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Laparoscopy and Robotic Surgery in Urology

• Laparoscopy in Urology
• Laparoscopy in Urology: surgical technique
• Laparoscopy in Urology: complications

Surgical Technique of Laparoscopy and Robotic Surgery

Preoperative Preparations:

• To improve the intraabdominal space, a clear liquid diet should the prescribed for the preoperative day.
• Enema the night before surgery.
• Perioperative placement of an indwelling catheter and gastric tube.
• Perioperative antibiotic prophylaxis if risk factors for surgical site infections are present or if the urinary tract is planned to be opened.

Patient Positioning for Renal Laparoscopic Procedures:

The patient is positioned in a lateral decubitus position at an angle of 45 degrees and with a mild lumbar hyperextension. A vacuum mattress enables a secure fixation of the patient, even if the operation table has to be tilted.

Patient Positioning for Pelvic Laparoscopic Procedures:

Supine position with a mild lumbar hyperextension, the arms next to the body. A vacuum mattress enables a secure fixation of the patient, even if a steep Trendelenburg positioning is needed.

Establishment of the Pneumoperitoneum:

Carbon dioxide (CO₂)is used for the distension of the abdominal cavity, the working pressure is usually between 12–15 mmHg. The establishment of the pneumoperitoneum can be done via a closed approach (Veress needle) or via an open approach, which is more secure and recommended (Hasson et al., 2000).

Open establishment of the pneumoperitoneum:

A 2 cm long incision is done next to the umbilicus. Incise the ventral fascia of the rectus sheath, use two small Langenbeck retractors for exposure. Place stay sutures at the corners of the incision if a Hasson trocar is used. Bluntly split of the rectus abdominis muscle. Incise the transversalis fascia and the peritoneum. Palpate for adherent bowel loops before placing the optic trokar (Hasson trocar or trocar with balloon fixation). Connect the insufflator to the trocar using a working pressure of 12 mmHg initially with maximum gas flow. The filling of the abdominal cavity through the trocar is very fast and compensates a little for the longer dissection time of the open technique.

Closed establishment of the pneumoperitoneum:

A 1 cm long incision is done next to the umbilicus. The abdominal wall is lifted and the Veress needle is advanced through the abdominal wall layers into the peritoneal cavity. The Veress needle is a spring loaded device, if the needle enters the peritoneal cavity, the sharp needle is hided by the dull inner stylet protecting the bowel. This is audible by a clicking sound. The correct position of Veress needle has to be checked using a 20 ml syringe which is filled with 10 ml of saline:

• Aspiration: neither fluid (blood, bile or stool) or air can be aspirated.
• Injection: 10 ml of saline can be injected without any resistance, which then may not be aspirated afterward.
• The needle may be advanced and rotated without significant resistance.

The insufflator is connected to fill the abdominal cavity with CO₂ with a working pressure of 12 mmHg: the gas flow should be above 1 l/min. An increase of the working pressure or a low flow rate suggest an incorrect position of the Veress needle. After complete filling of the abdominal cavity, this is indicated by a cessation of gas flow and the working pressure of 12 mmHg is reached. The optic trocar is gently advanced into the gas-filled peritoneal cavity. Modern systems allow advancement of the first trocar with optical control through the laparoscope.

Laparoscopy:

A systematic inspection of the entire abdominal cavity is done.

Working trocars:

The working trocars are placed under direct vision, the positions depend on the planned operation. The trocars are ideally positioned, if the instruments of right and left hand meet in the operative field at a right angle.

Laparoscopic Instruments:

In principle, laparoscopic instruments consist of a handle (locked or not locked), an isolated instrument shaft (normal length 33–36 cm) and the jaw insert, which is connected through the instrument shaft to the handle.

Scissors:

Most often a pair of scissors with curved branches are used (Metzenbaum scissors). It is possible to connect the monopolar current for simultaneous coagulation. Scissors with bipolar coagulation are also available.

Ultrasonic scalpel:

The ultrasound scalpel is cutting instrument and an alternative to the conventional scissors. The instruments uses high frequency vibration of the dull scalpel, which cuts and coagulates at the same time. The ultrasonic scalpel (harmonic scalpel) causes less lateral thermal damage than monopolar electrosurgery. The duration of laparoscopic surgeries can be reduced by using an harmonic scalpel, as cutting and coagulation are performed simultaneously.

Forceps and graspers:

There is a wide range of products with following characteristics in various combinations: sharp or blunt, different length, different tips, different angles of the tips, with or without bipolar or monopolar coagulation. Very suitable for normal preparation is a bipolar blunt forceps with good gripping properties. While using a cutting instrument with the right hand, the bipolar forceps enables grasping and coagulation with the left hand without changing the instrument.

Various important laparoscopic instruments:

Suction and irrigation devices, needle holders, different clip applicators, retrieval bags, retractors, linear cutting staplers.

Instruments for robotic surgery:

All important instruments mentioned above such as graspers, scissors, retractors and needle holders are also available for the robotic-assisted technology. The instruments have multiple joints and allow more degrees of freedom, similar to the mobility of a hand. Special tools such as linear cutting staplers are introduced into the abdominal cavity via separate trocars comparable to conventional laparoscopy and operated by the surgeon's assistant.

Hemostasis in Laparoscopic Surgery:

A good view on the operative field is achieved because bleeding is minimized by various techniques during laparoscopy. Minor venous bleeding is limited by the working pressure, which may be raised up to 20 mmHg, if significant venous bleeding is encountered to enable targeted coagulation. Hemostasis is performed depending on the severity with electrocoagulation, clips or vascular sutures. Arterial bleeding is not limited by the working pressure. If major arterial bleeding cannot be controlled, laparotomy for hemostasis is necessary and should not be postponed.

Electrocoagulation:

Bipolar electrocoagulation is safer and should be used exclusively. Monopolar electrocoagulation harbours incalculable risks due to instrument defects and fault currents.

Application of clips:

Standard titanium clips are used, which are also available in multi-fire clip appliers for easy use without changing the instrument. Polymer clips with locking mechanism are available for larger vessels, which enable the transection of large vessels such as the renal vein or artery.

Linear cutting stapler:

Linear cutting stapler are available for the transection of large vessels. The usage is considerably more expensive than suture liagation or polymer clips with locking mechanism.

Hemostats:

The use of hemostatic wound dressings or gels helps in hemostasis of larger surfaces, e.g., after partial nephrectomy.

References

  Deutsche Version: Operative Technik der Laparoskopie