Complications of Hand-Assisted Laparoscopic Urologic Surgery

Hand-assisted laparoscopy confers equal efficacy in simple and radical nephrectomy

These authors conclude that hand-assisted laparoscopic simple nephrectomy may be associated with similar operative times, length of postoperative stay, and comparable complication rates as those of hand-assisted laparoscopic radical nephrectomy.

Background and Objectives:

To evaluate outcomes for simple hand-assisted laparoscopic nephrectomy (HALSN).

Methods:

A retrospective chart review was performed at our institution for all patients who had undergone HALSN from January 2002 to January 2009. Thirty-three patients underwent HALSN during this time period and were matched with 33 patients who underwent radical hand-assisted laparoscopic nephrectomy (HALRN).

Results:

Operative times were similar between both groups (301 vs 286 min for HALSN vs HALRN; P=.54). There were no intraoperative or postoperative transfusions in either group. There was one conversion to open nephrectomy in the HALSN group in a patient with xanthogranulomatous pyelonephritis and no conversions in the HALRN group. The mean opioid equivalence requirement was not statistically different between both groups (110 vs 120 for HALSN vs HALRN, P=.70). Mean hospital stay was similar for patients undergoing HALSN and HALRN (5.0±3.8 days vs 4.0±1.2 days, P=.63). There was 1 major complication in the HALSN group (pulmonary embolus) and no major complications in the HALRN group. Rates of minor complications were comparable between the 2 groups (18% vs 24% for HALSN vs HALRN).

Conclusions:

HALSN may be associated with similar operative times and length of postoperative hospital stay as well as comparable complication rates compared to HALRN.

Management of intraoperative splenic injury during laparoscopic urological surgery

Study Type - Therapy (case series).

LEVEL OF EVIDENCE

4. What's known on the subject? and What does the study add? The exact incidence of splenic injury during laparoscopic urologic procedures is not known; however, it is an uncommon occurrence. Also, the optimal treatment algorithm is not well delineated and the efficacy of successfully treating minor injuries to the spleen without resorting to splenectomy is not well described in the urologic literature. This study outlines the rate of splenic injury during a variety of laparoscopic urologic procedures and we outline a treatment algorithm that has been successfully employed in the management of these patients, which in all cases, did not lead to splenectomy. An important point is also that multiple adjunctive hemostatic measures should be used when a splenic injury is recognized and that a thorough search should ensue when suspicion of an occult splenic injury exists, as an unrecognized splenic injury may lead to severe post operative haemorrhagic complications.

OBJECTIVE

• To evaluate incidence, risk factors for, and management of intraoperative splenic injury in our laparoscopic patient cohort.

PATIENTS AND METHODS

• All patients undergoing laparoscopic urological upper tract procedures at two institutions between January 2001 and April 2006 and January 2000 and December 2008, respectively, were retrospectively examined for complications. • From these patients, those with intraoperative splenic injuries were selected and examined. • Possible factors predisposing patients to splenic injury were evaluated and the management plan for each patient was analysed to identify optimal treatment efficacy.

RESULTS

• Of 2620 patients undergoing upper tract urological laparoscopic surgery, 14 patients (0.5%) sustained splenic injury and underwent left-sided surgery, 13 via a transperitoneal approach. • In 12 of the 14 patients, the splenic injury was recognized intraoperatively and all were effectively managed laparoscopically with a combination of argon beam coagulation, biological haemostatic agent FloSeal(TM) (Baxter, Deerfield, IL, USA), and bio-absorbable Surgicel® (Johnson and Johnson, Somerville, NJ, USA); none of these patients required splenectomy or developed any postoperative complications. • In two patients, the splenic injury was not recognized intraoperatively; both patients presented with delayed haemorrhage necessitating open splenectomy in each instance.

CONCLUSIONS

• Splenic injuries are uncommon during laparoscopic urological surgery, but when a significant splenic injury occurs, it can be effectively managed laparoscopically, using conservative measures, without need for splenectomy. • If the splenic injury is not recognized intraoperatively, delayed haemorrhage is likely to occur necessitating emergent re-exploration and splenectomy. • Prompt and accurate intraoperative diagnosis of splenic injury is critical for achieving a good outcome.

Intraoperative complications of laparoscopic adrenalectomy

A laparoscopic or retroperitoneoscopic access to the adrenal gland is the standard of care for adrenalectomy in most cases. Although in laparoscopic adrenalectomy the approach is minimally invasive, the procedure is challenging. This is reflected in the scope of possible complications. The surgeon must consider complications related to the anatomical topography of the adrenal gland, which typically encompasses the complications known from open surgery and complications related to the minimal invasive access. In this topic paper we will address the most frequently encountered complications of adrenalectomy: vascular injuries, injuries of the bowel, pleural tears, and injuries to the liver, spleen and pancreas. Fortunately, these complications occur rarely. However, many of these complications can have devastating consequences. Therefore, it's the surgeon's obligation to be aware of the possible complications he might encounter during laparoscopic adrenalectomy. This awareness is essential for their prevention and it helps the laparoscopic surgeon to identify complications intraoperatively.

Treatment of splenic injury during laparoscopic nephrectomy with BioGlue, a surgical adhesive

Splenic laceration is a recognized complication of both open and laparoscopic renal surgery. Laparoscopic renal surgery continues to become the new standard of care, and this potentially problematic complication may be encountered during mobilization to gain access to the retroperitoneum. We present 2 cases of splenic injury managed with BioGlue, a new surgical adhesive, during one hand-assisted and one pure laparoscopic nephrectomy. Application of the BioGlue adhesive resulted in satisfactory hemostasis for both injuries without the need for further intervention. These preliminary observations suggest that BioGlue may be a useful addition to the urologic armamentarium to achieve hemostasis in laparoscopic surgery.

Comparison of second-generation hand-assisted laparoscopic devices for surgeon pain and arm circulation

OBJECTIVES

To compare two second-generation hand-assist devices (HADs) for surgeon pain and manual blood flow over time in an in vitro model.

METHODS

Nineteen participants placed their nondominant hand through both the LapDisc and GelPort into a pneumoperitoneum chamber with an insufflation pressure of 15 mm Hg for a 2-hour test period. Pain, on a 10-point visual analog scale, and manual blood flow to the index finger using a laser Doppler skin probe were measured at 10 points during the 2 hours. Participants completed a questionnaire regarding hand comfort and the physical effects of the HAD.

RESULTS

At 30, 45, and 60 minutes after hand insertion, the pain scores were significantly greater for the GelPort than for the LapDisc (P = 0.04, P = 0.01, and P = 0.03, respectively). The GelPort caused an immediate reduction in manual blood flow, and the LapDisc caused a small initial increase in manual blood flow (P = 0.03) and, thereafter, a decrease in blood flow. Three participants voluntarily removed their hand at 30, 45, and 60 minutes owing to the pain from GelPort use. No participant withdrew from the LapDisc because of pain.

CONCLUSIONS

Both HADs resulted in surgeon discomfort in our in vitro model. The GelPort resulted in more subjective pain compared with the LapDisc. Both HADs caused a reduction in manual blood flow. However, compared with the LapDisc, the GelPort caused significantly more reduction in manual blood flow. Surgeon comfort is only one parameter to consider when choosing a HAD.

100-MINUTE RETROPERITONEOSCOPIC RADICAL NEPHRECTOMY: A NEW RETROPERITONEAL APPROACH WITH A HAND ASSISTED METHOD

PURPOSE

A new approach for retroperitoneoscopic radical nephrectomy is introduced. The point of our surgical method is the application of a combination of hand assistance and pure laparoscopic procedures with appropriate surgical steps via the retroperitoneal approach. In our early series we had good surgical results and we completed radical nephrectomy in about 100 minutes using this procedure.

MATERIALS AND METHODS

A total of 20 consecutive patients with renal cell carcinoma (cT1-2) who were operated on with this surgical method were analyzed. Surgical procedures occurred in 5 steps. In step 1 the retroperitoneal space was created manually from a pararectal incision at the umbilicus level. In step 2 the lateroconal fascia was incised and the renal hilar area was exposed with hand assistance. In step 3 hilar dissection was performed by pure laparoscopic procedure with another surgical instrument inserted from the hand device. Step 4 involved the application of hand assistance again for the quick mobilization of the kidney and adrenal gland. In step 5 the intact surgical specimen was retrieved from the hand device.

RESULTS

Mean operative time and estimated blood loss were 103 +/- 21 minutes (range 70 to 145) and 49 +/- 85 ml (range 5 to 360), respectively. Mean days to oral intake and ambulation were 1.0 and 1.1, respectively. Operative times of the steps of hilar dissection and mobilization of the kidney and adrenal were shorter than in other series performed by standard retroperitoneoscopic radical nephrectomy. Major complications were not experienced. At this point, no metastasis has been experienced.

CONCLUSIONS

Our surgical method may have the benefits of the retroperitoneal approach and hand assistance. The retroperitoneoscopic hand assisted method may be another important option in the 3 major approaches for laparoscopic radical nephrectomy, although longer-term followup is clearly required.

Laparoscopic partial nephrectomy: Technique, oncologic efficacy, and safety

Laparoscopic partial nephrectomy is emerging as an attractive approach for selected renal masses, but has been performed with significant variability in technique. The procedure's evolution, a merger of proven open techniques with applicable laparoscopic techniques and limitations, is very much a work in progress. Just as long-term follow-up for open nephron-sparing surgery for selected renal masses has demonstrated recurrence-free survival equivalent to radical nephrectomy, a few large series of laparoscopic partial nephrectomy are beginning to surface that demonstrate its clinical efficacy, although duration of follow-up is still too short to make definitive statements. This article reviews the literature and the authors share their experience and preferences in technique, derived from 100 consecutive laparoscopic partial nephrectomies and from their assessment of the acute sealant effectiveness for partial nephrectomy in a large, hypertensive, porcine model that approximates clinical situations. This review aims to assist the urologic surgeon in determining which renal tumors to approach laparoscopically and which surgical approach best fits their laparoscopic expertise.