Laparoscopic condom dissection: new technique of retroperitoneoscopy

Surgical Anatomy of the Retroperitoneal Spaces, Part V: Surgical Applications and Complications

Knowledge of the surgical anatomy of the retroperitoneum is crucial for surgery of the retroperitoneal organs. Surgery is essential for treatment of retroperitoneal pathologies. The list of these diseases is extensive and comprises acute and chronic inflammatory processes (abscess, injury, hematoma, idiopathic fibrosis), metastatic neoplasms, and primary neoplasms from fibroadipose tissue, connective tissue, smooth and striated muscle, vascular tissue, somatic and sympathetic nervous tissue, extraadrenal chromaffin tissue, and lymphatic tissue. The retroperitoneum can be approached and explored by several routes, including the transperitoneal route and the extraperitoneal route. The retroperitoneal approach to the iliac fossa is used for ectopic renal transplantation. Safe and reliable primary retroperitoneal access can be performed for laparoscopic exploration. The anatomic complications of retroperitoneal surgery are the complications of the organs located in several compartments of the retroperitoneal space. Complications may arise from incisions to the somatic wall, somatic nerves, blood and lymphatic vessels, lymph nodes, visceral autonomous plexuses, and neighboring splanchna.

Two-glove-finger-balloon dissection of retroperitoneal space for laparoscopic urology

BACKGROUND

We present our experience in retroperitoneal interventions with 2 catheter mounted glove fingers through 2 access points.

METHODS

Patients were placed in the lateral decubitus position, and the retroperitoneum was accessed by blunt dissection through a 10-mm transverse skin incision on the posterior axillary line. Another incision was performed through the anterior axillary line, and the surgeon inserted his finger to dissect the muscle layers in the retroperitoneum to develop an initial space to place the glove finger balloon, which was attached to a 14-F Nelaton catheter.

RESULTS

This technique was performed on 32 patients. The mean operation time was 57.4 +/- 26.7 minutes. A satisfactory retroperitoneal space for the operation was provided and both balloons inflated to 500 mL. No complications were observed.

CONCLUSION

Retroperitoneal laparoscopy using 2 balloons is a safe, cheap, effective minimally invasive procedure, and we believe that the technique described above both decreases both the operation time and cost.

Original Dissecting Balloon for Retroperitoneal Laparoscopy: A Cost-Effective Alternative to the Commercially Available Device

Objective: Optimal retroperitoneal space creation is of pivotal importance in laparoscopic retroperitoneal surgery. The aim of this study is to report the balloon dissecting technique developed at our institution, comparing the costs of such device with that of the commercially available balloon retroperitoneal expanders. Materials and Methods: Twenty patients, scheduled to undergo retroperitoneoscopic surgery, were randomly divided into two groups. In group 1, retroperitoneal dilatation was performed with the commercially available balloon expander. In group 2, we employed the original balloon dilator created with two middle fingers of a #8 powder-free surgical glove tied to a nondisposable 11 mm trocar and filled with 600 mL of saline, employing simultaneously two 50 mL syringes. Subjective evaluation of the created space was performed by a surgeon blinded in both groups. Economical evaluation included the costs of the disposable materials and of the time in the operative room required to create the dilation. Results: In all the cases, the created dilatation was considered good. In group 1, the time required to dilate the retroperitoneal space was medially 3.15 minutes, whereas in group 2, the time required to prepare the dissecting balloon was medially 1.16 minutes and the time required to dissect the retroperitoneal space was 4.41 minutes (total 5.57 minutes). Considering the costs of the disposable material, the overall costs to create the retroperitoneal space resulted to be 141.95€ in group 1 and 60.27€ in group 2 (p < 0.005). Conclusion: The original dissecting balloon employed at our institution revealed to be easy and of fast manner and offers a valid option for the proper retroperitoneal dissection. Moreover, it revealed to be cost-effective compared with the commercially available supply.

Submucosal endoscopy with mucosal flap safety valve

BACKGROUND

There is no reliable endoscopic method to selectively resect deeper layers of the gut wall or to access the peritoneal cavity and prevent peritoneal soiling.

OBJECTIVES

To determine the technical feasibility and safety of submucosal endoscopy with mucosal flap (SEMF) in accessing the peritoneal cavity through a large full-thickness gastric-muscle-wall resection.

DESIGN

Ex vivo feasibility exploration and survival animal study.

SETTINGS

Ex vivo samples were obtained from fresh harvested organs. In vivo procedures were conducted with the pigs under standard general anesthesia.

INTERVENTIONS

High-pressure carbon dioxide (CO(2)) injection and balloon dissection created a large submucosal working space for insertion of a cap-fitted endoscope. By using the EMR cap, a full-thickness resection of the muscularis propria was performed. This full-thickness defect was sealed with the overlying mucosal flap and the use of hemoclips or tissue anchors.

RESULTS

By using the SEMF technique in the ex vivo experiment, the gastric wall was successfully traversed in each stomach after submucosal dissection and full-thickness resection of the musclaris. Similarly, by using the SEMF technique in the in vivo procedures, the peritoneal cavity was successfully accessed and the defect was completely sealed by using the mucosal flap. All animals survived 1 week after the procedure. Ulceration was noted in 3 pigs, and a small bowel injury was noted in 1 pig. Leak testing was negative in all stomachs.

CONCLUSIONS

By using the SEMF technique, submucosal space endoscopy and deep-layer gastric-wall resection were successfully performed. Furthermore, the mucosa overlying the dissected submucosal space served as a safe flap valve, preventing peritoneal leakage.

Transperitoneal and retroperitoneal laparoscopic heminephrectomy--what approach for which patient?

PURPOSE

We report our experience with laparoscopic heminephrectomy using the transperitoneal and retroperitoneal approaches in 48 pediatric patients.

MATERIALS AND METHODS

A total of 48 laparoscopic heminephrectomies were performed in 35 girls and 13 boys 45 days to 17 years old (mean 4.08 years) between September 1998 and March 2005. The procedures consisted of 44 upper pole heminephrectomies with partial or total ureterectomies and 4 lower pole heminephroureterectomies. Surgeries were performed using a transperitoneal approach in 32 patients (67%) and a retroperitoneal approach in 16 (33%).

RESULTS

Followup ranged from 0.75 to 7.25 years (mean 3.53). In the retroperitoneal group 2 procedures required conversion, 1 to open heminephrectomy and 1 to a transperitoneal laparoscopic approach. Complications were seen in 5 of 48 patients (10%). Complications in the retroperitoneal group were seen in 2 patients. One patient had a postoperative urinary leak that resolved spontaneously. Another patient had development of a urinoma that was treated conservatively. Complications in the transperitoneal group were seen in 3 patients. One patient required an intraoperative chest tube due to pneumothorax, 1 had recurrent urinary tract infection that required excision of a short ureteral remnant and 1, 6-month-old boy had development of postoperative hypertension. Four of the 5 complications (80%) were seen in patients younger than 1 year.

CONCLUSIONS

Transperitoneal and retroperitoneal laparoscopic heminephrectomy can be performed for benign disease in children with minimal morbidity, improved cosmesis and short hospital stay. Complication rate does not depend on the surgical approach, but rather on the age of the patient.

Technical aspects and access devices for preperitoneal and retroperitoneal endoscopic surgery

The main advantages of preperitoneal and retroperitoneal endoscopic surgery over conventional laparoscopy or open surgery are the decreased risk of injury to organs and reduced postoperative adhesion formation. Exact knowledge of anatomy, as well as correct positioning of the patient, is essential for its success. While a blunt dissection technique, using either the fingers or an endoscope under pneumodissection, is preferred for preperitoneal surgery, the introduction of a balloon dissection device directly into the retroperitoneal cavity simplifies this procedure for retroperitoneoscopy. Different general surgical procedures are described for preperitoneal (hernia) and retroperitoneal (adrenalectomy, neurectomy/ sympathectomy) surgery. Urological/gynaecological procedures (kidney, tumor biopsy, lymphadenectomy) are excluded from this review. In recent years, the number of possible preperitoneal and retroperitoneal surgical procedures has increased, mainly as a result of the development of commercially-available balloon trocars and balloon-tipped trocars, which create and maintain a working space.

Use of Foley's catheter to gain access for retroperitoneoscopy

With the increasing popularity of laparoscopic urologic surgery, many different methods have been used to dissect the extraperitoneal space and gain access to the kidney and ureter. We present our initial experience using a Foley catheter to gain retroperitoneal access. This technique was successfully used in 30 children. We have not encountered any major complications and recommend its use in children.

Simple nephrectomy: retroperitoneal approach

Direct extraperitoneal surgery has become the preferred approach to laparoscopic nephrectomy since the introduction of the balloon dilation method. The lateral decubitus position provides good exposure, but the prone position is used at some centers to gain better exposure with the aid of gravity. The open conversion rate ranges from 0 to 16% and the complication rate from 5% to 45%, with most complications being minor. Retroperitoneal laparoscopic simple nephrectomy is definitely superior to open nephrectomy as judged by analgesic use and recovery time. The higher complication rate and lower efficiency can be taken care of by experience and proper case selection.

Anatomic basis of minimal anterior extraperitoneal approach to the lumbar spine

Anterior lumbar spine approaches may be indicated for fusion in degenerative lumbar spine disorders or to fill discal and bone gaps after fracture reduction. We present an anterior extraperitoneal approach applicable to any discal and vertebral levels from T12 to S1. The anatomic study, based on 25 cadavers, highlights retroperitoneal dissection principles for easy kidney and duodenopancreatic mobilisation and direct left anterior access to the entire lumbar spine. We established a precise description of the lumbar veins and the anastomoses between the left renal vein and hemiazygos system, in order to define different topographic and anatomic factors related to safe and easily reproducible approaches for cage or graft implementation. Independent of the level and previous intraperitoneal surgery, lumbar spine access with this approach safeguards the kidney, ureter, spleen, hypogastric plexus and duodenopancreatic system. Regarding operating time, blood-loss and possibilities for freshening and grafting, this technique seems an effective counterbalance to the difficulties and complex technology of endoscopic approaches. The clinical study includes our first 42 cases in traumatic and degenerative lesions. Avoiding the neurologic or hemorrhagic risk inherent in classical posterior lumbar interbody fusion (PLIF) techniques, it can be considered as a reasonable and valid alternative. This technique could be used in the near future for mini invasive discal prosthesis insertion.

Anterior endoscopic approach to the thoracolumbar spine

STUDY DESIGN

A technique for anterior endoscopic exposure of the thoracolumbar spine is described.

OBJECTIVE

To develop an endoscopic approach to the thoracolumbar spine with fewer complications than are encountered in the conventional approach.

SUMMARY OF BACKGROUND DATA

The efficacy of the anterior endoscopic approach to the thoracic spine has been shown. The thoracolumbar hinge is usually approached by open surgery.

METHODS

The study was performed in three stages. The first phase was carried out on experimental animals (pigs). Once the bases were established, the approach was studied in fresh cadavers. Finally, it was performed on three patients with thoracolumbar scoliosis who required discectomy and anterior release.

RESULTS

After a series of attempts on the animals, it was found that the most effective method for exposure of the thoracolumbar spine was the initial thoracoscopic approach followed by the retroperitoneal endoscopic approach. This was confirmed in cadavers. When applied to the clinical situation, there were no significant complications in any of the patients treated with this method, and postoperative pain and discomfort were minimal.

CONCLUSIONS

The anterior endoscopic approach to the lumbar spine involves minor trauma, results in rapid recovery and less pain, and produces good results aesthetically.