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Laparoscopic Pyeloplasty

Laparoscopic Pyeloplasty. Jaime Landman, MD Assistant Professor of Urology Columbia University Department of Urology. Patient Selection. Indications Symptomatic UPJ obstruction Asymptomatic UPJ obstruction with documented deterioration of renal function Contraindications

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Laparoscopic Pyeloplasty

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  1. Laparoscopic Pyeloplasty Jaime Landman, MD Assistant Professor of Urology Columbia University Department of Urology

  2. Patient Selection • Indications • Symptomatic UPJ obstruction • Asymptomatic UPJ obstruction with documented deterioration of renal function • Contraindications • Intra-renal pelvis • Multiple prior abdominal surgeries (relative)

  3. Equipment Required • Veress needle (14G) • Knife with #15 blade • Dilating trocars: 12 mm (1), 5 mm (2 or 3) • 10 mm laparoscope with 30 Lens • 5 mm laparoscope with 0 Lens • Harmonic Shears-5 mm curved [Ethicon] • Macrobipolar grasper [Aesculap] • Endoshears with disposable tip (Microline) • 5 mm suction irrigation device • Endoholder (self-retaining retractor) [Codman] • Padron Endoscopic Retractor (PEER) [J Jamner] • Suture: 4-Vicryl on an SH needle • Lapra-Ty clip applier and clips [Ethicon] • 7 mm Jackson Pratt drain

  4. Patient Positioning • Standard full flank, ventral surface on edge of table • Lower (left) leg bent, 3 pillows supporting upper (right) leg • Table flexed 15 • Axillary roll • OR table covered with gel pad (never bean bag) • Arm draped over chest, supported by 2 pillows • Arms, hips, and lower leg secured by tape • No kidney rest

  5. Patient Positioning = Areas that are carefully padded

  6. Trocar Placement • Veress needle placed medial and superior to the anterior superior iliac spine, followed by 5 mm trocar that will be the right hand working site • 5 mm trocar beneath costal margin in anterior axillary line for left hand working site • 12 mm trocar in midline between the two working trocars for the laparoscope • Optional 5 mm trocar in posterior axillary line between the working trocars for lateral retraction

  7. Port Placement =12mm trocar =5 mm trocar =5 mm trocar (optional)

  8. Port Placement (post-operative) Feet Head 7mm Jackson Pratt drain in retractor site 5mm left hand working site 5mm right hand working site 12mm laparoscope site

  9. Steps of the procedure • Deployment of trocars* • Mobilization of Colon and Kocherizing the duodenum (right side) • Identification and limited mobilization of ureter and the renal pelvis with preservation of crossing vessels when present *If not done pre-operatively, cystoscopy, retrograde ureteropyelogram, and JJ stent deployment can be done before laparoscopy OR a JJ stent can be deployed laparoscopically after transection of the UPJ

  10. Steps of the procedure 4. Transection of the UPJ and spatulation of the ureter. Reduction of renal pelvis (when redundant) 5. Anastomosis (anterior to crossing vessels when present) and deployment of drain

  11. Step 1. Deployment of Trocars

  12. Step 2. Mobilization of Colon and Kocherizing the duodenum (right side)

  13. Step 3. Identification and limited mobilization of the ureter

  14. Step 4. Transection of the UPJ and spatulation of the ureter

  15. Step 5. Anastomosis

  16. Technical points: Tips • Pre-operative CT angiogram is reliable in the detection of crossing vessels and can warn of the existence of crossing vessels • Patients with JJ stents placed prior to surgery will have thickened reactive ureters which may make the ureteral dissection and anastomosis more challenging • Application of the PEER retractor and the Endoholder opens the operative field and facilitates dissection • Microline scissors have a disposable tip which is always sharp for ureteral transection and spatulation • Lapra-Ty clips will securely anchor the running anterior and posterior suture lines and will facilitate a tight closure

  17. Technical points: Caveats • Facility with intracorporeal suturing is essential and will make the running anastomosis relatively expeditious and easy • Early in the surgeon’s experience, application of three 12 mm trocars will facilitate the procedure • It is ideal to work with the laproscope between the two “working” trocars. However, the laparoscope may be moved to optimize the angle of vision • When using 5 mm working trocars, the needle and Lapra-Ty clip applier are inserted through the 12 mm (laparoscope) trocar and a 5 mm laparoscope is used

  18. Credits Surgeon: Jaime Landman Director of Minimally Invasive Urology Columbia University Department of Urology, New York, NY Assistant: Sean Collins Director of Minimally Invasive Urology Louisiana State University Department of Urology, New Orlenes, LA

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