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Alessandro Settimi Ciro Esposito

“Federico II” University, Naples Italy Division of Pediatric Surgery Chief: Prof Alessandro Settimi. Minimally Invasive Surgery In Pediatric Urology. Alessandro Settimi Ciro Esposito. MIS is an alternative approach to OPEN SURGERY. Instruments.

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Alessandro Settimi Ciro Esposito

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  1. “Federico II” University, Naples Italy Division of Pediatric Surgery Chief: Prof Alessandro Settimi Minimally Invasive Surgery In Pediatric Urology Alessandro Settimi Ciro Esposito

  2. MISis an alternative approach to OPEN SURGERY

  3. Instruments

  4. Laparoscopic Primary Pullthrough for Hirschsprung’s disease Aspetto Estetico LAPAROSCOPIA LAPAROTOMIA

  5. Urinarytractpathologies • VUR • UPJO • MKDK • Non functioning Kidney • Duplex Kidney • Stones • Urachal cysts • Ureter pathology

  6. Duplex Kidney

  7. Partial - Nephrectomy Indication • Non-functioning upper or lower pole secondary to complicated duplex anomalies of the kidney • The usual pathology of the upperpole is obstruction associated with a ureterocele or incontinence secondary to an ectopic ureter • The usual pathology in the lower pole is reflux

  8. Partial Nephrectomy • Partial nephrectomy is technically more demanding than total nephrectomy • Currently, this procedure is performed using a retroperitoneal or transperitoneal approach. Lee RS et al: Pediatric retroperitoneal lap… J Urol 174: 702, 2005

  9. LAPAROSCOPIC PARTIAL NEPHRECTOMY (LPN)

  10. Patient’s Position Position for a right Nephrectomy LATERAL POSITION A ballast is placed under the patient

  11. Patient’s Position #2

  12. Team

  13. Trocars 5mm 1: 10mm 2: 5mm 3: 5mm 4: 5mm 4 4

  14. Step # 1 Stent positioning Incision of the lateral peritoneal fold

  15. STEP # 2 Colon

  16. STEP # 3 Ureteral section

  17. STEP # 4 Kidney

  18. STEP # 5 vessels u.p.

  19. STEP # 6 Hemi-nephrect u.p.

  20. STEP # 7 Specimen removal

  21. LPN personal Results • Operative time: 90 min (70 to 120) • Lenght of stay: 3-4 days • Conversions: 0

  22. Laparoscopic transposition of lower pole crossing vessels in extrinsic uretero-pelvic junction (UPJO) obstruction in children

  23. Background # 2 • A recent study demonstrated that 58% of older children with symptomatic PUJO had lower pole crossing vessels [ • The traditional management for lower pole vessels causing PUJO has been dismembered pyeloplasty • The Hellstrom procedure , in which crossing polar vessels are relocated, has been an option in adult urological practice

  24. Clinical findings • Indication: abdominal pain presenting as Dietl’s crisis , UTI and rarely haematuria • Median age of presentation > 6 years • Absence of pre-natally detected hydronephrosis

  25. Pre-operative work-up • Renal ultrasonography • Doppler ultrasound • Scintigraphy • MRI

  26. Technique # 1 At laparoscopy the presence of a lower pole vessel is confirmed in the absence of a narrow PUJ The PUJ and the pelvis are adequately mobilised achieving easy displacement of vessels

  27. Technique # 2 The ‘ shoe-shine ’ manoeuvre of the mobilised anterior pelvis behind the lower pole vessels confirms adequate availability of the pelvis to perform a loose wrap around the vessels

  28. Technique # 3 Two or three interrupted sutures may be necessary to achieve an adequate tunnel within the anterior pelvic wall

  29. Trocars 1: 10mm 2: 5mm 3: 5mm 4 4

  30. STEP # 1 Dissection

  31. STEP # 2 pelvis

  32. STEP # 3 wrap

  33. Classic UPJO

  34. Patient’s Position #2

  35. Trocars 1: 10mm 2: 5mm 3: 5mm 4 4

  36. Lap Pyeloplasty

  37. Urachal Anomalies In Pediatric Patients

  38. Background • Urachus is a 3-layered canal that connects the allantois to the fetal bladder. • Descent of the bladder in month 5 of development stretches the urachus, causing its lumen to obliterate and become the median umbilical ligament . • Occasionally this process may be incomplete and an epithelialized urachal canal may persist into adulthood.

  39. Background # 2 • This leaves the potential for various urachal anomalies, including cysts, sinus tracts, diverticula and malignancies 1) vesicourachal diverticulum 2) urachal cyst 3) Umbilical-urachus sinus

  40. Indication • Childrenwithurachalanomalies, in about60-70 % ofpatientshavesymptoms (umbilicaldrainage, hematuria, UTI, abdominalpain), • In the other30-40 %ofpatients the urachalanomalies are diagnosedincidentallyduringabdominalsurgeryperformedforanotherindication

  41. Technique # 1

  42. Technique # 2

  43. Technique # 3

  44. Technique # 4

  45. Technique # 5

  46. LEVUR Laparoscopic Lich-Gregoir procedure In patients with VUR

  47. VUR Techniques STING COHEN 70-85 % Success Rate 95 -98 % Day Surgery Hospitalisation 6-10 days No Pain +++++ Yes Ureteral Cath after No

  48. LEVUR Laparoscopic Lich-Gregoir procedure

  49. Trocars Position Optic 5mm 30° 3-mm trocars

  50. LEVUR # 1 Ureter Isolation

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