Renal hydatid cyst treatment: Retroperitoneoscopic “closed cyst” pericystectomy

Cystic hydatid disease is an endemic disease caused by the larval form of Echinococcus spp. Isolated renal involvement is extremely rare. The treatment methods for renal hydatid disease require some form of intervention, ranging from traditional open techniques to laparoscopic techniques. Herein, we present a large hydatid cyst in the lower pole of the left kidney in a 43‐year‐old male patient who was treated by the “closed cyst” method via the retroperitoneal laparoscopic approach to prevent soiling of the peritoneal cavity. To our knowledge, this is the first case of a renal hydatid cyst treated by preserving the renal parenchyma by pericystectomy via the retroperitoneoscopic laparoscopic approach in an adult patient. No complications occurred during the perioperative and postoperative periods. After 9 months of follow up, the patient was asymptomatic with no evidence of clinical recurrence. Retroperitoneoscopic laparoscopic closed cyst pericystectomy can be an alternative minimally invasive treatment technique for the treatment of renal hydatid disease.     

Minimally invasive surgery for posterior gastric stromal tumors

Background: Because involvement is extremely rare, surgery for gastric stromal tumors consists of local excision with clear resection margins. The aim of this study was to report the results of a consecutive series of nine patients with posterior gastric stromal tumors that were excised using a minimally invasive method. Methods: Patients received a general anesthetic before placement of three laparoscopic ports— a 10-mm (umbilical) port for the telescope and two working ports, a 12-mm port (left upper quadrant) and a 10-mm port (right upper quadrant). Grasping forceps were placed through an anteriorly placed gastrotomy to deliver the tumor through the gastrotomy into the abdominal cavity, thus allowing an endoscopic linear cutter to excise the tumor with a cuff of normal gastric tissue. Results: Nine consecutive patients with a median age of 73 years (range, 47–83) were treated. In seven patients, laparoscopic removal of the tumor was achieved. Two patients required conversion to an open operation because the tumor could not be delivered into the abdominal cavity. The median length of postoperative stay for the seven patients in whom the procedure was completed laparoscopically was 3 days (range, 2–6). Conclusions: Posterior gastric stromal tumors can be removed safely using this minimally invasive method. Delivery of the tumor through the gastrotomy is essential for success. Received: 30 April 1999/Accepted: 12 July 1999     

Laparoscopic screening of surgical candidates with pancreatic cancer or liver tumors

Background: Patients with colorectal or pancreatic cancers may have peritoneal implants which are too small to be detected by current radiologic imaging techniques. Since such implants often preclude surgical removal of the primary tumor or isolated metastasis, their detection prior to open abdominal exploration may spare patients the morbidity of a large abdominal incision when there is no benefit to resection and lifespan is limited. Methods: In the past 30 months, patients with pancreatic cancer, hepatoma, or isolated colorectal cancer metastases, who were candidates for surgical resection on the basis of standard radiologic scans, were examined with the laparoscope through a 10-mm periumbilical incision prior to undertaking open abdominal exploration. If unexpected implants were noted, biopsy was obtained through a 5-mm port placed through a convenient site. Results: Since January 1993, 11 patients with pancreatic carcinoma, three patients with primary hepatic malignancies, and 12 patients with isolated metastases from colorectal cancers have undergone laparoscopic examination prior to celiotomy. Eight of these patients had unexpected peritoneal or liver involvement which precluded resection. Laparoscopy was successful in detecting disease in six such patients (75%). Conclusion: Although adding 20–30 min to the operative time when unrevealing, laparoscopy provided an effective way to avoid celiotomy in patients with carcinomatosis.     

Intracardiac Wilms' tumor: diagnosis and management

Complete excision of Wilms' tumor may require resection of adjacent organs and removal of intracaval tumor propagation. Extension of tumor to the right atrium can be determined preoperatively guiding a direct and safe approach to intracardiac tumor at the time of nephrectomy. Preoperative ultrasonography of two children with Wilms' tumor demonstrated caval and right atrial tumor. Laparotomy for nephrectomy and abdominal caval exposure was combined with cardiopulmonary bypass and atriotomy. In both patients, tumor contiguous with the renal pelvis extended from the iliac bifurcation into the right atrium with a large atrial mass. In one patient nephrectomy was performed first, and she was then placed on cardiopulmonary bypass. Caval tumor was easily removed through the atriotomy and open renal vein. In the second patient, bypass was instituted first because of cardiac instability. The large right atrial mass extended through an atrial septal defect into the left atrium. The cardiac tumor and a large amount of caval tumor were removed. Bypass was discontinued after repair of the ASD. Tumor remained in the IVC below the renal veins necessitating a separate venotomy. Combined abdominal and cardiac exploration allows safe and complete excision of all gross tumor. Ultrasonography is a sensitive and noninvasive method of diagnosing retrohepatic and atrial tumor extension and can be obtained easily even on very sick patients.     

Does laparoscopic adrenalectomy jeopardize oncologic outcomes for patients with adrenocortical carcinoma?

Background

For patients with known or suspected adrenocortical carcinoma (ACC), considerable controversy exists over the use of laparoscopic adrenalectomy. The purpose of this study was to assess recurrence and survival patterns in patients with a pathologic diagnosis of ACC treated with laparoscopic versus open adrenalectomy.

Methods

All patients referred to our center with a diagnosis of ACC from April 1, 1993 to May 1, 2012 were reviewed. Three groups of patients were compared: patients referred after laparoscopic resection elsewhere, patients referred after open resection elsewhere, and patients treated primarily at our center (all resected by the open approach). Clinical factors and overall, recurrence-free, and peritoneal recurrence-free survivals were compared between groups.

Results

During the study period, 46 patients presented after laparoscopic resection at an outside institution, 210 patients after open resection at an outside institution, and 46 patients were treated at our institution with open resection. Despite a smaller tumor size, patients treated laparoscopically developed peritoneal carcinomatosis more frequently compared to those treated with an open approach (p = 0.006 for number with peritoneal recurrence). When controlling for tumor stage, open-approach patients experienced superior recurrence-free and overall survival.

Conclusion

Despite typically being performed in patients with smaller tumors, laparoscopic adrenalectomy for ACC is associated with higher rates of recurrence, particularly peritoneal recurrence. For patients with known or suspected ACC, the oncologic benefits of open resection outweigh the short-term benefits of minimally invasive surgery.     

Laparoscopic radical nephrectomy incorporating intraoperative ultrasonography for renal cell carcinoma with renal vein tumor thrombus

The purpose of this study was to describe the technique of laparoscopic right radical nephrectomy incorporating intraoperative, real-time ultrasonography in the management of renal cell carcinoma with level 1 renal vein tumor thrombus. With the patient in a modified flank position, a transperitoneal four-port approach was used to laparoscopically resect an 8.5-cm right renal mass with tumor thrombus extending to, but not into, the inferior vena cava. Early arterial control with gentle traction on the right renal vein provided a short proximal renal venous segment devoid of tumor on laparoscopic inspection. Intraoperative laparoscopic ultrasonography allowed confident identification of the proximal extent of the tumor thrombus. After hilar control, complete resection and intact removal of the renal specimen was performed using standard non-hand-assisted laparoscopic techniques. The actual surgical time was 180 minutes. Surgical resection was successfully performed laparoscopically. No postoperative complications or hospital readmission occurred. Pathologic examination confirmed T3b renal cell carcinoma with negative surgical margins. Laparoscopic right radical nephrectomy incorporating intraoperative, real-time ultrasonography is feasible in the management of renal cell carcinoma with a large-sized level 1 renal vein thrombus. Additional studies are necessary to evaluate its role in urologic oncologic surgery.     

Laparoscopic resection of a periampullary villous adenoma

Background: Adenomas of the duodenal papilla are rare lesions. Because of their malignant potential, resection is mandatory. Options for resection include endoscopic resection, transduodenal local excision, and pancreaticoduodenectomy. This report details a case of periampullary villous adenoma diagnosed endoscopically and resected laparoscopically via a transduodenal approach. Case report: A healthy 75-year-old woman with heartburn underwent an upper endoscopy for vague right upper abdominal pain. A periampullary tumor was diagnosed. Endoscopic biopsy results were consistent with a villous adenoma, and endoscopic ultrasound showed distal bile duct involvement. The patient underwent laparoscopic transduodenal local excision of the tumor with biliary reconstruction. Conclusions: Laparoscopic transduodenal resection of periampullary lesions provides advantages similar to those of an endoscopic resection by removal of the tumor using minimally invasive techniques. In addition, laparoscopic surgery maintains the surgical tenents of open transduodenal resection with en bloc tumor resection including the adjacent duodenal wall and ductal structures as necessary. As noted in this case, laparoscopic techniques resect ampullary lesions involving the ductal structures as well. Laparoscopic transduodenal ampullectomy is a valuable treatment option for benign and selected premalignant ampullary lesions.     

William Stewart Halsted: Father of American Modern Surgery

Peritoneal dialysis is an established alternative method for the management of patients with end-stage renal disease. Recently, laparoscopy has been utilized in assisting the insertion of catheters under direct vision. The efficacy of the laparoscopic approach for patients with a history of abdominal surgery remains largely unknown. The purpose of this study is to evaluate laparoscopy in the placement of peritoneal dialysis catheters for selected patients with previous abdominal operation. Laparoscopic assisted placement of peritoneal dialysis catheters was performed in 20 patients, who were carefully selected preoperatively and who also underwent previous abdominal operation between April 1999 and July 2001. Previous abdominal operation included appendectomy, ovarian resection, hysterectomy, cesarean section, open cholecystectomy, segmental resection of the small intestine, and truncal vagotomy with pyloroplasty. The procedure was performed using two 10-mm and one 5-mm abdominal trocar. All of the patients tolerated this procedure without significant surgical complications. However, 3 patients developed temporary hemoperitoneum, and 1 patient developed dialysate leakage. The overall success rate of catheter function (> 30 days after laparoscopy) was 90%, except in 2 cases where the catheter functioned poorly due to severe intra-abdominal adhesions. Simultaneous laparoscopic adhesiolysis was successfully performed in 5 cases. Laparoscopic implantation of peritoneal dialysis catheters appears to be a straightforward procedure, even for patients with previous abdominal operation. We believe that this technique may extend the application of peritoneal dialysis treatment in patients with previous abdominal surgery after discreet evaluation preoperatively.     

Laparoscopic assisted placement of peritoneal dialysis catheters for selected patients with previous abdominal operation.

Peritoneal dialysis is an established alternative method for the management of patients with end-stage renal disease. Recently, laparoscopy has been utilized in assisting the insertion of catheters under direct vision. The efficacy of the laparoscopic approach for patients with a history of abdominal surgery remains largely unknown. The purpose of this study is to evaluate laparoscopy in the placement of peritoneal dialysis catheters for selected patients with previous abdominal operation. Laparoscopic assisted placement of peritoneal dialysis catheters was performed in 20 patients, who were carefully selected preoperatively and who also underwent previous abdominal operation between April 1999 and July 2001. Previous abdominal operation included appendectomy, ovarian resection, hysterectomy, cesarean section, open cholecystectomy, segmental resection of the small intestine, and truncal vagotomy with pyloroplasty. The procedure was performed using two 10-mm and one 5-mm abdominal trocar. All of the patients tolerated this procedure without significant surgical complications. However, 3 patients developed temporary hemoperitoneum, and 1 patient developed dialysate leakage. The overall success rate of catheter function (> 30 days after laparoscopy) was 90%, except in 2 cases where the catheter functioned poorly due to severe intra-abdominal adhesions. Simultaneous laparoscopic adhesiolysis was successfully performed in 5 cases. Laparoscopic implantation of peritoneal dialysis catheters appears to be a straightforward procedure, even for patients with previous abdominal operation. We believe that this technique may extend the application of peritoneal dialysis treatment in patients with previous abdominal surgery after discreet evaluation preoperatively.     

Laparoscopic resection of intra-abdominal metastasis from intracranial hemangiopericytoma

IntroductionHemangiopericytoma (HPC) is a rare mesenchymal tumor derived from capillary and postcapillary pericytes that often has an indolent course and occasionally presents with abdominal metastasis.Presentation of caseTwenty-three years after the initial resection of an intracranial HPC located in the right frontoparietal region and left lateral ventricle, a 63-year-old man experienced dull abdominal pain and early satiety and had a palpable epigastric mass. Computed tomography indicated a suspected metastasis of HPC to the left upper abdomen. On laparoscopic exploration, the tumor was found in the falciform ligament and was excised laparoscopically per request of the patient. He had a fast recovery and experienced good relief of his pain and satiety. The patient had 2 additional metastases at his 12-month follow-up, both in the right retroperitoneum, and he again underwent laparoscopic resection. At his next annual follow-up, new metastases were identified in his liver, small-bowel mesentery, and peritoneal surface, prompting a trial of systemic chemotherapy. Because of progress of a left lower abdominal preperitoneal metastasis on follow-up at 3 years, the patient underwent a further successful laparoscopic exploration. Postoperatively, systemic chemotherapy was maintained.DiscussionWe report the recurrent laparoscopic resection of peritoneal metastases of primary intracranial HPC with good symptom control and fast recovery. Both the patient and the referring physician requested a minimally invasive surgical approach.ConclusionLaparoscopic resection is a feasible treatment strategy for intraperitoneal metastases and is effective in symptom palliation.     

Laparoscopic resection of adrenal cortical carcinoma: a cautionary note

BACKGROUND: While laparoscopic removal of small, benign, functioning adrenal tumors is accepted, laparoscopic resection of adrenal tumors that may be adrenal cortical carcinoma (ACC) remains controversial. METHODS: The records of all patients with ACC evaluated at a single institution from 1991 through 2004 were reviewed retrospectively. RESULTS: Among 170 patients with ACC, 153 patients underwent open anterior adrenalectomy, 6 underwent laparoscopic adrenalectomy, 1 was treated via an open flank approach, and 10 had no operation. At a median follow-up of 28 months, 115 (86%) of 133 patients who had undergone open anterior resection of primary ACC had had a recurrence. Local recurrence and peritoneal carcinomatosis were components of initial failure in 46 (35%) and 11 patients (8%), respectively. In contrast, all 6 patients who underwent laparoscopic resection of ACC had recurrences, and peritoneal carcinomatosis was a component of initial failure in 5 (83%) of them (open vs laparoscopic resection, Fisher exact test P = .0001). CONCLUSIONS: Laparoscopic resection of ACC is associated with a high risk of peritoneal carcinomatosis. Open adrenalectomy remains the standard of care for patients presenting with an adrenal cortical tumor for which ACC is in the differential diagnosis.     

A case of adult Wilms' tumor]

Wilms' tumor is very rarely found in adults and there are no established treatment guidelines for such tumors in adults. A 56-year-old woman was referred to our hospital for further examination of macroscopic hematuria. Computed tomography scan revealed a large right renal mass with enlarged lymph nodes. Angiography showed a hypovascular tumor. She underwent right nephrectomy and resection of lymph node metastasis with a diagnosis of malignant renal tumor. Histopathological examination revealed nephroblastoma with lymph node metastasis. The disease was classified as stage III according to the National Wilms' Tumor Study classification. The patient received adjuvant chemotherapy consisting of ifosfamide, cisplatin, and etoposide. This protocol was selected because of the published poor results with the standard Wilms' tumor chemotherapeutic agents when used in adults. She remained without tumor recurrence as of six months after surgery. Development of better therapeutic approaches to adult Wilms' tumor is awaited.     

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.     

A murine model of laparoscopic-assisted intervention

Background: In order to better investigate the effects of laparoscopic surgery, it is necessary to establish reliable, reproducible, and economical animal models of laparoscopic intervention. Here we describe a mouse model of laparoscopic-assisted colon resection. Methods: After successful induction of anesthesia the mouse is placed in Trendelenburg position and the peritoneal cavity is insufflated with carbon dioxide gas through an angiocatheter placed in the right upper quadrant. A 4-mm rigid scope with camera attachment is then inserted through a midline port created just caudal to the xiphoid. A second port is then created in the right lower quadrant to allow introduction of laparoscopic forceps into the peritoneal cavity. The cecum, which extends 1.5 cm beyond the ileocecal valve, is grasped with forceps and exteriorized through the operative port. Extracorporeally, the cecum is ligated and resected before the cecal stump is returned to the peritoneal cavity. The abdominal wall defects are then stapled closed. Results: This simple model can be mastered by individuals with very limited surgical experience. This laparoscopic model has been used successfully in our laboratory in a number of experiments with an intraoperative complication rate of 3.2% (3/94), which was similar to the open surgery group rate of 2.1% (2/95, p= 0.99 by chi square). We observed no postoperative leaks in either group. The only postoperative death occurred in the open resection group due to dehiscence of the laparotomy wound. Conclusions: We propose that this model may be useful for comparing the effects of open to laparoscopic surgery. Received: 19 June 1996/Accepted: 2 November 1996     

Laparoscopic liver surgery for everyone: the hybrid method

Minimally invasive techniques have been described recently for liver resections. We have developed a surgical approach to liver resection that combines the benefits of minimally invasive surgery with the safety of open liver resection. We have applied this hybrid approach to selected cases, and we feel that it can be adopted by most hepatobiliary surgeons, even those with minimal or no laparoscopic experience. Briefly, this technique consists of laparoscopic mobilization of the target liver lobe, followed by standard open liver resection through the extraction site. The required incisions parallel those needed for hand-assisted laparoscopic liver resections. We have compared these hybrid procedures with contemporaneous laparoscopic, hand-assisted, and open liver resections at our institution and have found that they compare favorably with minimally invasive procedures. A wider utilization of this approach by both general and hepatobiliary surgeons will result in a more generalized acceptance of minimally invasive liver resection that ultimately will advance the field and benefit patients in need of liver surgery.     

Laparoscopic intraoperative ultrasonic localization and resection of an extra-adrenal pheochromocytoma

With advances in minimally invasive techniques, the safety and efficacy of laparoscopic adrenalectomy is well documented. Compared with open surgery, the laparoscopic approach results in shorter hospital stay, reduced morbidity, and more rapid recovery. In the setting of pheochromocytoma, tumor resection is feasible although somewhat more difficult because of catecholamine liberation and frequent large lesion size. We report the successful laparoscopic resection of a para-aortic, extra-adrenal paraganglioma using ultrasound guidance.     

Laparoscopic omentectomy for salvage of peritoneal dialysis catheters

BACKGROUND AND PURPOSE: Maintaining long-term peritoneal catheter function for peritoneal dialysis is commonly threatened by problems with catheter obstruction. Multiple methods have been used to salvage nonfunctioning catheters, including omentopexy, catheter repositioning, and omentectomy. We report on our experience with a laparoscopic method of omentectomy and catheter fixation for salvage of nonfunctioning peritoneal dialysis catheters. PATIENTS AND METHODS: Thirteen patients with nonfunctioning peritoneal dialysis catheters underwent 16 laparoscopic procedures with the intent to restore function. Clinically, all patients presented with outflow obstruction. At initial presentation, all patients underwent diagnostic laparoscopy and a definitive procedure. In 12 patients, catheters were enveloped by omentum, and we performed laparoscopic omentectomy and catheter fixation to the anterior pelvic wall. In one patient, we identified a broken catheter and performed a laparoscopic omentectomy at the time of catheter replacement. One 10-mm and two 5-mm trocars were utilized. Omentectomy was performed using either endo-GIA stapled resection (2 patients) or the Harmonic Scalpel (11 patients). All trocar incisions (including the 5-mm site) were closed with a suture-passing (Carter-Thomason) device to provide water-tight closure in anticipation of immediate return to peritoneal dialysis. Patients were followed postoperatively for an average of 17 months (range 4-35 months). RESULTS: All patients' catheter function was restored intraoperatively with laparoscopic omentectomy and catheter fixation. Eight catheters remained functioning following omentectomy without further intervention. Five patients (38%) experienced repeat catheter malfunction and underwent laparoscopic exploration. Of these, three catheters (60%) were restored to function with laparoscopic manipulation alone. Three catheters were found encased in extensive adhesions. Laparoscopic adhesiolysis was successful in one patient and unsuccessful in one patient, who converted to hemodialysis. One patient failed laparoscopic salvage and required open laparotomy and fibrin clot removal to restore catheter function. One catheter was found to be obstructed within a pericolic hematoma. One catheter was found within residual omentum at the hepatic flexure. Both of these catheters were freed laparoscopically and continued to function at 12 and 16 months' follow-up. Complications included one episode of peritonitis, one case of postoperative ileus, and one trocar site hernia necessitating repair. The nephrologists were instructed that they could begin peritoneal dialysis on postoperative day 1. Seven patients resumed peritoneal dialysis without leak from trocar sites. The remaining patients received temporary hemodialysis through a central venous catheter and returned to peritoneal dialysis at the discretion of their nephrologists. CONCLUSIONS: Laparoscopic omentectomy with catheter fixation is a minimally invasive means of salvaging peritoneal dialysis catheters with outflow obstruction. Complications are few, and closure of laparoscopic incisions in water-tight fashion allows rapid return to peritoneal dialysis.     

Retroperitoneal renal laparoscopy

The retroperitoneal laparoscopic approach to the kidney offers a minimally invasive access that mimics the open surgical techniques of renal surgery. It allows renal surgery without violation of the peritoneal cavity with its attendant complications such as bowel injury and ileus. Over the last two decades, all renal surgery has been shown to be feasible through this technique. This includes complicated procedures such as a donor nephrectomy and radical nephroureterectomy for upper tract transitional cell cancers. We began performing retroperitoneoscopic renal surgery in the early 1990s and have developed a number of modifications to existing techniques so as to make this surgery easy and cost effective. In this review, we discuss the evolution of retroperitoneoscopic renal surgery, the indications, techniques and outcome of all types of retroperitoneoscopic renal surgery.     

Laparoscopic resection of a proximal splenic artery aneurysm

The usual treatment for splenic artery aneurysm is resection under laparotomy. In recent years, the laparoscopic approach has consisted of ligation without resection. More recently,laparoscopic resection was reported by the Cleveland Clinic. In this paper, we describe the technique used in the laparoscopic resection of our first case of laparoscopic resection of splenic artery aneurysm (SAA). The patient was a young woman with a 12-mm SAA discovered on systematic abdominal ultrasound. The laparoscopic procedure was done successfully, and the aneurysm was resected using an ultrasonic dissector. The postoperative course was uneventful, and the patient was discharged on the 3rd postoperative day. Pathological examination revealed the atherosclerotic origin of the aneurysm. The patient is doing well 12 months after surgery, with normal splanchnic Doppler ultrasound. This procedure offers a one-step definitive cure via a minimally invasive surgical procedure.