2), aneurysmectomy with branch reimplantation (n=1), prosthetic interposition graft repair (n=1), and simple nephrectomy (n=1; this patient's data were excluded from analysis).

MEASUREMENTS

Demographics, RAA characteristics, intraoperative techniques, perioperative outcomes, and follow up data were analyzed. Aneurysms were diagnosed by computed tomography, angiography, or incidentally during the performance of a partial nephrectomy.

RESULTS AND LIMITATIONS

All cases were performed robotically, without conversion to open surgery. Median (range) operative time was 3.8 (3-6)h, warm ischemia time 26 (19-32)min, hypothermic renal perfusion time 34 (29-69)min, and estimated blood loss 100 (25-400)ml. No intraoperative blood transfusion was required. Median hospital stay was 3 (2-6)d. One patient had a Clavien-Dindo grade II complication. At median follow-up of 16 (2-67)mo, all patients had preserved renal function. Follow-up imaging confirmed normal caliber reconstructed renal arteries with globally perfused kidneys, except for two kidneys with small segmental infarcts due to an intentionally ligated small polar vessel. Limitations include the small number of patients and the retrospective nature of the study.

CONCLUSIONS

Robotic repair of complex RAAs is feasible. Surgical expertise, patient selection, and RAA-specific vascular reconstruction are critical for success. Greater experience is needed to evaluate the proper place of robotic repair of RAAs.

PATIENT SUMMARY

We report intracorporeal robotic repair for complex renal artery aneurysms. This robotic operation is feasible and safe, and replicates open principles. However, it requires considerable experience and expertise.

Robot-assisted laparoscopic reconstructed management of multiple aneurysms in renal artery primary bifurcations: a case report and literature review

BACKGROUND

Renal artery aneurysm (RAA) is rare and its incidence in the general population remains elusive. There have been few reports on the repair of multiple aneurysms conducted with the Da Vinci robot-assisted surgical platform (Intuitive Surgical Inc., Sunnyvale, CA, USA), especially for those located in renal artery primary bifurcations.

CASE PRESENTATION

We report our experience in the surgical management of two expanding right-sided RAAs in a 64-year-old man using a robot-assisted laparoscopic approach. Two aneurysms were located in renal artery primary bifurcations, whose diameter was 1.8 and 1.2 cm. The aneurysms were resected and the renal artery branch reconstructed by in situ arteriorrhaphy. The operation lasted for 2 h and 35 min with a warm ischemia time of 26 min and estimated blood loss of 150 ml. The hospital stay was 6 days. The computed tomography (CT) scan performed 2 months after the surgery showed resolution of the aneurysms. Additionally, split renal function indicated the preservation of right renal function in the follow-up period.

CONCLUSIONS

The robot-assisted laparoscopic procedure is a safe and effective surgical technique, which may be considered as an alternative to open surgery for complex multiple RAAs in the future.

Advances in the use of video-assisted thoracoscopic lobectomy in lung cancer: sleeve bronchoplasty and arterioplasty

SUMMARY 

This article focuses on the technical strategies for performing sleeve bronchoplasty and pulmonary arterioplasty as advances in the application of video-assisted thoracoscopic surgery (VATS) as lobectomy with bronchovascular reconstruction is a favorable alternative to pneumonectomy in terms of the pulmonary function. When performing VATS sleeve bronchoplasty or arterioplasty, several technical issues should be discussed, including how to reduce the anastomotic tension of the airway, perform bronchial anastomosis, and clamp the pulmonary artery and select the type of vascular clamp. The traction device technique and continuous suture technique are thought to help surgeons perform VATS sleeve bronchoplasty, while cross-clamping of the pulmonary artery using thoracoscopic instruments aids in carrying out VATS arterioplasty.

Total laparoscopic renal artery bypass for restenosis after failed percutaneous transluminal renal stenting

OBJECTIVE

The purpose of this article was to report our experience of the repair of renal artery restenosis after percutaneous transluminal renal angioplasty (PTRA) using a total laparoscopic technique without robotic assistance.

METHODS

Between February 2005 and October 2009, we performed six total laparoscopic aortorenal artery bypasses for restenosis after failed PTRA. All these patients had recurrent hypertension with renal insufficiency.

RESULTS

The mean operative time was 246 minutes (range, 200-310 minutes). The mean warm renal ischemic time was 28 minutes (range, 22-35 minutes). All patients received a prosthetic graft interposition. The estimated surgical blood loss was 980 mL (range, 500-1400 mL). No conversion was observed and no in-hospital deaths occurred. There was no severe postoperative morbidity. Postoperative serum creatinine levels raised in all patients but all returned to baseline before discharge. Median length of postoperative hospital stay was 6 days (range, 4-8 days). Median follow-up was 13 months (range, 7-19 months). Color Doppler ultrasound scan examination and computed tomography (CT) with injection of contrast media showed patency of all bypasses. Hypertension was improved in all patients but renal insufficiency remained unchanged.

CONCLUSION

Total laparoscopic renal artery bypass is feasible and safe in patients after failed PTRA. This approach may reduce the morbidity of open repair but is technically demanding and necessitates a large previous experience in total laparoscopic aortic surgery.

Laparoscopic splenorenal venous bypass for nutcracker syndrome

Nutcracker syndrome is a rare entity caused by extrinsic compression on the left renal vein as it crosses between the superior mesenteric artery and the aorta. It can clinically present with flank pain and hematuria. Accepted treatments include open vascular bypass procedures or endoluminal stenting. We present the first description, to our knowledge, of a laparoscopic splenic vein-left renal vein bypass to relieve the outflow obstruction. The patient, a 29-year-old woman with debilitating left flank pain, presented with nutcracker syndrome. Left renal vein outflow was obstructed at the level of the intersection between the aorta and the superior mesenteric artery. The option of laparoscopic splenic to left renal vein bypass was discussed and performed. A five-port transperitoneal approach was used. Meticulous vascular control was achieved with numerous laparoscopic vascular bulldog clamps. With completely intracorporeal suturing techniques, the splenic vein was anastomosed to the superior aspect of the anterior left renal vein. Total warm ischemia time was 37 minutes. The anastomosis was watertight immediately upon unclamping. Interestingly, upon unclamping, the luminal diameter of the splenic vein appeared to increase to twice its native diameter. The proximal left renal vein appeared less distended, indicating preferential venous outflow through the newly created venous bypass. Blood loss was minimal, no intraoperative or postoperative complications occurred, and the patient's symptoms improved. This report continues to augment the indications for laparoscopic surgery in even complex, urologic vascular situations.

Repair of complex renal artery aneurysms by laparoscopic nephrectomy with ex vivo repair and autotransplantation

OBJECTIVE

Renal artery aneurysms are being discovered more frequently due to increased use of non-invasive imaging. Complex renal artery aneurysms involving multiple secondary or tertiary branches are not amenable to in vivo or endovascular treatment and often require ex vivo repair with autotransplantation. In order to minimize incisional morbidity and hasten recovery, we developed a technique of laparoscopic nephrectomy combined with backbench ex vivo repair, followed by autotransplantation through a small laparoscopic extraction incision. This study describes our initial experience with this combined technique in patients that were not candidates for endovascular techniques or in vivo arterial reconstruction.

METHODS

Seven patients with complex renal artery aneurysms underwent laparoscopic nephrectomy and ex vivo repair with multiple saphenous vein grafts and autotransplantation through the small laparoscopic extraction incision. The aneurysms ranged from 2.5 to 5.0 cm. In all cases, the aneurysm was resected ex vivo, leaving multiple branch arteries that were extended with saphenous vein grafts. Arterial inflow was then re-established with sequential saphenous vein anastomoses to the external iliac artery. Ureteral reconstruction was performed via standard Lich ureteroneocystostomy. Patients were followed postoperatively for two to eight years.

RESULTS

Laparoscopic nephrectomy with ex vivo repair of complex aneurysms was successfully employed in seven patients with renal aneurysms that were not amenable to endovascular or in vivo repair. There were no incisional morbidities and all patients had significant improvements in symptoms post-operatively. Renal function remained unchanged and there were no ureteral complications following surgery. All patients had postoperative ultrasound imaging done at two years which demonstrated patency of the anastomoses. The mean hospital stay was four days (range, two to seven days).

CONCLUSION

Repair of complex renal artery aneurysms involving distal branch arteries remains a challenge. This new technique combines the advantages of minimally invasive surgery with the effectiveness of ex vivo aneurysm repair.

[Renal artery aneurysm. Laparoscopic nephrectomy, ex-vivo reconstruction and autotrasplantation]

We report a case of severe hypertensive patient with poor response regardless 5 drugs, that is diagnosed with right renal artery aneurysm, during the study of his HTN. Conservative surgery was performed by extracting laparoscopic kidney graft,ex-vivo pedicle reconstruction, followed by transplant in right iliac fossa utilizing the ilioinguinal incision used for the extraction, without need for two incisions. We perform a brief discussion of surgery indications of surgery in these patients.

Robot-assisted laparoscopic renal artery aneurysm reconstruction

We report the surgical management of an expanding 2.5-cm left-sided renal artery aneurysm using a robotic-assisted laparoscopic approach. Using the da Vinci surgical robotic system, we resected the aneurysm, and the anterior-inferior branch of the renal artery was reconstructed with an end-to-end anastomosis. The operative time was 360 minutes, hospitalization length of stay was 3 days, and postoperative analgesic requirements were minimal. Follow-up imaging and functional analysis demonstrated resolution of the aneurysm and preservation of renal function. This technique highlights the ability of surgical robotics to expand indications for minimally invasive surgery in complex cases.

[Complications of laparoscopic urological procedures]

Laparoscopic urology has evolved considerably during last decade as well as number and spectrum of surgical related complications. Experiences reported by laparoscopic trained groups allow preventing, promptly recognizing, and safe and efficient management of the laparoscopic related complications. We present our complications in all patients undergoing urological laparoscopic procedures from November 1992 to June 2005. A literature search was conduced to evaluate complications of every laparoscopic procedure.

Case Report: Laparoscopic Repair of Saccular Renal-Artery Aneurysm

We report successful laparoscopic repair of a saccular renal-artery aneurysm in a patient with renovascular hypertension. The repair was performed by clamping the renal hilum, excising the aneurysm, and suturing the vascular defect intracorporeally. Postoperative imaging studies confirmed normal arterial flow in the repaired artery.

Laparoscopic-assisted nephrectomy with inferior vena cava tumor thrombectomy: Preliminary results

OBJECTIVES

To evaluate the feasibility and outcome of laparoscopic-assisted radical nephrectomy and inferior vena cava (IVC) tumor thrombectomy in patients with renal cell carcinoma and level I IVC tumor thrombus.

METHODS

The clinical, operative, and pathologic data were retrospectively obtained from patients undergoing the above-mentioned procedure for renal tumors involving the IVC. This approach involved laparoscopic dissection of the kidney and renal vasculature/IVC. After renal artery ligation, an 8 to 12-cm incision was made from the tip of the 11th rib extending anteriorly toward the midline. Through this incision, a Satinsky vascular clamp was placed on the IVC in such a way as to include all the caval thrombus. The tumor thrombus was removed en bloc with the kidney and the cavotomy repaired with a running suture.

RESULTS

Four obese patients underwent transperitoneal laparoscopic-assisted right nephrectomy with inferior vena cava (IVC) thrombectomy. The mean tumor size was 9 cm (range 6 to 13), with the thrombus extending 2 cm into the IVC in all cases. Patients had a mean body mass index of 32.8 (range 30.5 to 37.2) and a mean American Society of Anesthesiologists score of 2.8 (range 2 to 3). The mean operative time was 248 minutes (range 225 to 274). The mean estimated blood loss was 517 mL (range 250 to 900). No intraoperative or postoperative complications occurred. The mean hospital stay was 6.2 days (range 4 to 11, median 5).

CONCLUSIONS

Laparoscopic-assisted nephrectomy and IVC thrombectomy is a difficult but feasible procedure. This approach allows a smaller incision than a typical open approach. Additional studies are needed to examine the advantages of this approach over a pure open approach.

Laparoscopic Radical Adrenalectomy With Adrenal Vein Tumor Thrombectomy: Technical Considerations

PURPOSE

We describe the technique of adrenal vein tumor thrombectomy during laparoscopic radical adrenalectomy for cancer.

MATERIALS AND METHODS

During laparoscopic adrenalectomy for a heterogeneous 7 cm left adrenal mass an adrenal vein thrombus was detected intraoperatively. Laparoscopic ultrasonography was used to delineate precisely the tumor thrombus and its extension into the left main renal vein. The left renal artery and vein were transiently controlled with atraumatic vascular clamps. The renal vein was incised and the intact tumor thrombus was removed en bloc with the radical adrenalectomy specimen. The renal vein was suture repaired with 4-zero prolene and the kidney was revascularized.

RESULTS

Renal warm ischemia time was 21 minutes, blood loss was 300 cc and operative time was 6.2 hours. Pathological evaluation revealed a 7.5 cm 68 gm adrenal cortical cancer with tumor thrombus. Soft tissue and adrenal vein margins were negative for cancer.

CONCLUSIONS

Laparoscopic radical adrenalectomy with en bloc adrenal vein tumor thrombectomy can be exclusively performed intracorporeally, while respecting oncological principles. Essential technical steps include wide margin excision of the adrenal gland, intraoperative ultrasonography, renal vascular control, en bloc tumor thrombectomy and renal venous suture repair in a bloodless field.

Laparoscopic Reconstructive Urology

PURPOSE

Although laparoscopy has emerged as a feasible and effective alternative for a majority of open ablative abdominopelvic urological procedures, minimally invasive reconstruction has come to the forefront only recently. We present the current state of the art of laparoscopic reconstructive urology.

MATERIALS AND METHODS

We conducted an extensive MEDLINE search of purely laparoscopic surgery from 1976 through 2002. Based on the results, we divide clinical reconstructive laparoscopic procedures into 2 broad categories-established and evolving. Each category is further classified according to the organ involved-adrenal and kidney, ureter (evolving only), bladder and prostate, and miscellaneous. Clinical procedures were considered established if our literature review revealed any report of more than 100 patients, or reports from at least 5 different centers greater than 20 patients each. If these criteria were not met, the procedure was considered clinically evolving.

RESULTS

Laparoscopic reconstructive procedures such as pyeloplasty, radical prostatectomy and orchiopexy have achieved clinically established status. Laparoscopic bladder neck suspension, although reported in a significant number of cases, remains controversial because of its contradictory reported long-term success rates. Multiple additional laparoscopic reconstructive procedures have been performed in fewer numbers clinically with promising results.

CONCLUSIONS

Until recently, urological laparoscopic surgery primarily focused on ablative procedures, with success. Building on this initial experience, advanced and sophisticated reconstructive procedures of considerable technical complexity are increasingly being performed purely laparoscopically. It is anticipated that in the future laparoscopic surgery could increasingly evolve into a preferred approach for advanced and sophisticated urological reconstruction.