Laparoscopic

Laparoscopic Renal Surgery

Dr. Zia TMO HMC, Surgery

Laparoscopic Surgery

Big Surgeon!

Big Incision! Big Success!

What’s Laparoscopic Surgery? ►

Minimally invasive surgery

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Gas-inflated abdomen Laparoscope and tools

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HISTORY

Video laparoscopic surgery The beginning-1990

Media and lay public hype • • • •

“Key-hole surgery” “Laser surgery” “Cure that’s quicker by tube” “World’s smartest operation

Major excitement amongst surgeons

Why Laparoscopic Surgery? 

Small incision, minimal scar, improved cosmesis



Improved visualization via telescopic magnification and minimal bleeding



Shorter recovery times

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Minimal post-operative pain

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Less chance of infection

Compare !

Today

Yesterday

General contraindications ►

Severe COPD or Cardiac Disease

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Grade II or III Shock

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Generalized peritonitis

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Previous extensive abdominal surgery

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Previous generalized inflammatory disease or irridaiation

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Hyper or Hypo-coagulable states

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Advanced stage of pregnancy

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Suspected Carcinoma

Intra operative Monitoring ► ECG ► Blood

Pressure ► Airway pressure monitor ► Pulse oximeter ► Endotracheal CO2 concentration (PETCO2) monitor ► Peripheral nerve stimulator ► Body temperature probe

Recent advances ► Robotic

surgery ► Tele robotic surery ► Incisionless surgery  Trans vaginal cholecystectomy ► Gasless

surgery

What is NOTES? Natural Orifice Translumenal Endoscopic Surgery: -Intentional puncture of one of the viscera (e.g., stomach, rectum, vagina, urinary bladder) to access the abdominal cavity -With an endoscope (flexible or stiff) -To perform an intraabdominal operation Pearl JP, Ponsky JL: J Gastrointest Surg. 2007 Dec 5

NOTES in humans: perhaps 300 cases world-wide  Hydrabad: Appendectomy, liver biopsy, tubal ligation: 22 cases.  Brazil: : Endoscopically-assisted transgastric and transvaginal laparoscopic cholecystectomy 10 cases.  4 transvaginal cholecystectomies and a transgastric laparoscopy for cancer  Ohio: Transgastric peritoneoscopy  New York: lap-assisted transvaginal chole  Oregon Transgastric cholecystectomy  Argentina and San Diego Transvaginal cholecystectomy (n=4) Transgastric cholecystectomy (n=2) Transgastric appendicectomy (n=2)  Mayo Clinic Transvesical (urinary bladder) peritoenoscopy  Chicago Transgastric cholecystectomy  Brazil. Transvaginal hybrid nephrectomy (n=1) data base of 150 cases in South America mostly cholecystectomy

Laparoscopy in renal diseases

Laparoscopic Nephrectomy was first performed in 1991 by Clayman, Kavoussi et al, where they removed the Right kidney from a patient diagnosed with Renal Oncocytoma

 Equivalent oncological efficacy compared to open approach, with advantages of: ►Lower morbidity ►Improved cosmesis ►Shorter hospitalization ►Quicker recovery

Laparoscopic approaches to kidneys ► Retroperitoneal ►

approach

Trans peritoneal approach Hand assisted surgery

Transperitoneal Approach

Retroperitoneal Approach

Transperitoneal approach

Anatomy

Renal hilum left

Renal hilum right

Relations Right Kidney

Relations left kidney

Laparoscopic nephrectomy

The team

Patient position

LANDMARKS

Patient position

Trocar placement

Trocar insertion

Mobilization of colon

Mobilization of colon

Identifying Ureter

Identifying Ureter

DISSECTION

Renal artery

Renal vein

Ureter and Gonadal Vein

DISSECTION LUMBAR FOSSA

Extraction

Post op care ► NG

tube removed ► Orally allowed on post op day 1 ► Drain removed if output less than 50cc/24hr ► Normal diet on day 2 post op. ► 1st follow up after 1 month ► Abdominal u/s and renal profile performed

HALN

► HAND

ASSISTED LAPAROSCOPIC NEPHRECTOMY

What is Hand-assisted Laparoscopic Nephrectomy ► “HALN”

stands for hand-assisted laparoscopic nephrectomy

► Surgeon

removes kidney laparoscopically with the assistance of the hand through a small 4 inch incision near the umbilicus

► Kidney

port

removed intact through hand

Why Hand assisted Laparoscopic Nephrectomy “Del iver y of kid ney a nywa y r equ ir es a 6 t o 9 c m inc isio n a t t he en d. S o it i s on ly l ogi cal t o us e t his i nc is ion a s a port t o h el p wi th r et ract ion a nd di ss ect ion of t he o rga n r igh t fr om s ta rt of t he s ur ger y”

Why Laparoscopic Hand-Assisted Nephrectomy

HAND IS THE MOST VERSATILE INSTRUMENT ( To Feel, to dissect, To Retract & For Knot-Tying)

‘Endohand’ for laparoscopy - undergoing trial ( Jackman – 1999)

Laparoscopic Hand Assisted Nephrectomy Versus Conventional Laparoscopic Nephrectomy I. No difference in:

a. Post operative Pain b. Return of Bowel function c. Duration of Convalescence II. Less number of complications III. Operation time less by 85 min (Wolf - 1997)

Our experience Supra renal masses

4

Radical nephrectomy

8

Atrophic Nonkidneys functioni Hydronephro ng tic Renal cysts

4 6 4

Pyeloplasties

4

Total

30

► Procedure

abandoned

► Complications ► Patient ► Drain ► Back

orally allowed

Out

to Home

3 cases No 1st POD 2nd POD 3rd POD

Thank You Our Team

Prof. Dr. Mazhar Khan Asst. Prof. Dr. Zahid Aman Registrar. Dr. Siddique SMO. Dr. Aziz Khan SMO. Dr. Sarfaraz Khan TMO’s

Dr. Zia Dr. Navid Anwar Dr. Zahid Wazir Dr. Rizwan Kundi

Dr. Yousaf Dr. Waqas Dr. Ahmed Din

“Every day you may make progress. Every step may be fruitful....You know you will never get to the end of the journey. But this, so far from discouraging, only adds to the joy and glory of the climb.”

Sir Winston Churchill British politician (1874 - 1965)