Manickam Ramalingam

Modified Technique of Laparoscopy-Assisted Surgeries (Transportal)

BACKGROUND AND PURPOSE We present the role of the transportal technique of laparoscopy-assisted surgeries.This report highlights the advantages of transportal technique over pure laparoscopic surgeries and laparoscopy-assisted surgeries. PATIENTS AND METHODS In the last 3 years, we have adopted this approach for six patients during various procedures. This report highlights modified extracorporeal (transportal) technique, namely, ileal isolation, restoration of ileal continuity in ileal conduit and ileal ureter; ileal isolation, restoration of ileal continuity detubularization of the loop in ileocystoplasty; and ureteral tailoring in the megaureter before ureteral reimplantation. This technique was performed by transportal exteriorization of the bowel through the 12- or 15- or 20-mm port followed by the conventional technique of hand-sewn anastomosis. The bowel and ureter are restored to the abdominal cavity through the same port once the extracorporeal part is completed. RESULTS There was no significant intraoperative or postoperative morbidity or mortality. The transportal technique without a formal incision reduces operative time; is less demanding; and avoids an abdominal incision,as in the laparoscopy-assisted technique. CONCLUSION The transportal technique of laparoscopy-assisted surgery achieves all the advantages of pure laparoscopic surgery without a formal incision, as in laparoscopy-assisted surgery. Hence, it is a less morbid, quicker, and cost-effective method.

Laparoscopic Boari Flap Repair: Report of 3 Cases

PURPOSE Boari flap reimplantation is one of the options for ureteric reimplantation when the diseased ureteric segment is long. Open Boari flap reimplantation is well established. In this paper, we describe laparoscopic Boari flap reimplantation in 3 patients. MATERIALS AND METHODS Since May 2004, 3 patients had a successful laparoscopic Boari flap ureteric reimplantation. Preoperative intravenous urogram and retrograde pyelogram confirmed the length and site of the obstruction. The first patient was a 16-year-old boy with primary obstructive megaureter, with the adynamic segment extending from just below the sacro iliac joint. The second was a middle-aged diabetic lady with a long lower ureteric stricture. The third was a ureteric injury that occurred following a laparoscopic ovarian cystectomy. RESULTS The mean operative time was around 320 minutes. There were no intra- or postoperative complications. All the patients recovered well and are being followed up clinically and radiologically. CONCLUSION Laparoscopic Boari flap reimplantation is a challenging procedure. With increasing technical skill and confidence, one can attempt the procedure with the obvious advantage to the patient.

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.

Transmesocolic Approach to Laparoscopic Pyeloplasty: Our 8-Year Experience

Open pyeloplasty is the gold standard in the treatment of congenital ureteropelvic junction obstruction. Several reports have shown that laparoscopic pyeloplasty produces comparable results. In this paper, we report a retrospective study of the transmesocolic approach to the left ureteropelvic junction obstruction in 26 patients. As colon mobilization is avoided, the field remains fairly clear. This direct approach also saves time and is least invasive. One patient was lost for follow-up, and 1 patient is awaiting a renogram. Among the remaining 24 patients, 22 patients had improved drainage (IVU or isotope renogram), and 2 of the patients had stable renal function.

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.

Laparoscopy-assisted ileal conduit in sacral agenesis.

Sacral agenesis is a rare congenital anomaly. The neurologic deficits are usually static. However, there are reports of progressive neurologic deterioration. They have neurogenic bladder, which usually present late and managed according to the presenting urodynamic pattern. In this paper, we report the urologic management in a 4-and-half-year-old boy with sacral agenesis. He presented with constant dribbling owing to gross instability with a small-capacity bladder. He also had bilateral ureteric obstruction (i.e., stricture at the level of bilateral ureteric reimplantation, which was done at the age of 1 year for high-grade reflux). He was not compliant with intermittent self-catheterization. Various options were discussed with the parents, but they preferred an ileal conduit (which could take care of the leak and avoid complex reconstructive surgery), with an option of reconstruction later. Laparoscopic ileal conduit was performed, with the uretero ileal anastomosis and restoration of ileal continuity performed extracorporeally. Extracorporeal part of the procedure was done without any additional incision (by bringing the ureters and ileal segment outside through the 12-mm port and then pushing it back inside after the completion of the anastomosis). We present this case report for the less-morbid management of a complicated urologic problem.

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.

Modified device-free HAL: an innovative cost-reductive approach.

Hand-assisted laparoscopy (HAL) has been in vogue since 1994. The major advantages are tactile sensation, quicker dissection, and easy removal of specimen. These advantages could not be availed in developing countries due to the cost of the available HAL devices. This has initiated the use of HAL without devices in our unit. Instead of a device, a double glove with a sponge between the inner and outer glove at the wrist acted as an obturating cuff. A muscle-splitting incision in the iliac fossa helped in minimizing the air leak. In this article, we report our experience in nephrectomy and nephroureterectomy.

A Novel Technique of Cystolithotripsy for Large Vesical Calculus in Children

Large bladder calculi in children have always been a challenge for the minimally invasive surgeon. We describe a novel technique in which a suprapubic laparoscopic grasper is used to stabilize and remove large fragments of the stone, disintegrated transurethrally. This procedure minimizes injury to the delicate urethra and bladder mucosa.