LAPAROENDOSCOPIC SINGLE-SITE PYELOLITHOTOMY (LESS-P) IN A PEDIATRIC PATIENT
CUA Online Library. WEHBI E. 06/22/13; 31442; UP-63
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Abstract
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Laparoendoscopic Single-Site Pyelolithotomy (LESS-P) in a Pediatric Patient
Elias Wehbi*, Niki Kanaroglou, Walid Farhat, Toronto, Canada
INTRODUCTION:
The preferred treatment for patients with a large stone burden is percutaneous nephrolithotomy (PCNL). Though it offers excellent stone clearance rates, access and treatment can be challenging, with considerable potential morbidity. In the modern era of routine minimally invasive surgery, we offer a novel, endourologic approach for patients with significant nephrolithiasis who may otherwise be offered only PCNL or an open procedure. LESS is an emerging surgical approach with limited data. To our knowledge, a pyelolithotomy using LESS has not been described in the literature.
BACKGROUND:
In the accompanying video, we present this novel surgical technique in a child with cystinuria, recurrent stones and previous complicated contralateral PCNL. Based on our larger initial experience with LESS in children, we use a variety of access devices and working instruments. Here we use a SILS-port access device (Covidien®) with articulating instruments (graspers, cauterizing L-hook) and articulating camera (Olympus®). We feel these instruments offer improved ergonomics and provide higher degrees of freedom.
SURGICAL TECHNIQUE:
A Double J stent is initially placed and the bladder filled to distend the renal pelvis. The patient is placed in mild flank and a 1.5 cm skin incision is used with a 2.5 cm fascial incision to accommodate the single port device. Optimal positioning of operating table, viewing screens and surgical team is essential for LESS. The camera and instruments are best triangulated in the access port device, with the working instruments on the same horizontal plane and of different lengths, and the camera angled to limit instrument collision. We favor a transmenteric approach when possible, to minimize mobilization of bowel. Unlike LESS pyeloplasty, minimal dissection is needed to expose the pelvis for eventual mini-pyelotomy and stone extraction. A hitch stitch is used to stabilize the pelvis and another is used to lift the mesenteric vessels to improve visualization and facilitate incision of the pelvis. The stones are removed and the pelvis is re-approximated. We use a standard approach to facilitate knot-tying during LESS with a straight needle driver and articulating grasper. The pelvis is closed around a stent and the stones are placed in a bag for removal.
CONCLUSIONS:
LESS-P is a novel approach for the treatment of extensive nephrolithiasis and it supplements current surgical options. For experienced laparoscopists, it can be less morbid than traditional alternatives. It should be considered whenever PCNL is not feasible, scarless surgery is desired, or when pyeloplasty is also indicated.
Source of Funding: none
Elias Wehbi*, Niki Kanaroglou, Walid Farhat, Toronto, Canada
INTRODUCTION:
The preferred treatment for patients with a large stone burden is percutaneous nephrolithotomy (PCNL). Though it offers excellent stone clearance rates, access and treatment can be challenging, with considerable potential morbidity. In the modern era of routine minimally invasive surgery, we offer a novel, endourologic approach for patients with significant nephrolithiasis who may otherwise be offered only PCNL or an open procedure. LESS is an emerging surgical approach with limited data. To our knowledge, a pyelolithotomy using LESS has not been described in the literature.
BACKGROUND:
In the accompanying video, we present this novel surgical technique in a child with cystinuria, recurrent stones and previous complicated contralateral PCNL. Based on our larger initial experience with LESS in children, we use a variety of access devices and working instruments. Here we use a SILS-port access device (Covidien®) with articulating instruments (graspers, cauterizing L-hook) and articulating camera (Olympus®). We feel these instruments offer improved ergonomics and provide higher degrees of freedom.
SURGICAL TECHNIQUE:
A Double J stent is initially placed and the bladder filled to distend the renal pelvis. The patient is placed in mild flank and a 1.5 cm skin incision is used with a 2.5 cm fascial incision to accommodate the single port device. Optimal positioning of operating table, viewing screens and surgical team is essential for LESS. The camera and instruments are best triangulated in the access port device, with the working instruments on the same horizontal plane and of different lengths, and the camera angled to limit instrument collision. We favor a transmenteric approach when possible, to minimize mobilization of bowel. Unlike LESS pyeloplasty, minimal dissection is needed to expose the pelvis for eventual mini-pyelotomy and stone extraction. A hitch stitch is used to stabilize the pelvis and another is used to lift the mesenteric vessels to improve visualization and facilitate incision of the pelvis. The stones are removed and the pelvis is re-approximated. We use a standard approach to facilitate knot-tying during LESS with a straight needle driver and articulating grasper. The pelvis is closed around a stent and the stones are placed in a bag for removal.
CONCLUSIONS:
LESS-P is a novel approach for the treatment of extensive nephrolithiasis and it supplements current surgical options. For experienced laparoscopists, it can be less morbid than traditional alternatives. It should be considered whenever PCNL is not feasible, scarless surgery is desired, or when pyeloplasty is also indicated.
Source of Funding: none
Laparoendoscopic Single-Site Pyelolithotomy (LESS-P) in a Pediatric Patient
Elias Wehbi*, Niki Kanaroglou, Walid Farhat, Toronto, Canada
INTRODUCTION:
The preferred treatment for patients with a large stone burden is percutaneous nephrolithotomy (PCNL). Though it offers excellent stone clearance rates, access and treatment can be challenging, with considerable potential morbidity. In the modern era of routine minimally invasive surgery, we offer a novel, endourologic approach for patients with significant nephrolithiasis who may otherwise be offered only PCNL or an open procedure. LESS is an emerging surgical approach with limited data. To our knowledge, a pyelolithotomy using LESS has not been described in the literature.
BACKGROUND:
In the accompanying video, we present this novel surgical technique in a child with cystinuria, recurrent stones and previous complicated contralateral PCNL. Based on our larger initial experience with LESS in children, we use a variety of access devices and working instruments. Here we use a SILS-port access device (Covidien®) with articulating instruments (graspers, cauterizing L-hook) and articulating camera (Olympus®). We feel these instruments offer improved ergonomics and provide higher degrees of freedom.
SURGICAL TECHNIQUE:
A Double J stent is initially placed and the bladder filled to distend the renal pelvis. The patient is placed in mild flank and a 1.5 cm skin incision is used with a 2.5 cm fascial incision to accommodate the single port device. Optimal positioning of operating table, viewing screens and surgical team is essential for LESS. The camera and instruments are best triangulated in the access port device, with the working instruments on the same horizontal plane and of different lengths, and the camera angled to limit instrument collision. We favor a transmenteric approach when possible, to minimize mobilization of bowel. Unlike LESS pyeloplasty, minimal dissection is needed to expose the pelvis for eventual mini-pyelotomy and stone extraction. A hitch stitch is used to stabilize the pelvis and another is used to lift the mesenteric vessels to improve visualization and facilitate incision of the pelvis. The stones are removed and the pelvis is re-approximated. We use a standard approach to facilitate knot-tying during LESS with a straight needle driver and articulating grasper. The pelvis is closed around a stent and the stones are placed in a bag for removal.
CONCLUSIONS:
LESS-P is a novel approach for the treatment of extensive nephrolithiasis and it supplements current surgical options. For experienced laparoscopists, it can be less morbid than traditional alternatives. It should be considered whenever PCNL is not feasible, scarless surgery is desired, or when pyeloplasty is also indicated.
Source of Funding: none
Elias Wehbi*, Niki Kanaroglou, Walid Farhat, Toronto, Canada
INTRODUCTION:
The preferred treatment for patients with a large stone burden is percutaneous nephrolithotomy (PCNL). Though it offers excellent stone clearance rates, access and treatment can be challenging, with considerable potential morbidity. In the modern era of routine minimally invasive surgery, we offer a novel, endourologic approach for patients with significant nephrolithiasis who may otherwise be offered only PCNL or an open procedure. LESS is an emerging surgical approach with limited data. To our knowledge, a pyelolithotomy using LESS has not been described in the literature.
BACKGROUND:
In the accompanying video, we present this novel surgical technique in a child with cystinuria, recurrent stones and previous complicated contralateral PCNL. Based on our larger initial experience with LESS in children, we use a variety of access devices and working instruments. Here we use a SILS-port access device (Covidien®) with articulating instruments (graspers, cauterizing L-hook) and articulating camera (Olympus®). We feel these instruments offer improved ergonomics and provide higher degrees of freedom.
SURGICAL TECHNIQUE:
A Double J stent is initially placed and the bladder filled to distend the renal pelvis. The patient is placed in mild flank and a 1.5 cm skin incision is used with a 2.5 cm fascial incision to accommodate the single port device. Optimal positioning of operating table, viewing screens and surgical team is essential for LESS. The camera and instruments are best triangulated in the access port device, with the working instruments on the same horizontal plane and of different lengths, and the camera angled to limit instrument collision. We favor a transmenteric approach when possible, to minimize mobilization of bowel. Unlike LESS pyeloplasty, minimal dissection is needed to expose the pelvis for eventual mini-pyelotomy and stone extraction. A hitch stitch is used to stabilize the pelvis and another is used to lift the mesenteric vessels to improve visualization and facilitate incision of the pelvis. The stones are removed and the pelvis is re-approximated. We use a standard approach to facilitate knot-tying during LESS with a straight needle driver and articulating grasper. The pelvis is closed around a stent and the stones are placed in a bag for removal.
CONCLUSIONS:
LESS-P is a novel approach for the treatment of extensive nephrolithiasis and it supplements current surgical options. For experienced laparoscopists, it can be less morbid than traditional alternatives. It should be considered whenever PCNL is not feasible, scarless surgery is desired, or when pyeloplasty is also indicated.
Source of Funding: none
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