Is laparoscopic surgery the technique of choice in nephrectomy?

Laparoscopic is performed in adults for the treatment of benign renal diseases. It is widely accepted that laparoscopic surgery has more advantages than open surgery in many procedures such as nephrectomy, but there is no further experience in this technique. In pediatric urology laparoscopy has become an accepted approach for varicocele, non palpable testis, bladder augmentation, adrenalectomy and urinary diversion. We report our experience with 25 laparoscopic nephrectomies in children.     

Is laparoscopic donor nephrectomy the new criterion standard?

HYPOTHESIS: The posttransplantation renal function outcomes between consecutive open donor and laparoscopic donor nephrectomies (LDNs) are similar and affect living donation. DESIGN: Using the medical records of renal living donor-recipient pairs, 36 consecutive open donor nephrectomies were compared with the subsequent 100 LDNs. Data collected on donor characteristics included demographics (age, race, sex, weight, and height), renal vascular and ureteral anatomical features, surgical information (blood loss, number of blood transfusions, operating time, warm ischemia time, and renal injury), complications, and length of hospital stay. Recipients' data also included renal function information (serum creatinine level on postoperative days 7 and 30) and ureteral complications during the initial hospital stay. SETTING: A not-for-profit tertiary care teaching hospital in a metropolitan area. PATIENTS: Adults who had end-stage renal disease and received a living donation kidney. MAIN OUTCOME MEASURES: Operative time, warm ischemia time, blood loss, and posttransplantation serum creatinine level. RESULTS: Patient characteristics were not significantly different between the open donor nephrectomy and LDN groups. No right kidney LDNs were done because of the shortness of the right renal vein; and, after the initial experience, left kidneys with more than 2 arteries were excluded. Warm ischemia time was recorded only for LDN, and it was found that a warm ischemia time of 10 minutes or longer was associated with difficulty in extraction and was uniformly associated with elevated mean serum creatinine levels on postoperative day 7. CONCLUSIONS: The length of hospital stay was decreased and cosmetic result enhanced. The number of living donors has increased from 28 in 1997 to 53 in 1998 and to 63 in 1999 at our institution. The length of hospital stay, incidence of complications, and comparable kidney quality indicate that LDN should be the initiating procedure for most patients.     

Is the laparoscopic approach reasonable in cases of splenomegaly?

Laparoscopic splenectomy in cases of splenomegaly has been shown to be feasible in experienced hands, even though the size of the spleen increases the operative time and difficulty. Laparoscopic splenectomy for splenomegaly offers the same advantages as for patients with smaller spleens: a shorter hospital stay and a faster recovery. Recent experience has shown that hand-assisted laparoscopic surgery makes the surgical maneuvers during laparoscopic splenectomy in cases of splenomegaly considerably easier while preserving the advantages of a purely laparoscopic approach. This technique may facilitate and broaden the application of laparoscopy for splenectomy in patients with enlarged spleens.     

Is right laparoscopic donor nephrectomy right?

Introduction  Laparoscopic donor nephrectomy has become the standard of care in many renal transplant centers. Many centers are reluctant to perform right laparoscopic donor nephrectomies, primarily due to concerns about transplanting a kidney with a short renal vein. Methods  A retrospective review of 26 right and 24 left consecutive donor nephrectomies and their recipients was performed. Patient demographics, preoperative, perioperative, and postoperative data were recorded and compared. Results  Patient demographics were similar between groups. Multiple vessels were encountered more frequently on the right side (10 vs. 3, p = 0.04) and the donated kidney had lesser preoperative function in the right group as determined by nuclear medicine imaging (46.5% vs. 49.4%, p < 0.001). Donor operating times were less in the right group (198 vs. 226 min, p = 0.016). There was no difference in implantation difficulty as demonstrated by similar operative and warm ischemia times. Complication rates were similar between both groups of donors and recipients. Conclusions  Right laparoscopic donor nephrectomy requires less operating time than, and is associated with similar outcomes for donors and recipients as, left laparoscopic donor nephrectomy. Right laparoscopic donor nephrectomy may be preferable in general and should be considered when multiple renal vessels are present on the left side and/or when preoperative function of the left kidney is greater than the right.     

Is the laparoscopic approach appropriate for porcelain gallbladder?

Contrary to the fears raised in surgical publications of the 1950's and 60's, the prognosis of porcelain gallbladder is not automatically associated with an increased risk of gallbladder carcinoma. Two recent cohort studies have allowed a better definition of the appropriate therapeutic attitude for a patient with a calcified gallbladder. In cases of "true" porcelain gallbladder, i.e., the presence of complete transmural calcification of the entire gallbladder wall, indications for cholecystectomy are based on biliary symptoms, all the more so since choledocholithiasis is often associated with porcelain gallbladder. In the case of partial calcification of the gallbladder, i.e., focal plaques of calcification involving the mucosa, prophylatic operative treatment is indicated. In these cases, the incidence of malignancy is markedly increased (14 times that of a control population). Cholecystectomy can still be performed laparascopically as long as the rules for prevention of peritoneal dissemination of tumor cells are scrupulously observed--the gallbladder should not be opened nor bile spilled, the specimen should be placed in a bag for removal through the abdominal wall, the pneumoperitoneum should be evacuated with the trocars still in place and the specimen should be opened and examined after removal with immediate frozen section pathologic exam if there is any question of tumor.     

Is the laparoscopic approach to colectomy safe for the morbidly obese?

Background

The feasibility and safety of laparoscopic colectomy (LC) for morbidly obese patients has not been reported previously. This study aimed to assess the clinical outcomes of patients with a body mass index (BMI) of 40 kg/m³ or more who undergo laparoscopic colorectal surgery.

Methods

Prospectively accrued data for patients with a BMI of 40 kg/m³ or more (group A) who undergo LC were compared with those for patients with BMI lower than 30 kg/m³ (group B) matched for year of surgery, indication, operating surgeon, and type of procedure.

Results

Each group had 36 patients. The group A patients were significantly younger (54 vs. 61 years; P = 0.04), had higher American Society of Anesthesiology (ASA) scores (P = 0.001), and had diabetes mellitus (P = 0.04). The indications for surgery and the operations performed were similar. The two groups had similar operating times (177.9 vs. 136.4 min; P = 0.12), estimated blood losses (222.3 vs. 157 ml; P = 0.1), median lengths of hospital stay (LOS) (4.5 vs. 4 days; P = 0.2), and returns of bowel function (4.2 vs. 3.9 days; P = 0.45). Group A had significantly longer incisions (6.9 vs. 5 cm; P = 0.02). Conversions (5 vs. 3 patients; P = 0.7), readmissions (12 vs. 6 patients; P = 0.46), reoperations (5 vs. 3 patients; P = 0.17), wound infections (7 vs. 2 patients; P = 0.14), anastomotic leaks (3 vs. 2 patients; P = 0.7), and abdominal abscesses (3 vs. 2 patients; P = 0.7) were more predominant in group A, although the differences did not reach statistical significance.

Conclusions

Laparoscopic colectomy is feasible for morbidly obese patients and results in recovery of intestinal function and LOS equivalent to that for nonobese patients. As expected, morbidity and conversion rates are higher for morbidly obese patients undergoing LC than for nonobese patients.     

Is robotic technology facilitating the minimally invasive approach to partial nephrectomy?

Study Type – Therapy (case series) Level of Evidence 4 What's known on the subject? and What does the study add? Open partial nephrectomy has been defined as the standard of care for the treatment of small renal masses. Robotic platforms may offer the solution to bridge the gap between open and laparoscopic approaches, providing similar oncological and functional results via a shorter learning curve. This study reviews the current literature, and reports developments in robotic‐assisted partial nephrectomy (RPN). It highlights the important results from various studies which investigate the oncological and functional efficacy of RPN, and establishes its current status as at least equivalent to the laparoscopic approach. Trends are emerging that highlight the advantage of the robotic interface in facilitating this approach, and we postulate that this may become more apparent in future studies.

OBJECTIVE

• ? To establish its current status, this study reviews the literature, and reports developments in robotic‐assisted partial nephrectomy (RPN), highlighting results from various studies that investigate the oncological and functional efficacy of RPN. Partial nephrectomy has become the standard therapy for the management of small renal masses. In an effort to overcome the perioperative morbidity associated with an open approach, and the extended warm ischaemia times associated with a laparoscopic approach, robotic platforms have been introduced.

PATIENTS AND METHODS

• ? A search of Medline, EMBASE and Cochrane library databases was completed in July 2010 and used to identify pertinent original articles, editorials, comments and reviews, using the search term ‘partial nephrectomy’. Links to related references were surveyed, and all articles finally included were based on relevance and importance of content, as determined by the authors.

RESULTS

• ? The robotic platform may offer the solution to bridge the gap between open and laparoscopic approaches, achieving warm ischaemia times that consistently average 20 minutes, and providing similar oncological and functional results via a shorter learning curve. It offers cosmesis and convalescence equivalent to that from laparoscopic partial nephrectomy, but with potentially fewer postoperative complications.

CONCLUSION

• ? In terms of oncological and functional outcomes, the early experiences of RPN in selected series of patients appear at least equivalent to open and laparoscopic partial nephrectomy series. Randomized comparisons between the approaches are lacking, as are longer‐term follow‐up data for the robotic technique and formal cost analysis; these will be necessary before RPN can replace open partial nephrectomy as the new standard for the management of small renal masses. Trends continue to emerge that highlight the advantage of using the robotic platform to achieve a minimally invasive approach for partial nephrectomy, and with time and increasing expertise, this may become further apparent.

     

Renal parenchymal malacoplakia: a different stage of xanthogranulomatous pyelonephritis?

Malacoplakia is a rare inflammatory condition characterized by demonstrative Michaelis-Gutmann bodies, which are foamy histiocytes with distinctive basophilic inclusions. Malacoplakia is caused by the inadequate elimination of bacteria by macrophages or monocytes as a result of defective phagocytic activity. Xanthogranulomatous pyelonephritis is characterized by the destruction of renal parenchyma and its replacement by solid sheets of foamy lipid-laden macrophages. Prolonged infection of the kidney, which is frequently caused by an obstruction of the urinary tract, is the pathologic mechanism of that condition. We present a 6-year-old patient with a poorly functioning kidney who had a prolonged recurrent urinary tract infection. The results of histologic analysis revealed an inflammatory infiltration consisting predominantly of foamy and epithelioid histiocytes that contained round intracytoplasmic concretions characteristic of Michaelis-Gutmann bodies. We suggest that malacoplakia might be a stage of xanthogranulomatous pyelonephritis.     

Cholecystitis in the octogenarian: is laparoscopic cholecystectomy the best approach?

Management of biliary disease in the octogenarian has evolved over the last decade. Laparoscopic cholecystectomy is now more commonly performed in this patient population. Octogenarians with biliary pathology frequently present with complications of acute disease such as biliary pancreatitis, choledocholithiasis, and acute cholecystitis. As a result, laparoscopic management in this patient population can frequently be more challenging than in younger patients. We retrospectively reviewed 70 patients who were 80 years of age and older who underwent cholecystectomy at our institution for biliary tract disease. Seventeen patients presented to the Day Surgery unit for elective management of chronic biliary disease. Sixteen (94%) of these patients were attempted laparoscopically and one (6%) underwent open cholecystectomy. Two patients attempted laparoscopically were converted to open surgery (conversion rate 12.5%). Average length of hospital stay was 3.7 days for those treated laparoscopically and 11 days for patients treated with open cholecystectomy. There were three complications (19%) in this group and no deaths. The remaining 53 patients presented via the emergency room with acute complications of cholelithiasis. Laparoscopic cholecystectomy was attempted in 28 (52%) and open cholecystectomy was performed in 25 (48%) patients. Ten (37%) of the patients attempted laparoscopically were converted to an open procedure. Average length of stay in this group was 11.7 days for those treated laparoscopically and 15.7 days for patients managed with open technique. There were ten (56%) complications in the laparoscopic group and five (14%) complications in the open group. There were four deaths (22%) among those treated laparoscopically and three deaths (8.6%) in the open cholecystectomy group. Comorbid conditions were common in the patients with acute biliary pathology and those presenting for elective cholecystectomy. Laparoscopic cholecystectomy is the procedure of choice in the elective management of biliary tract disease in the octogenarian. Laparoscopic cholecystectomy has no benefit with respect to morbidity and mortality over open cholecystectomy in the management of acute biliary tract disease in this elderly population. When possible, chronic cholecystitis in the elderly should be managed with elective laparoscopic cholecystectomy rather than waiting for complications to develop.     

Is laparoscopic approach to lumbar spine fusion worthwhile?

BACKGROUND: Laparoscopic lumbar spine fusion has been recently described. The aim of this study is to evaluate the safety and efficacy of this procedure for single- and multiple-level degenerative disc disease. METHODS: Twenty-four consecutive laparoscopic interbody lumbar fusions were evaluated prospectively (18 single-level were compared with 6 multiple-level procedures). Results of the laparoscopic multiple-level procedures were further compared with 12 open multiple-level operations. RESULTS: Twenty procedures were completed laparoscopically. The conversions were related to iliac vein lacerations (3 cases) and a mesenteric tear. Single-level cases had lower morbidity (22% versus 83%), shorter hospital stay (2 versus 10 days), and higher fusion rate (88% versus 50%) than multiple-level procedures. Overall results in the latter group were worse than in the matched open group. CONCLUSIONS: Laparoscopic single-level fusion (L5-S1) is safe and carries the benefits of minimal access surgery. Morbidity after multiple level approach is high, and this procedure cannot be advocated at this time.     

The laparoscopic approach in abdominal emergencies: has the attitude changed?

Background Laparoscopy has been practiced more and more in the management of abdominal emergencies. The aim of the present work was to illustrate retrospectively the results of a case-control 5-year experience of laparoscopic versus open surgery for abdominal emergencies carried out at our institution, especially with regard to whether our attitude toward use of this procedure has changed as compared with the beginning of our laparoscopic emergency experience (1991–2002). Materials and Methods From January 2002 to January 2007 a total of 670 patients underwent emergent and/or urgent laparoscopy (small bowel obstruction, 17; gastroduodenal ulcer disease, 16; biliary disease, 118; pelvic disease and non-specific abdominal pain (NSAP), 512; colonic perforations, 7) at the hands of a surgical team trained in laparoscopy Results The conversion rate was 0.15%. Major complications ranged as high as 1.9% with no postoperative mortality. A definitive diagnosis was accomplished in 98.3% of the cases, and all such patients were treated successfully by laparoscopy. Conclusions We believe that laparoscopy is not an alternative to physical examination/good clinical judgment or to conventional noninvasive diagnostic methods in treating the patient with symptoms of an acute abdomen. However it must be considered an effective option in treating patients in whom these methods fail and as a challenging alternative to open surgery in the management algorithm for abdominal emergencies.