Optimizing the technique of right laparoscopic adrenalectomy with a modified trocar arrangement and dynamic liver retraction: a comparative study with standard technique.

OBJECTIVES: Right Laparoscopic adrenalectomy (LA) is technically more challenging than left LA, because of the anatomical position of the right adrenal gland and vein. We modified the technique for right LA to optimize the procedure, and compared the operative outcome with standard technique. PATIENTS AND METHODS: The operative outcome of 13 cases of right adrenal mass treated with modified LA were compared retrospectively with 29 cases of standard right LA. For modified right LA, we used a 4-port transperitoneal laparoscopic approach that omitted the subxiphoid trocar (classically used for liver retraction), and instead, an assistant applied continuous, dynamic upward liver retraction in a plane perpendicular to the inferior vena cava (IVC). RESULTS: Modified Right LA was done in 13 patients (3 men, 23.1%), without difficulty and with excellent direct exposure of the upper and medial aspect of the adrenal gland and adrenal vein. Mean operative time was significantly shorter compared with standard technique (122.3 ± 20.1 vs. 165 ± 33.6 min; P < 0.0001) There were no bleeding complication and open conversion in modified technique which was promising compared with 2 bleeding complications in our experience with 29 cases of right LA using standard technique. CONCLUSION: Modified right LA with a 4-port approach and dynamic upward liver retraction in a plane perpendicular to IVC resulted in direct exposure of the upper and medial aspect of the adrenal gland and adrenal vein. This approach can be effective in challenging cases when the infrahepatic fossa is poorly exposed.

Laparoscopic nephrectomy for nonfunctioning kidneys is feasible after previous ipsilateral renal surgery: a prospective cohort trial.

PURPOSE: Previous renal surgery is a relative contraindication to laparoscopic nephrectomy because adhesion formation makes surgical dissection difficult. We determined whether previous surgery at the same anatomical site would affected the surgical outcome in patients who underwent transperitoneal laparoscopic nephrectomy. MATERIALS AND METHODS: During the study period 79 consecutive patients who underwent transperitoneal laparoscopic nephrectomy were evaluated prospectively. All patients had symptomatic nonfunctioning small or hydronephrotic kidneys. Patients were divided into 29 with and 50 without prior surgery at the same anatomical site. Previous surgery included open nephrolithotomy in 16 patients, percutaneous nephrolithotomy in 8, open and percutaneous nephrolithotomy in 3, pyelolithotomy in 1 and pyeloplasty in 1. RESULTS: Patients who underwent prior surgery were older than patients who did not (average age 46.6 vs 34.9 years, p=0.008). Other patient characteristics, including gender ratio, body mass index and side of surgery, did not differ significantly between the 2 groups. Mean operative time was longer in patients with previous surgery than in the other group (98.6 vs 62.3 minutes, p=0.03). Other operative data, including blood loss, intraoperative and postoperative complications, open conversion and hospital stay, were similar in the groups. One case per group was converted to open surgery due to difficult pedicle dissection. CONCLUSIONS: Transperitoneal laparoscopic nephrectomy in patients with a history of ipsilateral renal surgery can be done safely in timely fashion. Although mean operative time was longer, there was no significant increase in the operative complication rate in patients with prior surgery.

Laparoscopic nephrolithotomy in a patient with crossed fused renal ectopia.

BACKGROUND: A 32-year-old man was referred to a tertiary care center for stone management. The patient had initially presented to his primary physician 3 months earlier with right flank pain of 2 month's duration. Abdominopelvic ultrasonography and intravenous urography had revealed left-to-right crossed fused renal ectopia with a 25 mm opaque stone in the crossed kidney. The patient had received two sessions of extracorporeal shock wave lithotripsy, which had failed to remove the renal stone. INVESTIGATIONS: Noncontrast CT, blood tests (hemoglobin and creatinine levels), abdominopelvic ultrasonography and intravenous urography. DIAGNOSIS: Left-to-right crossed fused ectopia with a 25 mm opaque renal stone in the anomalous kidney. MANAGEMENT: The patient underwent laparoscopic nephrolithotomy to remove the renal stone. Intravenous urography and abdominopelvic ultrasonography 1 month after surgery confirmed that the patient was stone free and had functional renal units. The patient will be followed up every 3 months with abdominopelvic ultrasonography for early detection of stone recurrence.