Laparoscopic Urologic Surgery

Wide ranges of benign and malignant urologic conditions are treated using laparoscopic urologic surgery. Most commonly Pyeloplasty, Nephrectomy, Partial Nephrectomy, Radical prostatectomy and Radical Cystectomy are performed laparoscopically.

 

Standardized imaging procedures are of utmost importance. The decision for most of the surgical procedures depends mainly on the results of certain preoperative imagings. At times, affected organ size may be a hindrance to laparoscopic surgery. For example, if in kidneys, the renal tumors are very large then the space required for mobilization of the specimen is restricted. Similarly, if an adjacent organ is pathologically enlarged, then the surgical space is reduced which further restricts a surgeon to perform laparoscopic surgery.

It is the responsibility of the doctor to inform the patient about the possible operative risks involved with the surgery. The patient must be aware that certain conditions like fibrosis or adhesions that cannot be rectified through laparoscopic surgery and the surgeon might need to convert to an open surgery.

Although comparatively less blood loss is associated with laparoscopic approach, the surgeon makes sure that packed red blood cells are available prior to the surgery, whenever expected.

Patient Positioning

The patient’s position depends on the selected surgical procedure. A transperitoneal approach is used for any adrenal or renal dissection. In this approach, the patient is placed in a modified lateral position permitting easy access to the abdominal cavity. In retroperitoneoscopic approach, the patient is in a stiff lateral position. The decision of going for retroperitoneal or transperitoneal approach totally depends on the surgeon. Pelvis procedures such as prostatectomy require a specialized position called as Trendelenburg, where the leg is in an elevated position and head is down.

Technique Approach

1. Transperitoneal approach: A pneumoperitoneum is established prior to a laparoscopic procedure. Pneumoperitoneum means the presence of gas in the peritoneal cavity. Usually, CO2 is used for insufflation in laparoscopy. Two techniques are used to achieve pneumoperitoneum; open approach, and Verress needle. In Verress technique, the needle is inserted at the cranial perimeter of the umbilicus. Special care needs to be taken in order to avoid any damage to bowels or any major blood vessels. The open approach is implemented to shun away from the possible complications associated with Verress technique. In open approach, a slightly larger incision is made for the surgery. The incision size is of not much importance as the same incision can be used for post placement and/or specimen retrieval.
2. Extraperitoneal approach: In extraperitoneal approach, ample space is not available as compared to intraperitoneal approach and therefore space is artificially created. A small incision is made at the 12th rib in the mid-axillary line; then mostly a balloon dilatation is performed for making room for the surgery. The working space is created between the psoas muscle and the posterior layer of Gerota’s fascia. Adequate working space is required for introduction of trocars.
3. Port placement: Ports acts as a portal for the placement of other instruments during the surgery. Once the working space is established then only it is safe to place the Ports. Post laparoscope insertion, the surgery space is carefully inspected for any adhesions and abnormalities. Further, additional Ports are introduced under direct vision of the surgeon. Special care is taken while placing the Port in the cavity to avoid any injury to the sutures.

Two things are kept in mind before the surgery, one is excellent visualization, and the other one is the duplication of open surgery principles. Similar to an open surgery, laparoscopic devices are composed of scissors, dissectors, vascular staplers, graspers, scalpels and more. The only difference is that they are simply elongated. Whenever, laparoscopic procedures require specimen retrieval, it is achieved using a specimen retrieval bag. It is inserted through the port and then unfolded in the surgical space. The specimen is entrapped in the bag, and then it is closed for extraction. Once the specimen is extracted, the laparoscope is re-introduced to verify the presence of bleeding. In order to control any sort of unexpected bleeding, the ports are removed under direct vision. The pneumoperitoneum is deflated before the removal of the last trocar. These small incisions are then closed similarly as performed in an open surgery.

Post-operative complications are usually very less in expert hands. Patients should take note of any abnormal sensation post laparoscopic surgery. If bowels are injured thermally or mechanically, then symptoms will generally occur in several days. In case of any bladder lesions caused during the surgery, the patient may develop urinary ascites. Laparoscopic surgery is known for its limited post-operative pain. If pain persists, the patient should consult the doctor as incomplete deflation may cause some pain in the shoulder girdle.

The most significant advantages of laparoscopic surgery include:

• Reduced Bleeding: This reduces the chances of requiring a blood transfusion.
• Smaller Incision: This not only reduces pain but also shortens recovery time, resulting in less post-surgery scarring and surgery marks.
• Less Pain: Because it is a minimally invasive surgery, patients experience minimal pain.
• Less Hospital Stay: Although the surgery time is usually slightly longer, the hospital stay is comparatively less in this surgery. In many cases, the patient is discharged the same day.
• Reduced Risk of Catching Infections: The surgery decreases the exposure of internal organs to external contaminants thereby reducing the risk of catching infections.

As mentioned earlier, laparoscopic urologic surgery is well known for its minimal post-operative pain. It is one of the most important aspects in the field of surgery as patients are more concerned about post-operative care than the surgery itself. Hence laparoscopic urologic surgery provides the perfect attributes for patients. It nullifies the use of epidural catheters or controlled analgesics. Oral nutrition is started the very next day. A single shot of antibiotic prophylaxis is administered prior to the surgery which is not required later. Routine lab tests are performed on the same evening and the next morning which helps the doctor to monitor the patient, if required.