Laparoscopic Management of Lymphoceles
Lymphoceles are not uncommon after renal transplantation; an incidence of 0.6 to 18 percent has been reported. It can also occur after pelvic lymphadenectomy, and an incidence of 5.6 percent 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.
The technique of lymphocele drainage is described as follows. After the induction of general endotracheal anesthesia, the surgeon places a urethral catheter to drain the bladder, and a nasogastric tube is then inserted. A Veress needle is inserted into the peritoneal cavity in the left upper quadrant to avoid the transplanted allograft. A pneumoperitoneum is achieved in the usual manner, and a 10 mm trocar sheath is inserted through the same site into the peritoneal cavity. The video endoscope is placed through this port, and two additional 5 mm ports are inserted under direct vision in the periumbilical area in the right upper quadrant at the level of the midclavicular line.
The abdomen is carefully inspected, and the renal transplant and associated lymphocele are visualized. They appear as two extrinsic bulges in the retroperitoneum. The lymphocele is distinguishable by its superolateral location to the graft and the soft consistency on probing. The lymphocele also transmits light readily when the light source is placed at its wall. The patient is placed in Trendelenburg’s position to allow the small bowel to fall cephalad and to facilitate the visibility of the lymphocele. The lymphocele is then entered using electrocautery. The peritoneum and its attached lymphocele wall are grasped, and the incision is extended circumferentially using laparoscopic scissors. An ellipse of the lymphocele wall is removed, thereby creating a window. After careful marsupialization of the edges of the window, the lymphocele is inspected, and all internal loculations are lysed and excised to create a single cavity. At the end of the surgery, the cavity is irrigated and inspected for adequate hemostasis prior to the usual completion of the laparoscopic procedure.
Usually, the patient underwent laparoscopic ureterolysis via a transperitoneal approach. An external ureteral stent should be placed to help identify the ureter as is done with laparoscopic nephrectomy. The ureter is identified by close up vision of telescope and then successfully mobilized laparoscopically. Laparoscopic biopsy forceps should be used to obtain multiple biopsy specimens of the periureteral tissue. Laparoscopic ureterolysis is not a very frequently performed procedure. Additional experience will help determine how applicable laparoscopic ureterolysis will become in the future.
Laparocopic Ileal Conduit
In many centers, laparoscopic surgeons are performing laparoscopic ileal loop conduit. This procedure is commonly performed for palliation of obstruction in an 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, hand-sewn, 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, the cure cannot be achieved with radical prostatectomy or radiation therapy, and hormonal therapy is indicated in these patients for palliation. Vascular injuries are the 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 10 mm port is usually placed in the umbilicus for the laparoscope. An additional 10 mm port is placed in at least one other site for tissue removal. Another 10 mm port is used for the endoscopic clip applier. Usually, 5 mm 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 (a 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 to the medial umbilical ligament. Early identification of the ureter is important to avoid ureteral injury. The vas deferens are 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.
Electrosurgery 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 obturator 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.