Sutureless laparoscopic heminephrectomy using laser tissue soldering

BACKGROUND AND PURPOSE: Widespread application of laparoscopic partial nephrectomy has been limited by the lack of a reliable means of attaining hemostasis. We describe laser tissue welding using human albumin as a solder to control bleeding and seal the collecting system during laparoscopic heminephrectomy in a porcine model. MATERIALS AND METHODS: Laparoscopic left lower-pole heminephrectomy was performed in five female domestic pigs after occluding the hilar vessels. Using an 810-nm pulsed diode laser (20 W), a 50% liquid albumin-indocyanine green solder was welded to the cut edge of the renal parenchyma to seal the collecting system and achieve hemostasis. Two weeks later, an identical procedure was performed on the right kidney, after which, the animals were sacrificed and both kidneys were harvested for ex vivo retrograde pyelograms and histopathologic analysis. RESULTS: All 10 heminephrectomies were performed without complication. The mean operative time was 82 minutes, with an average blood loss of 43.5 mL per procedure. The mean warm ischemia time was 11.7 minutes. For each heminephrectomy, a mean of 4.2 mL of solder was welded to the cut parenchymal surface. In three of the five acute kidneys and all five 2-week kidneys, ex vivo retrograde pyelograms demonstrated no extravasation. In addition, no animal had clinical evidence of urinoma or delayed hemorrhage. Histopathologic analysis showed preservation of the renal parenchyma immediately beneath the solder. DISCUSSION: Laser tissue welding provided reliable hemostasis and closure of the collecting system while protecting the underlying parenchyma from the deleterious effect of the laser during porcine laparoscopic heminephrectomy.     

Cost-effective treatment for ureteropelvic junction obstruction: a decision tree analysis

PURPOSE: We determined the optimal treatment for primary ureteropelvic junction obstruction based on cost using a decision tree model. MATERIALS AND METHODS: A comprehensive literature search for articles addressing surgical correction of ureteropelvic junction obstruction was performed and data were abstracted on operative time, hospital stay, complications and success rate. The overall cost and individual cost centers at our institution for antegrade endopyelotomy, retrograde ureteroscopic endopyelotomy, Acucise (Applied Medical Resources, Laguna Hills, California) endopyelotomy, laparoscopic pyeloplasty and open pyeloplasty were compared. A decision tree model estimated the cost of treatment and followup for each modality using commercially available software. Sensitivity analyses were performed to evaluate the effect of individual treatment variables on overall cost. RESULTS: Based on cost center review retrograde ureteroscopic endopyelotomy was the least costly procedure ($2,891). In the decision tree model the rank order of overall treatment costs was: retrograde ureteroscopic endopyelotomy ($3,842), Acucise endopyelotomy ($4,427), antegrade endopyelotomy ($5,297), laparoscopic pyeloplasty ($7,026) and open pyeloplasty ($7,119). Despite various hospital stay, operative time, equipment cost and success rate data 1-way sensitivity analysis revealed that antegrade endopyelotomy, laparoscopic pyeloplasty and open pyeloplasty were never cost effective compared with retrograde ureteroscopic endopyelotomy or Acucise endopyelotomy, while 2-way sensitivity analysis favored retrograde ureteroscopic endopyelotomy. CONCLUSIONS: Primary cost variables for ureteropelvic junction obstruction treatments include operative time, hospital stay, equipment cost and success rate. Decision tree analysis showed that retrograde ureteroscopic or Acucise endopyelotomy is the most cost-effective treatment modality at our institution. However, cost is only 1 of a number of factors that are considered when deciding on an optimal course of treatment.     

Assessment of basic human performance resources predicts operative performance of laparoscopic surgery

BACKGROUND: Interest in laparoscopic surgery has prompted development of educational programs designed to teach and assess laparoscopic skills. Although these programs are beneficial, because of the inherent demands imposed by laparoscopy some aspects of operative performance might not improve with practice. This suggests that innate ability could predict level of operative skill. Assessment of operative and technical potential to date has relied largely on subjective rather than objective criteria. In this study, the relationships between objective measures of human basic performance resources (BPRs) and laparoscopic performance were evaluated using Nonlinear Causal Resource Analysis (NCRA), a novel predictive and explanatory modeling approach based on General Systems Performance Theory. STUDY DESIGN: Twenty urology residents were voluntary enrolled. Thirteen validated BPRs were measured and analyzed relative to operative laparoscopic performance (assessed by two experts) of two porcine laparoscopic nephrectomies (LN). The laparoscopic procedure, representing a High Level Task (HLT), was evaluated using a modified Global Rating of Operative Performance Scale. NCRA models were devised to predict performance of the HLT laparoscopic nephrectomies based on BPRs and to determine the limiting performance resource. RESULTS: NCRA models predicted excellent agreement with actual operative performance, suggesting that measures of innate ability (or BPRs) predicted performance of laparoscopic nephrectomy. In 65%, the prediction by NCRA was near identical to the expert rating on the HLT. In 25% of cases, NCRA overpredicted performance; in 10%, NCRA underpredicted performance of the HLT compared to the subjective ratings. Neuromotor channel capacity was the most common performance-limiting resource. CONCLUSIONS: Preliminary findings suggest objective prediction of laparoscopic performance with limiting resource diagnostics for an individual surgeon is possible and practical using appropriate new measurement and modeling methods. Selection of surgical candidates, training, and educational curriculum could be positively affected.     

Resorbable clip migration in the collecting system after laparoscopic partial nephrectomy

A complication is reported in which Lapra-Ty absorbable suture clips (Ethicon EndoSurgery) migrated from a laparoscopic partial nephrectomy bed into the collecting system, causing renal colic. During surgery performed with hilar occlusion, visual inspection did not reveal collecting system entry. Transected vessels were oversewn with absorbable suture secured with Lapra-Tys. Absorbable bolsters were placed in the parenchymal bed, and compression sutures secured with Lapra-Tys were placed through the renal capsule. Six weeks postoperatively, the patient developed ipsilateral renal colic, and computed tomography demonstrated several 3-mm opacities within the ureter. After 2 weeks of conservative management, he spontaneously passed several Lapra-Ty clips.     

Surgical technique and anatomic study of latissimus dorsi and teres major transfers

BACKGROUND: Combined latissimus dorsi and teres major musculotendinous transfer has been described for the treatment of massive rotator cuff deficits. The procedure is technically complex because of the proximity of the radial nerve, the axillary nerve and its posterior branches, and the neurovascular bundles to the muscles. The purpose of the present cadaveric study was to examine surgically relevant relationships for latissimus dorsi and teres major tendon transfers. METHODS: Twelve cadaveric shoulder girdles were dissected, and the latissimus dorsi, the teres major, and the posterior cord of the brachial plexus and its branches were identified. The relationships between the tendons and local neurologic structures were measured during various steps of the latissimus dorsi/teres major transfer procedure. The effect of humeral rotation on the exposure of the latissimus dorsi and teres major tendons through the posterior approach was quantified, and relevant surgical landmarks were described. RESULTS: The radial nerve passed directly anterior to the tendons at an average of 2.9 cm medial to the superior aspect and 2.3 cm medial to the inferior aspect of the humeral insertions. From the posterior axillary approach, maximal internal rotation facilitated exposure for tenotomy by delivering the tendon insertions on the humerus into the surgical field. During axial mobilization of the musculotendinous units, the neurovascular pedicles to the latissimus dorsi and teres major were identified at an average of 13.1 and 7.4 cm axial to the humeral insertions, respectively. The posterior branch of the axillary nerve was noted to cross superficially over the transferred tendons as they were tunneled under the posterior deltoid. CONCLUSIONS: Multiple steps of the combined latissimus dorsi and teres major musculotendinous transfer place local neurologic structures at risk. These steps include tendon release, musculotendinous axial mobilization, and tendon tunneling in the plane between the infraspinatus-teres minor and the posterior deltoid. We have quantified and described the relationship of the axillary and radial nerves to the tendons during tenotomy, the distance from the tendons' insertions to their neurovascular bundle that must be identified during axial mobilization, and the course of the posterior branch of the axillary nerve in relation to the tunneled path of the tendons. CLINICAL RELEVANCE: The present study provides important anatomic findings for the safe mobilization and transfer of the latissimus dorsi and teres major tendons during the surgical treatment of irreparable rotator cuff tears.