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Laparoscopic transperitoneal pyeloplasty using a remote-controlled robotic surgical system, ureteropyelic junction reconstruction

Authors

Abstract

This surgical video demonstrates the advantages of using the DaVinci robot for dissection and anastomosis of the upper ureter to the renal pelvis. A potentially difficult procedure is simplified by the dexterity of the robotic instruments.

Classification

robotic

Keywords

robot, anastomosis, upper ureter, renal pelvis

Media type

Duration

10'22''

Publication

2007-03

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E-publication

WeBSurg.com, Mar 2007;7(03).
URL: http://www.websurg.com/doi-vd01en2088.htm

Laparoscopic transperitoneal pyeloplasty using a remote-controlled robotic surgical system, ureteropyelic junction reconstruction

1. Dissection of ureter and renal vein 00'21''

This is a typical case of a 21-year-old woman with a right UPJ syndrome and inferior polar pedicle revealed on the CT-scan. The inferior pole of the right kidney is easily identified and a small incision of the peritoneum is performed. Using the electrocautery hook on the right hand and the micro-forceps on the left, the dissection goes on in order to identify the upper ureter. Following the ureter upwards allows the access to the inferior polar pedicle and particularly to the inferior polar vein. This vein is carefully dissected. Hemostasis is performed step by step with the bipolar forceps. Going on with the dissection under the liver leads us to the pyelum. The anterior and posterior aspects of the pyelum are dissected using the electrocautery hook. The ureter and the inferior part of the pyelum have been now completely dissected. You can see the block effect of the inferior vein on the ureter, this explaining the development of the UPJ obstruction. We now use the articulated scissors in the right hand in order to cut the upper part of the ureter obliquely.

2. Division of renal pelvis and ureter 02'19''

The redundant part of the pyelum is also resected. The extent of the resection depends on the volume of the pyelum. In that case, the pyelum dilation was moderate and there was no need for an extensive resection. A longitudinal incision of the ureter allows creation of a spatula. The so-called “ears” of the spatula can be precisely excised, this allowing to perform a precise spatula like in open surgery. The instruments are changed. We now use 2 micro-forceps. The anastomosis is going to be performed with 6/0 suture thread.

3. Pelvi-ureteric anastomosis 03'20''

The 1st stitch is put on the inferior part of the pyelum. The stitch is performed forehand and can be done very precisely. You can appreciate how easy it is to transfer the needle from one needle holder to the other. The next stitch on the lower part of the ureter spatula has to be performed back-hand also very precisely. Ureter and pyelum are brought up together in order to facilitate the knot-tying. This is one of the surgical actions which are the most simplified by robotics when compared to standard laparoscopy. The lack of tactile feedback does not hinder the tying as the feedback is visually reconstructed by the surgeon’s brain. The needle is transferred behind the ureter in order to begin the running suture on the posterior aspect of the anastomosis. A12cm long thread is used for that purpose. The 2nd stitch is done very precisely. This precision is similar to the one that was obtained in open surgery when using magnifying glasses. With some training, this kind of suture can be performed as quickly as in open surgery. Again this is easily performed thanks to the articulated instrument tips and the 7 degrees of freedom which are equivalent to those of the human wrist. The suture of the posterior aspect of the anastomosis has now been completed. A new 6/0 thread is now used for the beginning of the 2nd running suture on the anterior aspect of the anastomosis. Again you can appreciate how easy it is to tie knots. This is related to the articulated instruments and to the 3-D vision. What you see on the screen is a classical 2-dimensional image but what the surgeon sees at the console is a real 3-D image, this thanks to 2 separate optic channels which provide a complementary vision for the left and right eyes of the surgeon. The size of the urethral lumen has been checked and a hydrophilic guide wire is now introduced in the upper ureter and progressively pushed down to the bladder using the 2 micro-forceps. An 8 French double-J stent is then slit down on the guide wire. This is also efficiently done by the surgeon. The guide wire is then withdrawn by the bedside assistant and the upper part of the double-J stent is gently introduced into the pyelum. The 7 degrees of freedom of the instrument tips can be of great help in manipulating the double-J stent. The anterior aspect of the anastomosis is now to be completed with a running suture. This running suture can be performed by the surgeon without any help from the assistant. The 2 threads are now tied together and the threads cut by the assistant. You can appreciate the stability of the robotic instruments when compared to the unwanted movements of the scissors of the assistant.

4. Reperitonization 08'10''

A 2/0 running suture is going to be performed on the retroperitoneum. You can notice how the body of the right instrument allows to recline the liver. While performing the stitches on the peritoneum, this allows to avoid using an additional trocar. Tying the knot beneath the liver could be something tedious in standard laparoscopy. Robotics brings more autonomy to the surgeon and reduces the need for an additional instrument. The insufflation pressure is reduced in order to check for hemostasis. We can clearly see the uncrossed ureter and the polar pedicle lying now posteriorly to him. The peritoneum is now going to be closed with a 2/0 running suture. Knots can be tied even with very short stump, this thanks to the thin and articulated instrument tips, to the image magnification, to the movement scaling and filtering.The operation is now completed. The peritoneum is closed and the trocars are removed under visual control. Once can conclude that UPJ syndrome treatment is an intervention where advantages provided by robotics are exploited in an optimal way.

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