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HERNIAS AFTER PEDIATRIC LAPAROSCOPIC UROLOGIC SURGERY
THE JOURNAL OF UROLOGY®
Vol. 181, No. 4, Supplement, Tuesday, April 28, 2009
13 months (range 3-33) after surgery. Patients with retroperitoneal metastases or local recurrence received adjuvant chemotherapy. One (1.3%) patient with negative retroperitoneal histology and local recurrence developed a pulmonary metastasis. All patients are free of disease. Anterograde ejaculation was preserved in all cases. CONCLUSIONS: The oncological efficacy of LRLND is feasible and associated with low morbidity if performed by experienced hands. Source of Funding: None
1291 STANDARDIZED LINEAR PORT PLACEMENT FOR ALL TRANSPERITONEAL LAPAROSCOPIC RENAL AND ADRENAL SURGERY: EXPERIENCE WITH 1102 CASES Jonathan D Harper*, John T Leppert, Aqsa A Khan, Sanjay G Patel, Alberto Breda, Peter G Schulam, Los Angeles, CA INTRODUCTION AND OBJECTIVES: Traditional laparoscopic port placement typically involves a diamond configuration, camera access via the umbilicus and modification of ports for different surgeries. A simplified linear port configuration has been used for nearly all urologic retroperitoneal surgery at our institution since a transition began in late 2000. The objective of this paper is to describe our experience with this technique, and discuss feasibility and perceived advantages. METHODS: A chart and database review was conducted of all laparoscopic cases between 2000 and 2008 at our institution. All surgeries using the linear port configuration were included. The technique includes three ports placed along the ipsilateral pararectal line with the most inferior one at the level of the umbilicus. A 5mm camera is utilized through the most superior port. An additional port is placed off the 11th or 12th rib for lateral retraction. Typically four 5mm ports are used with modification if needed. Extraction site is typically through a low transverse incision in which a 15mm port for a stapling device or endoscopic bag can be placed. RESULTS: 1102 laparoscopic cases were performed. Of these, there were 159 radical and simple nephrectomies, 750 donor nephrectomies, 47 partial nephrectomies, 29 nephroureterectomies, 46 adrenalectomies, 44 pyeloplasties, 18 cryoablations, and 12 miscellaneous renal procedures. 98.3% were performed successfully via this port configuration. There were 19 (1.7%) open conversions: 15 were elective and four secondary to complications. CONCLUSIONS: Standardization of port placement via a linear configuration for both right and left renal and adrenal surgery is practical, easy to learn, and simplifies strategic planning preoperatively. Utilizing camera access through the superior port allows for direct visualization and minimizes the surgeon and camera holder from entering each others working envelope. Source of Funding: None
1292 HERNIAS AFTER PEDIATRIC LAPAROSCOPIC UROLOGIC SURGERY Nicholas G Cost*, Joy J Lee, Warren T Snodgrass, Duncan T Wilcox, Linda A Baker, Dallas, TX INTRODUCTION AND OBJECTIVES: The incidence of port site hernia development after adult laparoscopic surgery is reported between 0.1-3.0%. Contributing factors are thought to include: trocar size, location or fascial closure. Other patient characteristics such obesity, smoking, diabetes or wound infections are also suspected. However, there are no published reports concerning hernia incidence or related factors after pediatric urologic laparoscopic (PUL) interventions. We present our experience with port site incisional hernias following PUL. METHODS: We reviewed PUL performed at Children’s Medical Center from 2000 to 2008. There were 261 cases identified, with followup available in 218 (83.4%). In 187 cases there was sufficient data to evaluate outcomes for each port-site separately and compare its size, location and fascial closure to hernia development.
461
RESULTS: Median age was 6.1yr(0.4-18.8), 218 patients had follow-up at a median of 5.7 mo(0.2-83.4). 7 hernias (3.2%) were diagnosed at a median of 1.2mo(0.1-15.1) post-op. The hernia group was younger than the non-hernia group, 1.1yr(0.5-3.9) vs 6.2yr(0.418.8), p=0.04. There were 571 port-sites analyzed in 187 cases and the fascia was closed in 385(67.4%) of the ports. 7 ports had hernias. 4 of 385 ports (1.0%) that were closed had hernias vs 3 of 186 ports (1.6%) that were not closed. No significant relationship could be found between hernia development and the port size or location. Hernias developed in 3 umbilical, 1 midepigastric, 1 paramedian, 1 scrotal and 1 retroperitoneal port. Patient 1 presented with omental herniation at a midepigastric site 1 day after lap nephrectomy. This required open closure. Patient 2 presented 5wks after lap orchiopexy with a defect at a paramedian site. He was observed for 5mo when the hernia resolved spontaneously. Patient 3 presented 15mo after lap orchiopexy with a hernia at a scrotal port site which required closure. Patient 4 presented 1mo after lap heminephrectomy with swelling and a defect at the umbilical site. This was observed to resolve 4mo later. Patient 5 presented 4mo post-op with a reducible hernia at a retroperitoneal port site which was observed to resolve 2yr later. Patients 6 and 7 presented within 24hrs after diagnostic laparoscopy for non-palpable testes, both required fascial closure. CONCLUSIONS: Incidence of port site hernias after PUL was 3.2%, similar to the published incidence in adults. While developing a hernia after PUL is rare, it is more likely in infants. Due to the low incidence of this complication it is difficult to draw conclusions on contributing factors. Source of Funding: None
1293 A COMPARISON OF C-VIEW PANORAMIC ENDOSCOPY VERSES TRADITIONAL ROD LENS ENDOSCOPY Andrew T Zabinski*, Albany, NY; Jason E Smith, Haibo Liu, Jiayin Ma, Michelle Simkulet, Troy, NY INTRODUCTION AND OBJECTIVES: C-View lens system (Interscience, Inc™), is a lens that can project an image 360 degrees in the horizontal axis and 270 degrees in the vertical axis onto a single plane. Traditional endoscopic procedures use a combination of angled lenses to visualize an entire cavity where the surgeon works. We sought to evaluate the use of a C-View lens in visualizing a surgical field and compare it to a traditional rod lens system. METHODS: Using an artificial bladder labeled for anatomical orientation, we compared the use of the traditional rod lens system to the C-View lens system. Variables measured included, the number of anatomical landmarks visualized by each lens system at any time and the time to visualize the entire cavity. RESULTS: The traditional rod lens system could visualize 4/10 anatomical landmarks at any single time during the procedure. C-View could visualize 10/10 landmarks at any time during the procedure. The traditional rod lens system took a significantly longer time to visualize all 10 anatomical landmarks, 15 seconds vs. 3 seconds. CONCLUSIONS: The C-View lens system offered visualization of the entire cavity at any time and is significantly faster than the traditional rod lens system. C-View could allow for better orientation, shorter operative times and less manipulation during endoscopic procedures. Source of Funding: NIDDK
1294 DAY CASE LAPAROSCOPIC PYELOPLASTY - A SAFE AND FEASIBLE OPTION Aniruddha Chakravarti*, Sashi S Kommu, Christopher J Luscombe, Anurag Golash, Stoke-on-trent, United Kingdom INTRODUCTION AND OBJECTIVE: Laparoscopic pyeloplasty (LP) is considered a gold standard treatment for PUJ obstruction in
Vol. 181, No. 4, Supplement, Tuesday, April 28, 2009
13 months (range 3-33) after surgery. Patients with retroperitoneal metastases or local recurrence received adjuvant chemotherapy. One (1.3%) patient with negative retroperitoneal histology and local recurrence developed a pulmonary metastasis. All patients are free of disease. Anterograde ejaculation was preserved in all cases. CONCLUSIONS: The oncological efficacy of LRLND is feasible and associated with low morbidity if performed by experienced hands. Source of Funding: None
1291 STANDARDIZED LINEAR PORT PLACEMENT FOR ALL TRANSPERITONEAL LAPAROSCOPIC RENAL AND ADRENAL SURGERY: EXPERIENCE WITH 1102 CASES Jonathan D Harper*, John T Leppert, Aqsa A Khan, Sanjay G Patel, Alberto Breda, Peter G Schulam, Los Angeles, CA INTRODUCTION AND OBJECTIVES: Traditional laparoscopic port placement typically involves a diamond configuration, camera access via the umbilicus and modification of ports for different surgeries. A simplified linear port configuration has been used for nearly all urologic retroperitoneal surgery at our institution since a transition began in late 2000. The objective of this paper is to describe our experience with this technique, and discuss feasibility and perceived advantages. METHODS: A chart and database review was conducted of all laparoscopic cases between 2000 and 2008 at our institution. All surgeries using the linear port configuration were included. The technique includes three ports placed along the ipsilateral pararectal line with the most inferior one at the level of the umbilicus. A 5mm camera is utilized through the most superior port. An additional port is placed off the 11th or 12th rib for lateral retraction. Typically four 5mm ports are used with modification if needed. Extraction site is typically through a low transverse incision in which a 15mm port for a stapling device or endoscopic bag can be placed. RESULTS: 1102 laparoscopic cases were performed. Of these, there were 159 radical and simple nephrectomies, 750 donor nephrectomies, 47 partial nephrectomies, 29 nephroureterectomies, 46 adrenalectomies, 44 pyeloplasties, 18 cryoablations, and 12 miscellaneous renal procedures. 98.3% were performed successfully via this port configuration. There were 19 (1.7%) open conversions: 15 were elective and four secondary to complications. CONCLUSIONS: Standardization of port placement via a linear configuration for both right and left renal and adrenal surgery is practical, easy to learn, and simplifies strategic planning preoperatively. Utilizing camera access through the superior port allows for direct visualization and minimizes the surgeon and camera holder from entering each others working envelope. Source of Funding: None
1292 HERNIAS AFTER PEDIATRIC LAPAROSCOPIC UROLOGIC SURGERY Nicholas G Cost*, Joy J Lee, Warren T Snodgrass, Duncan T Wilcox, Linda A Baker, Dallas, TX INTRODUCTION AND OBJECTIVES: The incidence of port site hernia development after adult laparoscopic surgery is reported between 0.1-3.0%. Contributing factors are thought to include: trocar size, location or fascial closure. Other patient characteristics such obesity, smoking, diabetes or wound infections are also suspected. However, there are no published reports concerning hernia incidence or related factors after pediatric urologic laparoscopic (PUL) interventions. We present our experience with port site incisional hernias following PUL. METHODS: We reviewed PUL performed at Children’s Medical Center from 2000 to 2008. There were 261 cases identified, with followup available in 218 (83.4%). In 187 cases there was sufficient data to evaluate outcomes for each port-site separately and compare its size, location and fascial closure to hernia development.
461
RESULTS: Median age was 6.1yr(0.4-18.8), 218 patients had follow-up at a median of 5.7 mo(0.2-83.4). 7 hernias (3.2%) were diagnosed at a median of 1.2mo(0.1-15.1) post-op. The hernia group was younger than the non-hernia group, 1.1yr(0.5-3.9) vs 6.2yr(0.418.8), p=0.04. There were 571 port-sites analyzed in 187 cases and the fascia was closed in 385(67.4%) of the ports. 7 ports had hernias. 4 of 385 ports (1.0%) that were closed had hernias vs 3 of 186 ports (1.6%) that were not closed. No significant relationship could be found between hernia development and the port size or location. Hernias developed in 3 umbilical, 1 midepigastric, 1 paramedian, 1 scrotal and 1 retroperitoneal port. Patient 1 presented with omental herniation at a midepigastric site 1 day after lap nephrectomy. This required open closure. Patient 2 presented 5wks after lap orchiopexy with a defect at a paramedian site. He was observed for 5mo when the hernia resolved spontaneously. Patient 3 presented 15mo after lap orchiopexy with a hernia at a scrotal port site which required closure. Patient 4 presented 1mo after lap heminephrectomy with swelling and a defect at the umbilical site. This was observed to resolve 4mo later. Patient 5 presented 4mo post-op with a reducible hernia at a retroperitoneal port site which was observed to resolve 2yr later. Patients 6 and 7 presented within 24hrs after diagnostic laparoscopy for non-palpable testes, both required fascial closure. CONCLUSIONS: Incidence of port site hernias after PUL was 3.2%, similar to the published incidence in adults. While developing a hernia after PUL is rare, it is more likely in infants. Due to the low incidence of this complication it is difficult to draw conclusions on contributing factors. Source of Funding: None
1293 A COMPARISON OF C-VIEW PANORAMIC ENDOSCOPY VERSES TRADITIONAL ROD LENS ENDOSCOPY Andrew T Zabinski*, Albany, NY; Jason E Smith, Haibo Liu, Jiayin Ma, Michelle Simkulet, Troy, NY INTRODUCTION AND OBJECTIVES: C-View lens system (Interscience, Inc™), is a lens that can project an image 360 degrees in the horizontal axis and 270 degrees in the vertical axis onto a single plane. Traditional endoscopic procedures use a combination of angled lenses to visualize an entire cavity where the surgeon works. We sought to evaluate the use of a C-View lens in visualizing a surgical field and compare it to a traditional rod lens system. METHODS: Using an artificial bladder labeled for anatomical orientation, we compared the use of the traditional rod lens system to the C-View lens system. Variables measured included, the number of anatomical landmarks visualized by each lens system at any time and the time to visualize the entire cavity. RESULTS: The traditional rod lens system could visualize 4/10 anatomical landmarks at any single time during the procedure. C-View could visualize 10/10 landmarks at any time during the procedure. The traditional rod lens system took a significantly longer time to visualize all 10 anatomical landmarks, 15 seconds vs. 3 seconds. CONCLUSIONS: The C-View lens system offered visualization of the entire cavity at any time and is significantly faster than the traditional rod lens system. C-View could allow for better orientation, shorter operative times and less manipulation during endoscopic procedures. Source of Funding: NIDDK
1294 DAY CASE LAPAROSCOPIC PYELOPLASTY - A SAFE AND FEASIBLE OPTION Aniruddha Chakravarti*, Sashi S Kommu, Christopher J Luscombe, Anurag Golash, Stoke-on-trent, United Kingdom INTRODUCTION AND OBJECTIVE: Laparoscopic pyeloplasty (LP) is considered a gold standard treatment for PUJ obstruction in