Page 10 - World Journal of Laparoscopic Surgery
P. 10

Piyush Singhania et al
                                                               open and took 4 hours. The operative time decreased with
                                                               surgeons experience. Average operating time for first 7 cases
                                                               was 4.36 hours and it decreased to an average of 3.14 hours for
                                                               the next 7 cases excluding 1 case which needed conversion to
                                                               open. Mean blood loss was 150 ml (range 70-250 ml). None of
                                                               our patients required any blood transfusion. Average amount
                                                               of gas used was 230 L (range 127-480 L). The mean duration of
                                                               analgesic use in our series was 5.2 days (ranging from 3 days to
                                                               10 days) excluding 2 patients who required open surgery. Mean
                                                               hospital stay after surgery was 7.6 days (range 3-23 days).
                                                               However, if two cases which required open surgery were
                                                               excluded the mean hospital stay, after surgery was 5.5 days
                                                               (range 3-9 days).
                                                                  There was one case of accidental division of upper end of
            A
                                                               DJ stent during pelvic transection. The upper end was
                                                               subsequently removed and the rest of the stent left in situ. An
                                                               eight years old child had very fragile pelvic and ureteral tissues
                                                               and there was repeated cut through of sutures during uretero
                                                               pelvic anastomosis. In this child, the procedure was converted
                                                               to open approach and pyeloplasty completed. Removal of
                                                               associated calculus was done in 3 out of 4 patients but clearance
                                                               was achieved in only one patient who had a pelvic calculus.
                                                               Rest of the patients with calyceal calculi which could not be
                                                               retrieved were advised ESWL postoperatively. Our second
                                                               patient had postoperative urinary extravasation and urinary
                                                               peritonitis. She required abdominal exploration with interrupted
                                                               suturing of anterior suture line and PCN on 7th postoperative
                                                               day. Subsequently the recovery was uneventful.
                                                                  Follow-up ranged from 4 months to 16 months. Mean follow-
                                                               up period was 10.6 months. 4 (26.7%) out of 15 patients
                                                               continued to complaints of intermittent flank pain inspite of
                                                               radiological evidence of definite improvement in drainage. One
            B                                                  patient had no improvement in symptoms and persistence of
                                                               radiologic evidence of obstruction. This patient had gross HN
                                                               with nil cortical thickness preoperatively.
              Figs 1A and B: Port sites for right transperitoneal pyeloplasty  Renogram revealed significant improvement in 12 out of 15
                  (1) – Laparoscope pararectally above umbilicus  patients at 3 months and in 13 out of 15 patients at 1 year. Out
                  (2) – Surgeon’s left hand at mid spino umbilical line
                  (3) – Surgeon’s right hand subcostally       of the remaining 2 patients, one patient had nonobstructive
                  (4) – Assistant, mid axillary line           renogram preoperatively and it remained stable in the
                                                               postoperative period. This patient had definite evidence of
                                                               obstruction with secondary mobile calculi in kidney on IVP.
            holding suture. In rest of the 14 patients the surgery could be  IVP was done at 1 year of follow-up in 6 patients and revealed
            successfully completed laparoscopically. Crossing vessels were  significant improvement in all cases. Thus, 14 (93.33%) out of
            identified in 7 (46.7%) out of 15 patients, which required  15 cases showed definite improvement in renal function and
            transposition of the ureter and pelvis before anastomosis.  drainage on radiographic evaluation. One of them had required
            Reduction of pelvis was required in 11 (73.3%) out of 15  conversion to open surgery.Thus the success rate in our initial
            pyeloplasties. Average operating time was 3.75 hours (range 3  series of 15 cases of laparoscopic pyeloplasty was 86.66% (13
            hours to 5 hours) excluding one case which was converted to  out of 15 cases).

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