Trocars: Site Selection, Instrumentation, and Overcoming Complications

Laparoscopic Radical Nephrectomy

In addition to its established advantages, laparoscopic radical nephrectomy (RN) poses a unique set of challenges over traditional open surgery. In this study, we discuss preoperative considerations and detailed steps for laparoscopic RN. We review the transabdominal approach in detail, including patient positioning, equipment, and port placement in addition to the surgical steps. Intraoperative decisions such as adrenal management, renal preservation, and tumor identification are reviewed. Common complications of laparoscopic renal surgery are also summarized.

Laparoscopic adrenalectomy

In the last three decades, endoscopic adrenalectomy has become the gold standard for the surgical treatment of most adrenal diseases. Gagner et al., first reported in 1992, the lateral trans-abdominal laparoscopic approach to adrenalectomy. Afterwards, several retrospective and comparative studies addressed the advantages of minimally invasive adrenalectomy specifically consistent in less postoperative pain, improved patients' satisfaction, shorter hospital stay and recovery time when compared to open adrenalectomy. The lateral transabdominal approach to the adrenals is currently one of the most widely used, since it allows an optimal comprehensive view of the adrenal region and surrounding structures, and provides and adequate working space. On the other hand, from a technical point of view, essential requirements for a successful laparoscopic adrenalectomy are an appropriate knowledge of retroperitoneal anatomy, a gentle tissue manipulation and a precise haemostasis technique in order to identify appropriately the structures of interest and avoid the troublesome 'oozing' that could complicate the surgical procedure.

Trocar Site Hernia After Retroperitoneal Laparoscopic Partial Nephrectomy: A Case Report and Literature Review

Trocar site hernia is a rare complication after laparoscopic surgery. The incidence of trocar hernia is rarer in retroperitoneal approach of urologic laparoscopy. We report a case of trocar site hernia after retroperitoneal laparoscopic partial nephrectomy.

Prospective Randomized Control Study on the Efficiency and Safety of a Novel Port-site Closure Device, the EZ-close Port-site Closure System

AIM

The efficiency and safety of EZ-close Port-Site Closure System were investigated in comparison with those of the Carter-Thomason CloseSure System (CT) device.

METHODS

This was a prospective randomized control study. The primary outcome was the time taken to complete the closure of the port site using either the EZ or CT. The suture time (mean±SD) for the EZ group was significantly less than that of the CT group (36.8±10.1 s for the EZ group vs. 48.9±21.5 s for the CT group, P=0.004). There was no need for additional instruments in the EZ group, but in 84.6% of the patients in the CT group, a grasper was required to hold the tie (P<0.05). There was no difference in the complication rates between the 2 groups.

CONCLUSIONS

The EZ device showed an improved efficiency and similar safety compared with that of the CT device. Its main advantage lied in enabling the surgeon to be totally self-sufficient for the whole port-site closing procedure.

Evaluation of the Role of Laparoendoscopic Single-Site Surgery vs Minilaparoscopy for Treatment of Upper Urinary Tract Pathologies: Prospective Randomized Comparative Study

OBJECTIVES

To present the first prospective randomized comparison between laparoendoscopic single-site surgery (LESS) and minilaparoscopy (ML) for treatment of upper urinary tract pathologies.

PATIENTS AND METHODS

Between January 2013 and June 2015, patients with different upper urinary pathologies were blindly randomized to both LESS and ML. All procedures were done by single experienced surgeon. Both cohorts were compared regarding demographic data, peri and postoperative characteristics, and visual analog pain scale (VAS). Cosmetic outcome was assessed after 12 months using patient scar assessment scale (PSAS) and observer scar assessment scale (OSAS).

RESULTS

Sixty patients were randomized into two equal groups with comparable demographic and preoperative characteristics. Indications included nephrectomy, pyeloplasty, cyst marsupialization, adrenalectomy, and repair of retrocaval ureter. Operative time was 167 ± 24 and 145 ± 39 minutes in LESS and ML groups, respectively (p = 0.09). Estimated blood loss was 59 ± 34 and 43 ± 42 mL in both groups, respectively (p = 0.2). VAS was 1.7 ± 0.6 and 2.8 ± 0.5 in both groups, respectively (p = 0.02). PSAS and OSAS were 5.9 ± 0.85 and 10.6 ± 1.98 vs 8.9 ± 0.9 and 13.5 ± 6.3 in both groups, respectively (p > 0.05). There were no intraoperative complications, conversions to open surgery, or conventional laparoscopy in both groups. Mean postoperative Diclofenac Na was 151.7 ± 35.6 and 169.7 ± 47.3 mg in both groups, respectively (p = 0.04). Postoperative complications rate and hospital stay were comparable between both groups.

CONCLUSION

Both LESS and ML have comparable operative time, blood loss, complication rate, and hospital stay in treatment of upper urinary tract pathologies. However, LESS is associated with less analgesic requirement and better cosmetic outcome.

Visceral and gastrointestinal complications in robotic urologic surgery

INTRODUCTION

with the widespread use of minimally invasive techniques, robot-assisted urologic surgery has become widely adopted. Despite their infrequency, visceral and gastrointestinal complications could be life-threatening.

OBJECTIVES

To identify the main gastrointestinal injuries that occur in a robot-assisted urologic surgery. To know the overall incidence and how is their management.

ACQUISITION OF THE EVIDENCE

Search in PubMed of articles related to visceral and gastrointestinal complications in robot-assisted urology surgery, written in English or Spanish. Relevant publications as well literature reviews and chapters from books were reviewed.

SYNTHESIS OF THE EVIDENCE

Along with vascular injuries, visceral and gastrointestinal lesions are among most dangerous complications. A complete preoperative study to individualize each patient characteristics and the correct use of imaging could help us to avoid complications in the first place. To know all the risky steps in the different robotic urologic procedures will let us anticipate the damage. Knowledge of main and most dangerous injuries in the different abdominal and pelvic organs is fully recommended. Early diagnosis and evaluation of lesions will let us an acute management during surgery. Recognition delay could change a repairable injury into a life-threatening situation.

CONCLUSIONS

Despite the undeniable benefits of robotic approach, there are minor and major gastrointestinal injuries that all urologic surgeons must know. Those related with trocar placement are especially important. Immediate diagnosis and management is mandatory.