Experimental studies for clinical standardization of transabdominal laparoscopic nephrectomy.

In keeping with the maxim that minimal invasiveness is the present working trend in most areas of surgery, we investigated the possibility of laparoscopically removing a diseased human kidney. Before any actual clinical attempt could be made in this direction, an experimental study was set up in order to determine the most beneficial methods and techniques which would guide us through our first clinical cases. This step-by-step training program consists of: (1) initial familiarization with different laparoscopic instruments, bimanual dissection, ligation and coagulation techniques, camera handling and trocar placement as well as organ retrieval systems using the lap simulator; (2) laparoscopic removal of the kidney and ureter of the pig either as short- or long-term study, and (3) laparoscopic simulation with the lap tent during open surgery.

Transperitoneal laparoscopic nephrectomy: training, technique, and results.

Transperitoneal laparoscopic nephrectomy was integrated into our daily routine within a 6-month period by means of a step-by-step training program progressing from a pelvic trainer to animal studies (N = 15) to laptent-assisted surgery. The pneumoperitoneum is created with the patient in the flank position, enabling insertion of three trocars: 10-mm periumbilical (Port I), 5/12-mm subcostal (Port II), and 12/5-mm above the iliac spine (Port III). After medial mobilization of the colon, two additional 5-mm trocars (Ports IV and V) are inserted into the lateral abdominal wall parallel to Ports II and III. Once clipping and dissection of the ovarian (spermatic) vein has been carried out, the ureter is identified and dissected. Retraction of the proximal ureter exposes the renal hilum, allowing dissection of the renal vessels. The renal vein is dissected using an endoscopic stapling device, while accessory veins and the renal artery are clipped. Organ retrieval is achieved with a specially designed tissue pouch (Lapsac) and digital fragmentation of the kidney within the organ bag. Using this technique, we have treated 24 patients with benign (N = 20) and malignant (N = 4, including adrenalectomy) renal disease. The mean operative time was 239 (115-300) minutes. In four cases, open surgery was required because of bleeding (N = 2), severe perinephric inflammation (N = 1), or bowel injury (N = 1). For relief of wound pain, an average of 1.15 vials of analgesic (morphine derivatives)/patient were administered for 2.4 days. The postoperative hospital stay averaged 6.2 (4-10) days.

Lap simulator, animal studies, and the Laptent. Bridging the gap between open and laparoscopic surgery.

In an effort to ensure proper training and to establish a routine amongst the surgical team right from the start, we began practicing laparoscopic techniques with the lap simulator. After having acquainted ourselves with the fundamentals of this minimal-invasive method, we applied our newfound experience to the animal model. Even though the subsequent studies with pigs were the best learning model in which to practice different surgical techniques--e.g., ureter clipping and renal vessel triple stapling with the Endo-GIA--various problems can arise in a true clinical situation since anatomical diversity exists between an animal and human situs. We found that a compromise could be reached by simulating laparoscopic conditions during open surgery without endangering the safety of the patient during any point of the operation. After open surgical exposure of the Gerota fascia was carried out, the operative site was completely covered with the Laptent. From this moment on, all operative steps were performed with laparoscopic instruments under continuous video monitoring. Our step-by-step training program has exposed the surgeon and OR staff to the complexity of this new surgical technique. The use of the Laptent has successfully bridged the gap between open and laparoscopic surgery. Most important of all, those surgical centers without access to extensive experimental studies will realize that Laptent-assisted surgery can be of benefit and facilitate the clinical introduction of this minimal-invasive method.

[Laparoscopic training in urology. An essential principle of laparoscopic interventions in the retroperitoneum]. / Laparoskopisches Training in der Urologie. Eine unverzichtbare Basis für laparoskopische Eingriffe im Retroperitoneum.

The main problem with clinical introduction of laparoscopic techniques in urology is that despite experience with endoscopy no significant endoscopic training is given. Laparoscopic nephrectomy, in particular, is a rather complicated procedure and needs an adequate training concept: The beginner should have the possibility of practising in vitro in a closed "pelvi-trainer" to learn video-optical coordination and orientation; then it is necessary to get used to handling the instruments and practise the different steps of the procedure (i.e. clipping of vessels, sacking of the kidney) either in phantom models or in explanted animal organs. On this basis, we performed laparoscopic nephrectomy in an animal model (n = 18 porcine kidneys). We were able to standardize the technique of creating a pneumoperitoneum, the positioning of the animal, the site and size of the trocars, and preparation and clipping techniques (i.e. Endo-GIA) and entrapment of the kidney (testing different organ bags). A step-by-step approach was used for the introduction to clinical application. For simulation and training of video-assisted preparation techniques in patients and step-wise introduction to laparoscopy (instruments, endocoagulation, trocars), we created a "lap-tent", which was placed over the wound after exposition of Gerota's fascia. Further preparation was performed under laparoscopic conditions (without pneumoperitoneum) with a limited time allowed (1 h). Thereafter, we started with time-limited laparoscopy and laparoscopic lymphadenectomy prior to pelvic surgery (prostatectomy, cystectomy) to introduce the staff to the technique of pneumoperitoneum and placement of the trocars and to the use of the instruments in general. Based on this step-by-step training concept, after a 6-months period we were successful in introducing transperitoneal laparoscopic nephrectomy (TLN) to our clinical routine. So far, we have performed 20 laparoscopic nephrectomies, 1 nephro-ureterectomy, 4 tumour nephrectomies (inducing adrenalectomy), 2 adrenalectomies, and 6 modified retroperitoneal lymphadenectomies. In the lesser pelvis we have experience with 20 laparoscopic varicocelectomies, 23 pelvic lymphadenectomies, and 5 diagnostic laparoscopies for cryptorchidism (February 1993).

The technique of transperitoneal laparoscopic nephrectomy, adrenalectomy and nephroureterectomy.

In the traditional kidney position three trocars are inserted after creation of a pneumoperitoneum: 10 mm periumbilical (port I), 10/12 mm subcostal (port II) and 12/10 mm above the iliac spine (port III) in the mamillary line. After laterocolic incision the colon is dissected away from the lateral wall. Thereafter two 5-mm trocars (ports IV, V) are inserted into the lateral abdominal wall parallel to parts II and III. Following clipping and dissection of the ovarian (spermatic) vein, the ureter is isolated and incised. Then the cranial part of the ureter is used as a retractor exposing the renal hilum for dissection of the renal vessels. The main renal artery and vein are dissected separately by use of an endoscopic stapling device (Endo-GIA, white magazine). Finally, the kidney including Gerota's fascia is isolated from the adrenal and the upper peritoneum. Entrapment of the organ is performed with a specially designed bag (Lap-sac). The neck of the bag is brought out onto the surface of the abdomen (via port II/III) allowing digital morcellation with index finger inside the bag and removal of the organ in several pieces. We have applied this technique for 17 procedures in the upper retroperitoneum: 9 transperitoneal laparoscopic nephrectomies (TLN) for benign disease (5 hydronephrosis, 3 renovascular disease, 1 chronic pyelonephritis), 3 radical TLN including adrenalectomy for renal cell carcinoma (T2G2), 1 adrenalectomy for a cortical adrenaloma, 1 nephroureterectomy, 1 diagnostic ureterolysis and 2 modified retroperitoneal lymphadenectomies for stage I testicular cancer. The mean operation time was 4 h (2-5), the mean postoperative hospital stay 6 days (4-12).(ABSTRACT TRUNCATED AT 250 WORDS)