Title: Laparoscopic Pyeloplasty
1Laparoscopic Pyeloplasty
- Jaime Landman, MD
- Assistant Professor of Urology
- Columbia University
- Department of Urology
2Patient Selection
- Indications
- Symptomatic UPJ obstruction
- Asymptomatic UPJ obstruction with documented
deterioration of renal function - Contraindications
- Intra-renal pelvis
- Multiple prior abdominal surgeries (relative)
3Equipment Required
- Veress needle (14G)
- Knife with 15 blade
- Dilating trocars 12 mm (1), 5 mm (2 or 3)
- 10 mm laparoscope with 30? Lens
- 5 mm laparoscope with 0? Lens
- Harmonic Shears-5 mm curved Ethicon
- Macrobipolar grasper Aesculap
- Endoshears with disposable tip (Microline)
- 5 mm suction irrigation device
- Endoholder (self-retaining retractor) Codman
- Padron Endoscopic Retractor (PEER) J Jamner
- Suture 4-Vicryl on an SH needle
- Lapra-Ty clip applier and clips Ethicon
- 7 mm Jackson Pratt drain
4Patient Positioning
- Standard full flank, ventral surface on edge of
table - Lower (left) leg bent, 3 pillows supporting upper
(right) leg - Table flexed 15?
- Axillary roll
- OR table covered with gel pad (never bean bag)
- Arm draped over chest, supported by 2 pillows
- Arms, hips, and lower leg secured by tape
- No kidney rest
5Patient Positioning
Areas that are carefully padded
6Trocar Placement
- Veress needle placed medial and superior to the
anterior superior iliac spine, followed by 5 mm
trocar that will be the right hand working site - 5 mm trocar beneath costal margin in anterior
axillary line for left hand working site - 12 mm trocar in midline between the two working
trocars for the laparoscope - Optional 5 mm trocar in posterior axillary line
between the working trocars for lateral
retraction
7Port Placement
12mm trocar
5 mm trocar
5 mm trocar (optional)
8Port Placement (post-operative)
Feet
Head
7mm Jackson Pratt drain in retractor site
5mm left hand working site
5mm right hand working site
12mm laparoscope site
9Steps of the procedure
- Deployment of trocars
- Mobilization of Colon and Kocherizing the
duodenum (right side) - Identification and limited mobilization of ureter
and the renal pelvis with preservation of
crossing vessels when present
If not done pre-operatively, cystoscopy,
retrograde ureteropyelogram, and JJ stent
deployment can be done before laparoscopy OR a JJ
stent can be deployed laparoscopically after
transection of the UPJ
10Steps of the procedure
4. Transection of the UPJ and spatulation of the
ureter. Reduction of renal pelvis (when
redundant) 5. Anastomosis (anterior to crossing
vessels when present) and deployment of drain
11Step 1. Deployment of Trocars
12Step 2. Mobilization of Colon and Kocherizing the
duodenum (right side)
13Step 3. Identification and limited mobilization
of the ureter
14Step 4. Transection of the UPJ and spatulation of
the ureter
15Step 5. Anastomosis
16Technical points Tips
- Pre-operative CT angiogram is reliable in the
detection of crossing vessels and can warn of the
existence of crossing vessels - Patients with JJ stents placed prior to surgery
will have thickened reactive ureters which may
make the ureteral dissection and anastomosis more
challenging - Application of the PEER retractor and the
Endoholder opens the operative field and
facilitates dissection - Microline scissors have a disposable tip which is
always sharp for ureteral transection and
spatulation - Lapra-Ty clips will securely anchor the running
anterior and posterior suture lines and will
facilitate a tight closure
17Technical points Caveats
- Facility with intracorporeal suturing is
essential and will make the running anastomosis
relatively expeditious and easy - Early in the surgeons experience, application of
three 12 mm trocars will facilitate the procedure - It is ideal to work with the laproscope between
the two working trocars. However, the
laparoscope may be moved to optimize the angle of
vision - When using 5 mm working trocars, the needle and
Lapra-Ty clip applier are inserted through the 12
mm (laparoscope) trocar and a 5 mm laparoscope is
used
18Credits
- Surgeon Jaime Landman
- Director of Minimally Invasive Urology
- Columbia University Department
of Urology, - New York, NY
-
- Assistant Sean Collins
- Director of Minimally Invasive
Urology - Louisiana State University
Department of Urology, - New Orlenes, LA
-