Figure: Laparoscopic Vricocelectomy
Laparoscopic varicocele ligation has been performed by many urologists, and reports from several medical centers have been published. The data suggest that laparoscopic varicocele ligation is therapeutically superior to open surgical and radiographic (embolization) techniques. Laparoscopic varicocelectomy appears to reduce postoperative morbidity. Whether it is necessary to identify and preserve the testicular artery during laparoscopic varicocelectomy remains controversial. Loughlin and Brooks reported on the use of a laparoscopic Doppler probe that they believe facilitates the identification and preservation of the testicular artery. Matsuda and coworkers claim that the testicular artery does not have to be preserved; they clip the testicular artery and veins en bloc. Further multicenter experience is needed to resolve whether the testicular artery should be preserved during laparoscopic varicocele ligation. Because the testicular artery is preserved during open surgical repair or radiographic embolization procedures. We generally preserve the testicular artery during varicocelectomy.
Picture (A,B): The spermatic vein is identified
The technique of laparoscopic varicocele ligation is straightforward. The procedure is usually performed using general anesthesia A urethral catheter is placed to empty the bladder, and a Veress needle is placed at the umbilicus to inflate the peritoneal cavity with carbon dioxide. Alternatively, hassons technique can be performed at the inferior margin of the umbilicus, and the trocar can be placed into the peritoneum under direct vision. Three laparoscopic ports are placed for varicocelectomy according to baseball diamond concept.
The intraabdominal vas deferens can be identified as structure joining the spermatic cord above the internal inguinal ring. The gonadal vessels are visualized easily in the retroperitoneum. The posterior peritoneum is excised with cautery, laser, or endoscopic scissors. The gonadal vessels are then mobilized; however, reliably identifying the spermatic artery and its branches is sometimes difficult through the laparoscope. Therefore, many surgeons prefer to use the laparoscopic Doppler probe to facilitate identification of the spermatic artery during laparoscopic varicocele ligation. The Doppler probe is 28.58 cm long and fits through a 5 mm laparoscopic port. After identifying the gonadal artery, the surgeon isolates the gonadal vein or veins using blunt dissection with atraumatic graspers.
Figure: Clips applied around spermatic vein
Endoscopic clip applier is used to secure it or intracorporeal suturing is used to ligate the gonadal vein or veins while sparing the artery.
LAPAROSCOPIC RETROPERITONEAL NODE DISSECTION
Laparoscopic retroperitoneal node dissection appears, at least for now, best applied to patients without evidence of bulky disease in the retroperitoneum who would otherwise be candidates for observation rather than surgical exploration. Although the laparoscopic procedure does not currently appear to be as thorough a dissection as the open node dissection, it offers the opportunity to have some pathologic documentation of nodal status in patients considered for observation. The technique for laparoscopic retroperitoneal node dissection has not been standardized and is still evolving; therefore, the reader is referred to the case reports for the authors individual techniques.
LAPAROSCOPIC MANAGEMENT OF LYMPHOCELES
Lymphoceles are not uncommon after renal transplantation; an incidence of 0.6% to 18% has been reported. It can also occur after pelvic lymphadenectomy, and an incidence of 5.6% has been reported in this circumstance . Most of these patients are asymptomatic and do not require much aggressive treatment. When the lymphocele becomes symptomatic or is associated with fever and potential infection, however, drainage of the lymphocele is indicated. Several investigators have reported successful laparoscopic drainage of lymphoceles.
In many centers laparoscopic surgeons are performing laparoscopic ileal loop conduit. This procedure is commonly performed for palliation of obstruction in old man with fibrosarcoma of the prostate. The ileal loop itself is fashioned laparoscopically using endoscopic stapling devices. To perform the ureteral anastomosis, however, the distal ureters and a portion of the conduit has to be brought in through a trocar site, and an extracorporeal, handsewn, ureteroileal anastomosis is performed on each side.
The report emphasizes the limitation of laparoscopic instrumentation at this time. Laparoscopic suturing is cumbersome, and the ureteroileal anastomosis could not have been completed easily laparoscopically. Until either tissue-welding techniques or better suturing techniques are available, only limited applications are available for laparoscopic reconstructive surgery such as that outlined in this case report.
LAPAROSCOPIC PELVIC LYMPHADENECTOMY
Laparoscopic pelvic lymphadenectomy has the potential to aid in the staging of prostate cancer. Most urologists embrace the philosophy that if the pelvic lymph nodes are involved in prostate cancer, cure cannot be achieved with radical prostatectomy or radiation therapy, and hormonal therapy is indicated in these patients for palliation.
Vascular injuries are most common complication during dissection. Adherence to good laparoscopic technique and familiarity with the anatomy are the most reliable ways to avoid complications.
The pneumoperitoneum is established in the standard manner. Trocar placement is then performed. The size and location of trocar sites for the procedure vary with the surgeon's preference. Most use the diamond configuration. An alternative used by some surgeons is the so-called fan configuration for trocar placement. This configuration allows the surgeon and the surgical assistant to manipulate instruments with both hands during the dissection. It is also helpful in obese patients or in those with a prominent urachus. The size of the trocars used at each site may vary. A 10mm port is usually placed in the umbilicus for the laparoscope. An additional 10mm port is placed in at least one other site for tissue removal. Another 10mm port is used for the endoscopic clip applier. Usually, 5mm ports are used for the remaining trocar sites. After completion of trocar placement, the laparoscopic landmarks for pelvic node dissection are identified. These landmarks include the medial umbilical ligament (remnant of the obliterated umbilical artery), urachus, bladder, vas deferens, iliac vessels, spermatic vessels, and internal ring. The next maneuver is to incise the posterior peritoneum parallel and lateral the medial umbilical ligament . Early identification of the ureter is important to avoid ureteral injury. The vas deferens is then divided to facilitate operative access to the obturator space. Using primarily blunt dissection, the iliac vein and artery are identified. The nodal tissue overlying the external iliac vein is then teased medially to expose the internal obturator muscle. A laparoscopic vein retractor can be used to retract the external iliac vein laterally and permit easier, more complete dissection of the nodal tissue beneath the vein. The dissection proceeds with removing tissue off the vein distally until Cooper's ligament and the pubic bone are identified.
Electro surgery is used to fulgurate small vessels and lymphatics, and the distal extent of the packet is freed from the pubic bone. The packet is pulled proximally and freed from the underside of the pubic bone. At this point, the obturator nerve is identified. Because nodal tissue can be quite bulky and difficult to grasp, adequate forceps can ensure a more reliable grasp of the specimen. With blunt dissection, the obdurator nerve is cleaned off proximally, and endoscopic clips are used to divide the distal portion of the dissection. At the completion of the laparoscopic pelvic lymphadenectomy, the iliac artery, vein, pubic bone, and obturator nerve can be seen clearly. The field is checked for hemostasis, and the dissection is performed in an identical manner on the opposite side. The trocars are removed, and the puncture sites are closed in the usual manner