Anandan Murugesan

Cost Reductive Laparoendoscopic Single Site Surgery Endotrainer and Animal Lab Training—Our Methodology

Laparoendoscopic single site surgery (LESS) is a new avenue in laparoscopic urology. The main advantage is the enhanced cosmetic benefits of single hidden scar. Lately many papers are being published on various procedures done by LESS. Like conventional laparoscopy, this approach is likely to be used more widely and hence exposure to this field is essential. However, formal training in this technique is not widely available. Expensive ports and nonavailability of endotrainer may be the factors deterring the training. We have modified the standard laparoscopic endotrainer with improvised ports, to make it suitable for single port laparoscopic training. For the animal lab training improvised ports and low cost instruments were used. Thus the overall cost of the training in LESS was reduced, and better confidence levels were achieved prior to human applications.

A Comparison of Continuous and Interrupted Suturing in Laparoscopic Pyeloplasty

Background: Laparoscopic pyeloplasty is one of the most common reconstructive procedures performed by urologists. Both continuous and interrupted sutures are being practiced for ureteropelvic anastomosis. The success rate and the complications associated with the suturing technique needs evaluation. We analyzed the results from of our patients who underwent laparoscopic pyeloplasty using both techniques. Objective: To review the outcome differences among patients undergoing laparoscopic pyeloplasty regarding suturing technique. Materials and Methods: All patients who underwent laparoscopic, transperitoneal dismembered pyeloplasty of the primary pelviureteric obstruction were analyzed. The primary outcome was successful pyeloplasty, as assessed by the resolution of symptoms and T½ <10 minutes. The secondary outcomes were the complication rate and the operative parameters. The difference in the parameters was assessed by Student t test analysis. Results: Of the 107 patients we studied, 65 had interrupted suturing and 42 had continuous suturing. The success rate was not significantly different among the 2 groups. The mean suturing time, postoperative drainage volume, postoperative hospital stay, and total cost of the procedure were significantly less in the continuous suturing group. Conclusion: The continuous suturing technique is preferred over the interrupted suturing technique for laparoscopic pyeloplasty because the success rates are equal and the postoperative stay, suturing time, drain output, and cost of the procedure are better.

Early-Onset Port Site (Drain Site) Hernia in Pediatric Laparoscopy: A Case Series

INTRODUCTION Laparoscopic procedures for children with urological problems are common under the present conditions. Laparoscopic surgery is associated with complications such as port site hernia that are not associated with open surgery. Drain site hernia is one variety of port site hernia. SUBJECTS AND METHODS We did a retrospective analysis for the development of port site hernias among pediatric patients who underwent laparoscopic procedures. We also analyzed the various methods of prevention. RESULTS Among the 148 children who underwent laparoscopic procedures, 5 (3.4%) had a port site hernia in the early postoperative period. All of them were drain site hernias with early presentations, and the content was omentum. Three patients had reduction under sedation. Two patients needed laparoscopy: one for the reduction into the preperitoneal space and the other for the nonreducible hernia due to omental edema. All the patients had an uneventful recovery. CONCLUSIONS Port site hernia is an uncommon complication in children undergoing laparoscopy. The drain site is the predominant location of port site hernia. Sedation during drain removal and judicious use of drain may help to decrease such occurrences.

Laparoscopic Undiversion in a Child with Sacral Agenesis into Augmentation Cystoplasty

Laparoscopic undiversion with ileal augmentation cystoplasty appears to be a feasible and effective procedure in a child with sacral agenesis.

Laparoscopic Nephrectomy with Adrenalectomy for Synchronous Adrenal Myelolipoma and Renal Cell Carcinoma.

Introduction. Adrenal myelolipomas are uncommon nonfunctioning tumors of the adrenal. Synchronous renal cell carcinomas with adrenal myelolipomas are very rare. We present the case report of adrenal myelolipoma with synchronous RCC managed laparoscopically. Case Report. A 60-year-old old gentleman presented with incidental right upper polar mass with right adrenal mass. Metastatic work-up was negative. Laparoscopic radical nephrectomy with adrenalectomy was done under general anesthesia. The biopsy report was right kidney clear cell adenocarcinoma (T1b) with right adrenal myelolipoma. Conclusion. This is the first case report of laparoscopic adrenalectomy with nephrectomy for ipsilateral synchronous renal cell carcinoma with adrenal myelolipoma.

Status of single nucleotide polymorphism of matrix gla protein gene (rs4236) in Nephrolithiasis: A preliminary study in indian population

Background: Urine is a supersaturated solution with solutes in very high concentration. Matrix gla protein (MGP) is one of the proteins involved in inhibition of extracellular calcification. Among the various polymorphisms studied, polymorphism of SNP rs4236 in the MGP gene is found to have association with nephrolithiasis. We evaluated the significance of SNP rs4236 polymorphism in nephrolithiasis among the Indian population. Materials and Methods: The study was conducted in 2013 and 2014 among fifty participants. Twenty-five of them were patients with documented symptomatic stone disease and the 25 controls had no history of stone disease and ultrasonogram was normal. Serum creatinine was estimated in all patients. DNA was isolated from the blood sample and amplified by polymerase chain reaction using defined primers. Single strand conformational polymorphism was done to identify abnormal bands and the same was sequenced. Results: The patients and controls were matched in age and sex. The serum creatinine levels were similar in both groups. The predominant change in SNP rs4236 in patients was a G to A nucleotide change, resulting in AA homozygous genotype. This was found in 60% of patients. The rest (40%) of patients and all (100%) controls had heterozygous AG genotype. This corresponds to a stone disease with an odds ratio (OR) of 75 (P < 0.003). Conclusion: This first study in Indian population shows that genotype AA polymorphism of SNP rs4236 of MGP gene was found to be significant risk factor for renal stone disease. Studies with larger sample size may be needed to confirm this finding and elucidate the exact OR.

Robot Assisted Radical Cystectomy with Intracorporeal Ileal Conduit

Radical cystectomy is one of the most technically demanding and morbid urological procedures. Robot assisted radical cystectomy (RARC) is now increasingly being preferred over the open approach in institutions where robotic surgical systems are available [1]. A robot assisted approach to radical cystectomy may be better accomplished than a pure laparoscopic approach and offers the advantage of a shorter learning curve, better vision and improved surgeon ergonomics [2]. This may prove beneficial in performing complex steps in the procedure such as extended lymphadenectomy, control of dorsal venous complex and urinary diversion. While the jury is still not out on the best method to perform urinary diversion during RARC (extracorporeal versus intracorporeal), some preliminary level 3 data indicate that an intracorporeal diversion may hasten recovery and decrease GI and infectious complications as compared to an extracorporeal technique [3]. The downside is the increased operating time, technical difficulty and learning curve involved in performing an intracorporeal diversion [1]. However, with growing experience, standardization of technique and evolution of structured training programs, intracorporeal urinary diversion is rapidly being adopted at centers of excellence around the world and is likely to gain further acceptability in the years to come.

Robot Assisted Renal Transplantation

Minimally invasive approach in the field of renal transplantation has largely been restricted to laparoscopic donor nephrectomy. Wound related complications do occur in recipients and may compromise graft outcome [1]. Laparoscopic renal transplantation has not been taken up except in a very few centers. The inherent difficulty of laparoscopic vascular suturing, risk of increasing warm and cold ischemia, necessity of incision to place the graft and air tight closure prior to commencing anastomosis are the reasons behind it [2]. We describe our robot assisted approach side stepping most of these drawbacks, with results equivalent to open surgery, and benefits of minimally invasive surgery to the patients.

Laparoscopy Assisted Ileocystoplasty

Laparoscopy assisted ileocystoplasty is a hybrid of open and laparoscopic approach. It gives the benefit of both minimally invasive approach (small incision) and open approach (less time consuming). Patient satisfaction is also better than open approach [1–5].

Laparoscopy Assisted Ileocystoplasy with Mitrofanoff Procedure (Yang Monti Technique)

In patients needing bladder augmentation, ileocystoplasty can be combined with catheterisable channel creation. In such cases, Yang-Monti tube can be constructed as a catheterisable channel. In laparoscopy assisted approach, bowel is brought out through a 5 cm subumbilcal incision and bowel segment isolated. This 15–20 cm segment is used for both creation of Yang Monti tube and ileal patch for augmentation. Initially, submucosal plane is created in the right anterolateral aspect of the bladder and tunneled anastomosis is done with the Yang-Monti tube, similar to ureteric reimplantation. Cystotomy for augmentation is done in a slightly oblique angulation to avoid disturbing the Monti tube. The rest of the augmentation is similar to the classical ileocystoplasty. Suprapubic catheter is usually placed, if both procedures are combined.