A 3 trocar technique for transperitoneal laparoscopic nephrectomy

PURPOSE: Additional trocars and retractor instruments may enhance the risk of iatrogenic injuries during laparoscopic nephrectomy. We describe a modified technique of laparoscopic nephrectomy requiring only 3 ports of entry and no extra instruments instead of the 5 ports, 2 of which are used for retractors, usually required. MATERIALS AND METHODS: With the patient in full flank position a 10 mm. trocar is inserted between the umbilicus and subcostal margin, a 5 mm. trocar is placed subcostal in the midclavicular line and a 12 mm. trocar is inserted over the iliac crest in the anterior axillary line. The first step is incision of the line of Toldt and medial reflection of the colon. During the second step of vascular controls the posterosuperior attachments of the kidney are left untouched, keeping the renal vessels stretched, with no need for an extra instrument. The third step consists of severing the remaining posterior and superior attachments of the kidney followed by specimen retrieval. A total of 14 consecutive patients underwent laparoscopic nephrectomy with this technique. RESULTS: All 14 procedures were completed without an additional port. There were no intraoperative or postoperative complications, except 1 abdominal wall hematoma. Mean operating time was 120 minutes (range 70 to 230) and mean hospital stay was 5 days (range 3 to 7). CONCLUSIONS: Transperitoneal laparoscopic nephrectomy with laparoscopic access limited to 3 trocars is a reliable and safe technique.     

Laparoscopic intragastric surgery using GelPort

In laparoscopic intragastric surgery for early gastric cancer and submucosal tumors, three trocars are routinely inserted in the gastric lumen. We placed a GelPort hand assist device through a 5-cm transverse incision in the upper abdomen, and inserted the trocars into the gastric lumen through the gel seal cap, snapping the gel seal cap on and off during the operation. This makes it possible to use an open technique in which trocars are inserted into the gastric lumen, and to close the trocar sites in the gastric wall. We believe that the technique described here is easier and saves time compared with inserting trocars and closing trocar sites laparoscopically.     

Hand-assisted laparoscopic nephrectomy in autosomal dominant polycystic kidney disease

BACKGROUND: Among patients with renal insufficiency secondary to autosomal dominant polycystic kidney disease (ADPKD), the onset of refractory urinary infection, hypertension, pain, or hematuria often necessitates a nephrectomy. However, the huge size of these kidneys makes a standard laparoscopic approach difficult, and the increased fragility of these patients makes an open nephrectomy risky. A compromise position has been found in the realm of hand-assisted laparoscopic techniques, especially for patients in need of a bilateral nephrectomy. TECHNIQUE: Hand-assisted laparoscopic nephrectomy (HALN) is performed via a hand-assist device placed in the midline. A subxiphoid midline port and a midclavicular subcostal port are placed on the ipsilateral side. The right hand is inserted for left nephrectomy and the left hand for a right nephrectomy. The laparoscope is introduced into the subxiphoid port, and the surgeon's primary working instrument is passed via the midclavicular port. Occasionally, it is helpful to place a 5-mm subcostal port in the midaxillary line to aid in retracting the kidney. Once the kidney is devascularized, it is removed via the 7- to 8-cm hand-assist incision; drainage of cysts may be necessary during extraction to reduce the kidney size so that it can be withdrawn. If a bilateral approach is to be done, then after the first nephrectomy, the lateral 5-mm port is closed, and the table is rolled such that the contralateral side is elevated about 30 degrees to 45 degrees; a subcostal midclavicular 12-mm port is placed, and, if needed, a 5-mm port is inserted subcostally in the midaxillary line for renal retraction. RESULTS: Seven bilateral hand-assisted laparoscopic nephrectomy cases have been reported. In two reports, the mean operating times were 4.8 and 5.5 hours. The mean estimated blood loss was <350 mL. CONCLUSION: The hand-assisted laparoscopic approach makes both unilateral and bilateral nephrectomy feasible in ADPKD patients with acceptable morbidity.     

Optical access trocar injuries in urological laparoscopic surgery

PURPOSE: Inadvertent injuries during trocar and Veress needle placement are a rare but potentially serious complication of laparoscopic surgery. An access alternative is an optical trocar under direct vision. Limited data are available regarding the safety of this technique. We reviewed complications related to optical access trocars during standard transperitoneal urological laparoscopic procedures performed at a single institution. MATERIALS AND METHODS: From 1995 to 2001 the optical access trocar was used as the initial trocar in 1,283 urological laparoscopic procedures. The procedures included simple and radical nephrectomy in 309 cases, donor nephrectomy in 386, partial nephrectomy in 79, pyeloplasty in 173 and various other procedures in 336. Intra-abdominal complications caused by optical access trocar were assessed. RESULTS: The optical trocar was inserted at the umbilicus in 88 patients (7.4%), in the right upper quadrant in 445 (34.7%) and in the left upper quadrant in 750 (58.5%). There were 4 injuries (0.31%) associated with the optical access trocar. Complications occurred on the left side in 3 cases and on the right side in 1, including 1 injury to bowel, 1 mesenteric injury resulting in a retroperitoneal hematoma and 2 injuries to epigastric vessels. Three cases were recognized and repaired immediately but in a case of epigastric vessel injury the expanding abdominal wall hematoma required postoperative repair. CONCLUSIONS: Optical access trocars provide a safe and rapid technique for initial trocar placement. Results of this large series support the finding that few trocar related complications are associated with the optical access trocar.     

Prospective randomized comparison of cutting and dilating disposable trocars for access during laparoscopic renal surgery.

BACKGROUND AND OBJECTIVES: Traditional trocar tip design for laparoscopic access incorporates cutting blades to penetrate the body wall. More recently, trocars applying tissue dilation have been used that create a smaller defect, seldom requiring fascial wound closure. Four 12-mm commercially available single-use trocar designs were evaluated for postoperative pain. METHODS: The 4-trocar types included 2 cutting (single or pyramidal bladed) and 2 dilating trocars (radially or axially dilating) type. Fifty-six patients undergoing transperitoneal laparoscopic renal surgery were randomized and blinded to one of the 4 trocar types. In each case, trocars were placed in a standard "diamond" configuration: three 12-mm study trocars and a lateral 5-mm trocar that served as a reference point for normalizing patients' pain scores. Postoperative pain based on a visual analog scale and complications were assessed. RESULTS: No statistically significant difference existed in pain scores between different trocar types or trocar sites at 3-hour, 24-hour, and 1-week postoperative assessment time points. Eight (4.8%) minor complications occurred: bleeding in 7 (4.2%) and 1 (0.6%) wound infection. The radially dilating trocar had more device malfunction (P<0.05) than did the others. CONCLUSION: All 4 disposable trocars, muscle cutting or dilating type, were safe and yielded similar postoperative pain scores with or without the fascial wound closure after renal laparoscopy.     

Retroperitoneal access for transperitoneal laparoscopy in patients at high risk for intra-abdominal scarring

BACKGROUND AND PURPOSE: Adhesions from prior extensive open abdominal surgery can make initial transperitoneal access for laparoscopy hazardous. An alternative to open port placement is a retroperitoneal approach to the peritoneal cavity. We describe our retroperitoneal access for transperitoneal laparoscopy and evaluate the success of the subsequent laparoscopic procedure. PATIENTS AND METHODS: Eight patients with a history of abdominal surgery have undergone retroperitoneal access to the peritoneum prior to a laparoscopic urologic procedure. With the patient in a lateral decubitus position, the retroperitoneum is entered with a 10-mm Visiport device (US Surgical Corp., Norwalk, CT) along the posterior axillary line. A working space is bluntly created, the peritoneum identified anterior to the colon, and the endoscope passed through a peritoneotomy. The abdomen is then inspected, transperitoneal ports are strategically placed under direct vision, and the intended procedure is commenced. RESULTS: In all cases, retroperitoneal access to the peritoneum and subsequent trocar placement was successful. In five cases, the intended procedure was completed laparoscopically. In a case of bilateral ureterolysis, one side was completed laparoscopically; however, the other required open conversion. In two nephrectomies for xanthogranulomatous pyelonephritis (XGP), open conversion was necessary because of fibrosis. CONCLUSION: Retroperitoneal access to the peritoneal cavity permits safe and effective port placement when previous abdominal surgery makes initial transabdominal access difficult. However, despite successful access, in patients at risk for extensive perinephric fibrosis (e.g., XGP), a high incidence of open conversion may be expected.     

Incisional hernia in a 12-mm non-bladed trocar site following laparoscopic nephrectomy

Non-bladed trocars, radially-dilating systems, and conical blunt devices are considered less traumatic to the abdominal wall because they do not incise the fascia itself. Consequently, several authors have suggested that closure of the abdominal fascia may be unnecessary if such non-bladed laparoscopic trocars are used. We report of a case in whom a port-site hernia was diagnosed at the site of a 12-mm non-bladed trocar 11 days after laparoscopic nephrectomy.     

Feasibility of a Combined Percutaneous Laparoscopic Three-Millimeter Device

Background and Objectives:

Needlescopic 3-mm instruments induce minimal trauma and produce excellent cosmetic results. A combination of a 3-mm abdominal wall incision and a 5-mm instrument in the abdominal cavity would combine the beneficial features of these two different sizes.

Methods:

The Percutaneous Surgical System (PSS) (Ethicon EndoSurgery, Galway, Ireland) is a new instrument consisting of a 3-mm shaft that is introduced percutaneously into the abdominal cavity. Through a 5-mm trocar, a loader with a 5-mm attachment such as a Maryland dissector is introduced. The attachment is connected to the shaft, and the loader is removed from the abdomen. The feasibility of this device was evaluated retrospectively in 3 Swedish hospitals between January and September 2012.

Results:

Twenty-eight patients were laparoscopically operated on (cholecystectomy, gastric bypass, fundoplication, incisional hernias, and totally extraperitoneal repair for inguinal hernia) by use of 1 or 2 PSSs in each operation (47 in total). It was feasible to use the PSS in all procedures except during the totally extraperitoneal repair procedure because of the limited available preperitoneal space. Especially in laparoscopic cholecystectomies, the two lateral 5-mm trocars were easily replaced by two 3-mm PSS instruments.

Conclusions:

The use of the PSS is feasible in a number of laparoscopic procedures, where it can replace 5-mm trocars. Randomized controlled trials are needed to determine the future role of the PSS versus, for example, needlescopic laparoscopy.     

Hand-assisted laparoscopic devices: the second generation

BACKGROUND AND PURPOSE: Hand-assisted laparoscopic (HAL) nephrectomy is an increasingly popular surgical modality. Within the last year, three newly designed second-generation hand-assist devices have emerged with the intention to improve efficacy and ease of use. We prospectively evaluated and compared these with each other and with the first-generation devices. MATERIALS AND METHODS: A total of 130 urologists performed two HAL nephrectomies in a porcine laboratory using two different hand devices at an American Urological Association-sponsored learning course. Sixty-three urologists utilized the second-generation devices (Gelport, Omniport, LapDisc), while 67 urologists used the first-generation devices (Handport, Intromit, PneumoSleeve). Each surgeon completed a 12-question survey evaluating the devices. RESULTS: Evaluation of the second-generation devices revealed that Gelport was statistically significantly superior in all parameters to the Omniport and in 5 of 10 parameters to the LapDisc. Comparison of the first- and second-generation devices revealed that only the Gelport achieved a significant increase in all ratings. Among the first-generation devices, no device scored better than 8.27 of 10 in any category. Analysis of the second-generation devices demonstrated that the Gelport scored a rating above 8.25 in all parameters with an overall satisfaction score of 8.59. Both the Omniport and the LapDisc attained ratings comparable to those of the first-generation devices. CONCLUSION: The HAL procedure relies heavily on devices that allow the hand to be introduced into the laparoscopic environment. The Gelport, when evaluated in a porcine model by training laparoscopic urologists, appears to be significantly better than other devices available to date. Further testing with larger cohorts and human clinical trials are required to confirm these findings.     

Dual-organ ablative surgery using a hand-assisted laparoscopic technique. A report of four cases

In clinical situations where more than one procedure is required, a properly positioned hand-assist device can be used to obviate the need for two large incisions. We present four cases of hand-assisted laparoscopic nephrectomy combined with a simultaneous second organ extraction. Each of the four primary procedures, as well as one of the four secondary procedures, was performed using a hand-assisted laparoscopic technique. In two cases, the secondary procedure was performed with an open surgical technique through the hand-assist incision. For the remaining secondary procedure, we used a laparoscopically assisted technique.     

Tip for microlaparoscopic cholecystectomy: easy removal of the gallbladder after laparoscopic cholecystectomy using the three-port technique

The standard laparoscopic cholecystectomy usually requires four trocars: two 10-mm and two 5-mm trocars. With the development of mini-instruments, laparoscopic surgeons have developed the two- or three-port techniques. The selection of the number and size of trocars depends on the surgeon's experience and preferences. Removal of the gallbladder is critical in the mini-instrument technique. To remove the gallbladder through the umbilical port, a 5-mm telescope should be inserted through one of the 5-mm ports, or one of the 5-mm trocars should be replaced with an 11-mm trocar by extending the incision. A simple and easy technique was applied to retrieve the gallbladder without changing the telescope or extending the skin incision for the trocar port to 11 mm. When the gallbladder is detached from the liver, the surgeon grasps the neck of the gallbladder via the 5-mm trocar and positions the gallbladder in the 11-mm trocar. While the surgeon keeps the gallbladder in the 11-mm trocar with the grasper held tangentially, the assistant removes the telescope and inserts a straight-toothed grasper to capture the gallbladder neck blindly. Subsequently, the removal of the gallbladder together with the trocar follows the usual technique. We have applied this technique to all our patients with limited or no inflammation of the gallbladder.     

Optical-access visual obturator trocar entry into desufflated abdomen during laparoscopy: assessment after 96 cases

BACKGROUND: The introduction of optical-access laparoscopic trocars was met with enthusiasm and the impression that these devices provide safer access with decreased complication rates. However, serious complications have been reported. PATIENTS AND METHODS: We retrospectively reviewed our first 96 consecutive cases (17 radical prostatectomies, 2 sacrocolpopexies, 6 adrenalectomies, and 71 renal procedures), performed between October 2001 and April 2003, of optical-access laparoscopic trocar placement as initial entry into the desufflated abdomen. After creating a 12-mm periumbilical or lateral-rectus incision, the 12-mm Endopath Bladeless visual obturator trocar (Ethicon Endosurgery, Cincinnati, OH) was inserted into the peritoneum while carefully observing the separation of the layers of fascia, muscle, and peritoneum. RESULTS: There were no vascular injuries. However, we observed 2 (2.1%) large-bowel injuries: a seromuscular injury and a through-and-through enterotomy of the mid-descending colon. In both cases, the visual obturator was placed lateral to the left rectus muscle, and the large colon was noted to be adherent to the anterior abdominal wall. The bowel injuries were repaired in two layers (running 3-0 Vicryl for the mucosa and 3-0 silk for the seromuscular layer). The operations were completed without open conversion and with uneventful recovery. CONCLUSIONS: Direct placement of an optical-access visual obturator trocar into the desufflated abdomen carries the potential for significant injury. Our current practice is to place the visual trocar after Veress-needle peritoneal insufflation.     

LAPAROSCOPY-ASSISTED RADICAL NEPHRECTOMY IN COMBINATION WITH MINILAPAROTOMY: REPORT OF INITIAL 7 CASES

We recently developed a new procedure for laparoscopy-assisted radical nephrectomy in combination with minilaparotomy to remove kidneys with renal cell carcinoma. A pararectal incision approximately 7 cm in length was performed from the subcostal region. A 12-mm trocar was placed at the mid-clavicular line at the level of the umbilicus. An 11 -mm trocar was placed at the tip of the rib. Under laparoscopic and trans-minilaparotomic observation, intra-abdominal manipulation was begun. The contents of Gerota's fascia were freed from the surrounding tissues and removed through the abdominal incision. Seven patients have been successfully treated with this procedure. The operating time for this procedure was shorter than the time of laparoscopic nephrectomy. There were none of the adverse hemodynamic or ventilatory effects associated with pneumoperitoneum in this procedure. This procedure also resulted in less postoperative pain and a shorter convalescence period when compared with open nephrectomy.     

Intraperitoneal adhesions in laparoscopic and standard open herniorrhaphy

Background: Intra-abdominal complications from transabdominal properitoneal (TAP) laparoscopic herniorrhaphy that would not be expected to occur in an open herniorrhaphy are possible. In a previous study, we reported the incidence of significant intra-abdominal adhesions from TAP herniorrhaphies using polypropylene in pigs. Methods: To compare this with an open herniorrhaphy technique, we performed open herniorrhaphies on 31 pigs. Additional animals underwent TAP herniorrhaphy with PTFE. Data were collected on operative and trocar-site adhesions. Graft incorporation was recorded. Results: No intra-abdominal adhesions were found in the 31 animals undergoing open herniorrhaphy. Fifteen adhesions were found in the 31 pigs that underwent TAP herniorrhaphy. These adhesions were graded and there were a total of nine significant adhesions with the TAP procedure. A total of 124 trocar sites resulted in two adhesions. Laparoscopically placed polypropylene was better incorporated than PTFE. The laparoscopically placed PTFE grafts commonly were poorly incorporated. Conclusions: We conclude that there is a risk of intra-abdominal adhesions to either the operative site or the trocar sites in TAP herniorrhaphy that is not present in open techniques. One should, therefore, be circumspect in the choice of TAP herniorrhaphy as a primary repair. Received: 8 April 1996/Accepted: 21 May 1996     

New technique of laparoscopic colectomy with the LAP DISC and a 5-mm flexible scope

Purpose We devised a new method for the safe introduction of the first trocar and induction of pneumoperitoneum for laparoscopic excision of the large intestine. Methods With this method, a small laparotomy is first conducted according to the size of the exposed affected intestinal tract or tumor size, prior to the application of a LAP DISC (LD) to the wound and introduction of a 12-mm trocar for the establishment of pneumoperitoneum. The method is advantageous in that organ injury and vessel injury are avoided when the small laparotomy is conducted first, and prompt transition to a conventional laparotomy is possible. The diaphragm of the iris bulb can be controlled in a non-stepwise manner. In addition, trocars, the stapler, and other instruments, can be inserted under the pneumoperitoneum. Furthermore, the use of a 5-mm flexible scope allows surgical maneuvers, except for application of LD, to be conducted via 5-mm trocars. In addition, the 5-mm scope can be inserted through any trocar, allowing multidirectional avoidance of dead space and intraperitoneal observation. When only 5-mm trocars are used, it is not necessary for the sites of trocar puncture to be closed by sutures, and this minimizes the risk of adhesions and port-site herniation. The method is also considered to be excellent from the point of view of esthetics. Results We employed this surgical approach in 50 patients with colorectal cancer at our hospital. None of the patients developed any traumatic complications associated with the insertion of trocars, and none of the patients, even those with a past history of abdominal operation, required conversion to conventional laparotomy. Conclusions Based on these results, this method involving a small laparotomy prior to the application of an LD and introduction of a 12-mm trocar for establishing pneumoperitoneum, with the efficient use of a 5-mm flexible camera, is considered to be safe and useful for laparoscopic excision of the large intestine.     

A novel minimally invasive technique for insertion of peritoneal dialysis catheter

The placement of a continuous ambulatory peritoneal dialysis (CAPD) catheter by conventional open surgical or trocar technique may cause a number of complications such as infection, hemorrhage, leakage, incisional hernia, and visceral organ perforation. Most complications are related to open surgery or insertion of the catheter with the guidewire without direct visualization. Insertion of the catheter laparoscopically under direct visualization has been previously described. The authors who described this technique used two or three ports for the camera and instruments. In this study we describe a laparoscopic technique for insertion of the peritoneal dialysis catheter under direct visualization with use of one-camera port and an accessory 2-mm umbilical incision. This prospective study was performed with the approval of the ethics committee of the Gazi University Hospital, in Ankara, Turkey. There were a total of eight patients: five males and three females, with an average age of 34.3 years (range, 11-54), who underwent laparoscopic CAPD insertion between 1997 and 2000. The catheter was inserted into the abdominal cavity 2 cm below the umbilicus. The subcutaneous tunnel was made with the assistance of a specially designed L-shaped trocar. All patients did well after the operation and had excellent cosmetic results. There was one leak in the early postoperative period, which was treated conservatively. The average operating time was 34.7 minutes (range, 25-45 minutes). The laparoscopic approach for peritoneal dialysis catheter insertion, for management of transmigrated CAPD catheters, and to resolve omental occlusions should be considered as an alternative to open surgery, especially for patients who have peritoneal adhesions secondary to a history of abdominal surgeries or recurrent peritonitis.     

Hand-assisted transperitoneal laparoscopic living donor nephrectomy

OBJECTIVE: We introduced and evaluated the advantages and disadvantages of the hand-assisted transperitoneal laparoscopic technique for living donor nephrectomy. MATERIALS AND METHODS: In December 2001, we started using the technique of hand-assisted transperitoneal laparoscopic living donor nephrectomy (HLDN) in 10 cases. The procedure utilizes a hand-assisted device to increase safety and control of the laparoscopic technique. RESULTS: Only left nephrectomy was performed. The mean total operating and the warm ischemia times were 130 minutes and 3.0 minutes, respectively. Average lengths of renal artery and vein were 1.95 cm and 2.8 cm, respectively. There were no intraoperative or postoperative complications. CONCLUSIONS: HLDN is an easier procedure than the traditional laparoscopic living donor nephrectomy and can greatly mitigate the learning curve. HLDN has shortened warm ischemia time and operating time. It is also good for trocar placement, prevention of torsion of the kidney, control of potential bleeding at the final stage of vascular stapling, and kidney removal. Therefore, HLDN is a promising method for living donor nephrectomy.     

Transballoon trocar insertion during preperitoneal hernia repair

Trocar insertion during laparoscopic preperitoneal hernia repair (TEP) can be troublesome because the space into which the trocars are inserted is smaller than that available for transabdominal approaches. Insertion of the trocars directly into the balloon used to dissect the preperitoneal space can facilitate this process. The insertion of a 5-mm trocar into the balloon does not usually result in balloon deflation, and a second trocar can be placed into the balloon as well. Removing the balloon, despite the trocars inside it, is straightforward, allowing the placement of a cannula at the balloon insertion site and initiation of the hernia repair.     

Laparoscopic radical nephrectomy: incorporating advantages of hand assisted and standard laparoscopy

PURPOSE: We present an approach to laparoscopic radical nephrectomy and intact specimen extraction, which incorporates hand assisted and standard laparoscopic techniques. MATERIALS AND METHODS: A refined approach to laparoscopic radical nephrectomy is described and our experience is reviewed. A low, muscle splitting Gibson incision is made just lateral to the rectus muscle and the hand port is inserted. A trocar is placed through the hand port and pneumoperitoneum is established. With the laparoscope in the hand port trocar 2 additional trocars are placed under direct vision. The laparoscope is then repositioned through the middle trocar and standard laparoscopic instruments are used through the other 2 trocars including the one in the hand port. If at any time during the procedure the surgeon believes the hand would be useful or needed, the trocar is removed from the hand port and the hand is inserted. RESULTS: This approach has been applied to 7 patients. Mean estimated blood loss was 200 cc (range 50 to 300) and mean operative time was 276.7 minutes (range 247 to 360). Mean specimen weight was 767 gm. (range 538 to 1,170). Pathologically 6 specimens were renal cell carcinoma (grades 2 to 4) and 1 was oncocytoma. Mean length of hospital stay was 3.71 days (range 2 to 7). There were no major complications. CONCLUSIONS: We believe that this approach enables the surgeon to incorporate the advantages of the hand assisted and standard laparoscopic approaches.     

One-trocar appendectomy

Background: Laparoscopic appendectomy is a feasible and a safe alternative to open appendectomy. Several laparoscopic procedures have been described that use one or more trocars. We report our experience with the treatment of acute appendicitis using a laparoscopy-assisted technique by means of only one transumbilical trocar. Methods: From February 1996 to February 1999 we performed 65 laparoscopic appendectomies. In the procedures, a 10-mm operative telescope was used, with a 450-mm atraumatic grasper introduced through the operative channel. After the intraabdominal laparoscopic dissection, the appendix was exteriorized through the umbilical trocar. The appendectomy was performed outside the abdomen as in the open procedure. The procedure was completed using only one trocar in 55 patients (84.6%). Regarding the other 10 cases (15.3%), in 5 we used more than one trocar and in 5 conversion to open surgery was needed. Results: The average operating time in our series was 25 min and the median time to discharge was 2 days. There were six (11%) postoperative complications (three serous umbilical secretion and three umbilical hematomas). Conclusions: Our results suggest that this technique, which combines the advantages of both the open and the laparoscopic procedures, is a valid alternative for the treatment of acute appendicitis. However, this procedure cannot always be completed using only one trocar, as happened in 10 cases in our series.