Retroperitoneoscopic Simple Nondismembered Pyeloplasty with Da Vinci Si Assistance to Prevent Alignment Shift.

Aims: Retroperitoneoscopic simple nondismembered pyeloplasty (SNDP) with da Vinci Si assistance was developed because of a possible risk for alignment shift after retroperitoneoscopic diamond-shaped bypass pyeloplasty (Diamond-Bypass; DP). Outcomes of SNDP and DP were compared. Materials and Methods: For SNDP, a small longitudinal incision is made on the border of the dilated pelvis and narrowed ureter at the ureteropelvic junction (UPJ). Extending this incision toward the pelvis allows identification of mucosa while maintaining the integrity of surrounding tissues that are so thin and fragile that they will not influence lumen alignment. Data for DP were obtained from a previously published article. Results: For SNDP (n = 3), mean age at surgery was 2.67 years (range: 1-4), mean operative time was 176 minutes. Mean postoperative Society of Fetal Urology (SFU) grades for hydronephrosis were 1.2, 0.7, and 0.6, 1, 2, and 3 months after stent removal, respectively. Postoperative diethylenetriaminepentaacetic acid (DTPA) was normal (n = 3). For DP (n = 5) mean age at surgery was 4.3 years (range: 1-14), mean operative time was 189 minutes. Mean postoperative SFU grades were 2.8, 2.2, and 1.6, respectively. Postoperative DTPA was normal (n = 4) and delayed (n = 1). All SNDP and DP were asymptomatic by 3 months after stent removal. Conclusion: Both SNDP and DP have favorable outcomes. If the UPJ is located at the lowest end of the renal pelvis, SNDP may improve hydronephrosis more quickly.

Comparative assessment of fully laparoscopic Duhamel-Z with minimal rectorectal dissection vs. laparoscopy-assisted Duhamel-Z with blunt manual rectorectal dissection for total colonic aganglionosis.

Aims: Early postoperative outcome (EPO) was compared between fully laparoscopic Duhamel-Z (F-Dz) and laparoscopy-assisted Duhamel-Z (A-Dz) anastomoses performed for total colonic aganglionosis (TCA). Methods: EPO was assessed quarterly for the first year after F-Dz/A-Dz using a continence evaluation score (CES) based on stool frequency (motions/day) and stool consistency (0 = liquid, 1 = soft, 2 = formed), presence of anal erosion (0 = severe, 1 = moderate, 2 = mild), and incidence of enterocolitis.Surgical technique involved taking the ileostomy down, dissecting the colon laparoscopically, and preparing the pull-through ileum through the stoma wound. In F-Dz (n = 3), a working port (SILS trocar) was inserted, and laparoscopic retrorectal dissection with forceps used to create a retrorectal tunnel from the peritoneal reflection extending downward as narrow as possible along the posterior wall of the rectum to prevent lateral nerve injury and preserve vascularity. After completing the tunnel, the ileum was pulled-through from an incision on the anorectal line and a Z-shaped ileorectal side-to-side anastomosis performed without a blind pouch. In A-Dz (n = 11), the retrorectal pull-through route was created through a Pfannenstiel incision using blunt manual (finger) dissection along the anterior surface of the sacrum. Results: Subject backgrounds were similar. Mean quarterly data were: frequency (F-Dz: 4.67, 4.67, 4.67, 3.33) vs. (A-Dz: 7.27, 7.09, 6.18, 5.36) p < .05; consistency (F-Dz: 0.33, 0.67, 0.67, 0.67) vs. (A-Dz: 0.27, 0.45, 0.70, 0.73) p = ns; anal erosion (F-Dz: 0.33, 0.33, 0.33, 0.67) vs. (A-Dz: 0.18, 0.36, 0.45, 0.64) p = ns; and enterocolitis (F-Dz: 1 episode in 1/3 cases or 33.3%) vs. (A-Dz: 7 episodes in 6/11 cases or 54.5%) p = ns. Conclusions: Overall, EPO after F-Dz was better than after A-Dz.

Remote cadaveric minimally invasive surgical training.

Objective: The aim of the study is to discuss the efficacy of live vs. remote cadaver surgical training (CST) for minimally invasive surgery (MIS). Methods: A cohort of 30 interns in their first and second years of training were divided into three groups: live observers (n = 12), live participants (n = 6), and remote observers: (n = 12). The interns had the opportunity to either observe or actively participate in two different surgical procedures, namely, laparoscopic lower anterior resection, performed by a colorectal surgical team, and laparoscopic fundoplication, performed by a pediatric surgical team. The procedures were conducted either at a base center or at a remote center affiliated with the institute. Some of the interns interacted directly with the surgical teams at the base center, and others interacted indirectly with the surgical teams from the remote center. All interns were administered questionnaires before and after completion of the CST in order to assess their understanding of various aspects related to the operating room layout/instruments (called "design"), accessing the surgical field (called "field"), understanding of anatomic relations (called "anatomy"), their skill of dissection (called "dissection"), ability to resolve procedural/technical problems (called "troubleshooting"), and their skill in planning surgery (called "planning") according to their confidence to operate using the following scale: 1 = not confident to operate independently; 4 = confident to operate with a more senior trainee; 7 = confident to operate with a peer; and 10 = confident to operate with a less experienced trainee. A p < 0.05 was considered statistically significant. Results: All scores improved after CST at both the base and remote centers. The following significant increases were observed: for remote observers: "field" (2.67→4.92; p < .01), "anatomy" (3.58→5.75; p < .01), "dissection" (3.08→4.33; p = .01), and "planning" (3.08→4.33; p < .01); for live observers: "design" (3.75→6.17; p < .01), "field" (2.83→5.17; p < .01), "anatomy" (3.67→5.58; p < .01), "dissection" (3.17→4.58; p < .01), "troubleshooting" (2.33→3.67; p < .01), and "planning" (2.92→4.25; p < .01); and for live participants: "design" (3.83→6.33; p = .02), "field" (2.83→6.83; p < .01), "anatomy" (3.67→5.67; p < .01), "dissection" (2.83→6.17; p < .01), "troubleshooting" (2.17→4.17; p < .01), and "planning" (2.83→4.67; p < .01). Understanding of "design" improved significantly after CST in live observers compared with remote observers (p < .01). Understanding of "field and "dissection" improved significantly after CST in live participants compared with live observers (p = .01, p = .03, respectively). Out of the 12 remote observers, 10 participants (83.3%) reported that interacting with surgical teams was easy because they were not on-site. Conclusions: Although all the responses were subjective and the respondents were aware that observation was inferior to hands-on experience, the results from both centers were equivalent, suggesting that remote learning could potentially be viable when resources are limited.

Robot-Assisted Retroperitoneoscopic Diamond Bypass Pyeloplasty.

AIM: Robot (da Vinci Si; Intuitive Surgical, Sunnyvale, CA) assisted retroperitoneoscopic diamond bypass pyeloplasty (R-RDBP) performed for ureteropelvic junction (UPJ) obstruction (n = 5) is presented. METHODS: Patients were placed affected side up and the retroperitoneal space accessed conventionally using 3-4 trocars. The diamond-shaped anastomosis involved incising the lowest part of the renal pelvis 12-15 mm transversely and the ureter distal to the obstruction 10-12 mm longitudinally. The first two sutures were placed retroperitoneoscopically; one from the mid-caudal line of the renal pelvis to the apex of the ureteric incision (the apex of the diamond) and the other from the corner of the incision in the renal pelvis to halfway along the ureteric incision. Trocars were replaced and the robot system docked. The first robot suture was placed between these two sutures, and the anastomosis completed by suturing from posterior to ventral applying minimal tension to keep the anastomosis close to the renal pelvis. All sutures were interrupted absorbable 5-0 monofilament. RESULTS: Mean age at R-RDBP was 4.3 (range: 1-14) years old. Height/weight were average. Preoperative Society for Fetal Urology (SFU) grading was 4.0 in all cases. All repairs were primary and progressed smoothly without perioperative complications; 3/5 had improved appetite postoperatively. Mean SFU grades 1-3 months postoperatively were 2.8, 2.2, and 1.6, respectively. Diuretic renography that was obstructive in all cases preoperatively was normal in four and delayed in one case, postoperatively. CONCLUSION: R-RDBP prevented rotation/kinking of the ureter, enhanced precision of suturing, and maximized the diameter at the anastomosis, facilitating smooth urine flow. LEVEL OF EVIDENCE: LEVEL IV.