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Single incision retro-peritoneoscopic paediatric nephrectomy: Early experience
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MODEL
Journal of Pediatric Urology (2014) xx, 1e3
Single incision retro-peritoneoscopic paediatric nephrectomy: Early experience A. Cherian a,*, G. De Win b a Department of Paediatric Urology, Great Ormond Street Hospital for Children NHS Foundation Trust, London WC1N 3JH, UK b Urology Department, Antwerp University Hospital, Antwerp, Belgium
Received 12 August 2013; accepted 18 December 2013
KEYWORDS Single incision; Single port; Single site; Nephrectomy; Retroperitoneoscopic; Children
Abstract Single incision, single port, or single site surgery for retro-peritoneoscopic nephrectomy and nephro-ureterectomy in paediatric practice using an advanced access platform (GelPOINT Mini) is described in two patients. One patient had bilateral synchronous nephrectomy. The technique, advantages, and challenges are reported. Beyond the initial hurdles and learning curve, this technique is promising and has the potential to be extended to other procedures in paediatric urology. ª 2014 Journal of Pediatric Urology Company. Published by Elsevier Ltd. All rights reserved.
Introduction
Case 2
The retro-peritoneoscopic approach using a single incision for paediatric nephrectomy and nephro-ureterectomy utilising the advanced access platform (GelPOINT Mini) is presented.
An eight-year-old girl with poorly functioning duplex kidney (5 cm) and dilated non-refluxing ureters underwent nephroureterectomy. GelPOINT Mini (Applied Medical, CA, USA) (Fig. 2), Epix in-line angled dissector (Applied Medical), (see Fig. 4), 30-degree, 5-mm telescope and other conventional instruments were used.
Patients and methods Case 1 A 13-year-old female with nephrotic syndrome had synchronous, bilateral nephrectomies (each 10 cm). * Corresponding author. Tel.: þ44 207 405 9200. E-mail addresses: [email protected], acnmac@ gmail.com (A. Cherian).
Technique In the prone position, the hips and the chest were elevated. A single transverse 2.5-cm incision was made at the midpoint on a line along the lateral border of erector spinae bound by lower border of the 12th rib and the iliac crest. Posterior abdominal muscles were gently split and the deep lumbodorsal fascia incised. The retro-peritoneum was entered and the inner ring (Fig. 1) positioned deep to the
1477-5131/$36 ª 2014 Journal of Pediatric Urology Company. Published by Elsevier Ltd. All rights reserved. http://dx.doi.org/10.1016/j.jpurol.2013.12.018
Please cite this article in press as: Cherian A, De Win G, Single incision retro-peritoneoscopic paediatric nephrectomy: Early experience, Journal of Pediatric Urology (2014), http://dx.doi.org/10.1016/j.jpurol.2013.12.018
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MODEL
2
A. Cherian, G. De Win
Figure 3 The Alexis retractor in position. Tightening the retractor aids in retraction of the wound opening, at all times. Figure 1 GelPOINT Mini e Advanced access platform kit. 1. Alexis retractor: inner ring (green), outer ring (white). 2. Retractor retrieval cord. 3. Sleeves. 4. Trocar/introducer. 5. Gel-seal cap. (For interpretation of the references to colour in this figure legend, the reader is referred to the web version of this article.)
lumbodorsal fascia (Fig. 3). Rolling in of the outer ring retracts the wound. Three sleeves were placed through the Gel-seal cap and then placed on the outer ring of the retractor and locked (Fig. 2). Hilar vessels were divided by
endoclip application or a harmonic scalpel. The kidney was retrieved using a 10-mm endobag in piecemeal fashion. In Case 2, the ureter was divided below the pelvic brim, and the kidney retrieved without an endobag. The Alexis retractor was removed and the wound closed in layers.
Results Three nephrectomies in two patients were performed at two centres. The first side in Case 1 took 170 min and the second side was completed in 55 min. Oral intake and mobility was resumed the same day in both patients. In Case 2, surgery was performed in 80 min and discharged the next day. Case 1 was discharged from urology care to the dialysis ward the next day for haemodialysis. There were no perioperative complications.
Discussion The GelPOINT Mini enables a novel approach to the retroperitoneum with ease and predictability, as access is under vision and control. A 2.5-cm incision seemed to be adequate even in the older child with large kidneys. The Alexis retractor prevents dissection in the wrong plane,
Figure 2 GelPOINT Mini e Advanced access platform: assembled. 1. Lock. 2. Inner ring of the Alexis retractor.
Figure 4 GelPOINT Mini e Advanced access platform in position and locked. 1. Epix in-line angled laparoscopic dissector.
Please cite this article in press as: Cherian A, De Win G, Single incision retro-peritoneoscopic paediatric nephrectomy: Early experience, Journal of Pediatric Urology (2014), http://dx.doi.org/10.1016/j.jpurol.2013.12.018
+
MODEL
Single incision retro-peritoneoscopic paediatric nephrectomy subcutaneous emphysema, and probably reduces the risk of wound infection [1]. The Gel-seal cap provides a flexible platform with freedom to change sleeve position without incisions. The sleeves are low profile and accommodate both 5 mm and 10 mm instruments. Two ports are generally sufficient for nephrectomy as previously described by our centre [2]. However, placing an additional instrument through another mounted sleeve, without another incision, has the potential to make the operation easier and quicker. The cap incorporates both insufflation and smoke evacuation channels, enabling continuous access and visualisation. Crowding of instruments is often a challenge to overcome and requires a combination of swapping the instruments and telescope between the different ports, and using angled instruments. The Epix dissector has a low profile mechanism, an in-line handle and diathermy cord, and a 20-degree angle, which facilitates freedom of movements without crowding (Fig. 4). Kidney retrieval with the endobag is straightforward without loss of working space. Smaller kidneys do not require an endobag as the Alexis retractor maintains the wound opening. Large kidneys, older children, excision of ureter, and reduction in subcutaneous emphysema, especially in children with nephrotic syndrome, are specific situations where the above approach would make it potentially less laborious, quicker, predictable, and teachable. Single incision trans-peritoneal nephrectomy has been previously described in children [3,4]. The retroperitoneal route employed in three adult patients using a different device has been reported [5]. To the best of our knowledge, our report is the first of its kind in children using the retro-
3 peritoneal prone approach. We are encouraged by our initial experience and short learning curve, and foresee the use of this technique in other settings.
Conflict of interest None.
Funding None.
References [1] Edwards JP, Ho AL, Tee MC, Dixon E, Ball CG. Wound protectors reduce surgical site infection: a meta-analysis of randomized controlled trials. Ann Surg 2012;256:53e9. [2] Garg S, Gundeti M, Mushtaq I. The single instrument port laparoscopic (SIMPL) nephrectomy. J Pediatr Urol 2006;2: 194e6. [3] Barbancho DC, Fraile AG, Va ´zquez FL, Bramtot AA. Single-port nephrectomy in infants: initial experience. J Pediatr Urol 2011;7:396e8. [4] Johnson KC, Cha DY, DaJusta DG, Barone JG, Ankem MK. Pediatric single-port-access nephrectomy for a multicystic, dysplastic kidney. J Pediatr Urol 2009;5:402e4. [5] Butterworth C, Gkougkousis E. Single port laparoscopic nephrectomy via a retroperitoneal approach. Br J Med Surg Urol 2010;3:128.
Please cite this article in press as: Cherian A, De Win G, Single incision retro-peritoneoscopic paediatric nephrectomy: Early experience, Journal of Pediatric Urology (2014), http://dx.doi.org/10.1016/j.jpurol.2013.12.018
MODEL
Journal of Pediatric Urology (2014) xx, 1e3
Single incision retro-peritoneoscopic paediatric nephrectomy: Early experience A. Cherian a,*, G. De Win b a Department of Paediatric Urology, Great Ormond Street Hospital for Children NHS Foundation Trust, London WC1N 3JH, UK b Urology Department, Antwerp University Hospital, Antwerp, Belgium
Received 12 August 2013; accepted 18 December 2013
KEYWORDS Single incision; Single port; Single site; Nephrectomy; Retroperitoneoscopic; Children
Abstract Single incision, single port, or single site surgery for retro-peritoneoscopic nephrectomy and nephro-ureterectomy in paediatric practice using an advanced access platform (GelPOINT Mini) is described in two patients. One patient had bilateral synchronous nephrectomy. The technique, advantages, and challenges are reported. Beyond the initial hurdles and learning curve, this technique is promising and has the potential to be extended to other procedures in paediatric urology. ª 2014 Journal of Pediatric Urology Company. Published by Elsevier Ltd. All rights reserved.
Introduction
Case 2
The retro-peritoneoscopic approach using a single incision for paediatric nephrectomy and nephro-ureterectomy utilising the advanced access platform (GelPOINT Mini) is presented.
An eight-year-old girl with poorly functioning duplex kidney (5 cm) and dilated non-refluxing ureters underwent nephroureterectomy. GelPOINT Mini (Applied Medical, CA, USA) (Fig. 2), Epix in-line angled dissector (Applied Medical), (see Fig. 4), 30-degree, 5-mm telescope and other conventional instruments were used.
Patients and methods Case 1 A 13-year-old female with nephrotic syndrome had synchronous, bilateral nephrectomies (each 10 cm). * Corresponding author. Tel.: þ44 207 405 9200. E-mail addresses: [email protected], acnmac@ gmail.com (A. Cherian).
Technique In the prone position, the hips and the chest were elevated. A single transverse 2.5-cm incision was made at the midpoint on a line along the lateral border of erector spinae bound by lower border of the 12th rib and the iliac crest. Posterior abdominal muscles were gently split and the deep lumbodorsal fascia incised. The retro-peritoneum was entered and the inner ring (Fig. 1) positioned deep to the
1477-5131/$36 ª 2014 Journal of Pediatric Urology Company. Published by Elsevier Ltd. All rights reserved. http://dx.doi.org/10.1016/j.jpurol.2013.12.018
Please cite this article in press as: Cherian A, De Win G, Single incision retro-peritoneoscopic paediatric nephrectomy: Early experience, Journal of Pediatric Urology (2014), http://dx.doi.org/10.1016/j.jpurol.2013.12.018
+
MODEL
2
A. Cherian, G. De Win
Figure 3 The Alexis retractor in position. Tightening the retractor aids in retraction of the wound opening, at all times. Figure 1 GelPOINT Mini e Advanced access platform kit. 1. Alexis retractor: inner ring (green), outer ring (white). 2. Retractor retrieval cord. 3. Sleeves. 4. Trocar/introducer. 5. Gel-seal cap. (For interpretation of the references to colour in this figure legend, the reader is referred to the web version of this article.)
lumbodorsal fascia (Fig. 3). Rolling in of the outer ring retracts the wound. Three sleeves were placed through the Gel-seal cap and then placed on the outer ring of the retractor and locked (Fig. 2). Hilar vessels were divided by
endoclip application or a harmonic scalpel. The kidney was retrieved using a 10-mm endobag in piecemeal fashion. In Case 2, the ureter was divided below the pelvic brim, and the kidney retrieved without an endobag. The Alexis retractor was removed and the wound closed in layers.
Results Three nephrectomies in two patients were performed at two centres. The first side in Case 1 took 170 min and the second side was completed in 55 min. Oral intake and mobility was resumed the same day in both patients. In Case 2, surgery was performed in 80 min and discharged the next day. Case 1 was discharged from urology care to the dialysis ward the next day for haemodialysis. There were no perioperative complications.
Discussion The GelPOINT Mini enables a novel approach to the retroperitoneum with ease and predictability, as access is under vision and control. A 2.5-cm incision seemed to be adequate even in the older child with large kidneys. The Alexis retractor prevents dissection in the wrong plane,
Figure 2 GelPOINT Mini e Advanced access platform: assembled. 1. Lock. 2. Inner ring of the Alexis retractor.
Figure 4 GelPOINT Mini e Advanced access platform in position and locked. 1. Epix in-line angled laparoscopic dissector.
Please cite this article in press as: Cherian A, De Win G, Single incision retro-peritoneoscopic paediatric nephrectomy: Early experience, Journal of Pediatric Urology (2014), http://dx.doi.org/10.1016/j.jpurol.2013.12.018
+
MODEL
Single incision retro-peritoneoscopic paediatric nephrectomy subcutaneous emphysema, and probably reduces the risk of wound infection [1]. The Gel-seal cap provides a flexible platform with freedom to change sleeve position without incisions. The sleeves are low profile and accommodate both 5 mm and 10 mm instruments. Two ports are generally sufficient for nephrectomy as previously described by our centre [2]. However, placing an additional instrument through another mounted sleeve, without another incision, has the potential to make the operation easier and quicker. The cap incorporates both insufflation and smoke evacuation channels, enabling continuous access and visualisation. Crowding of instruments is often a challenge to overcome and requires a combination of swapping the instruments and telescope between the different ports, and using angled instruments. The Epix dissector has a low profile mechanism, an in-line handle and diathermy cord, and a 20-degree angle, which facilitates freedom of movements without crowding (Fig. 4). Kidney retrieval with the endobag is straightforward without loss of working space. Smaller kidneys do not require an endobag as the Alexis retractor maintains the wound opening. Large kidneys, older children, excision of ureter, and reduction in subcutaneous emphysema, especially in children with nephrotic syndrome, are specific situations where the above approach would make it potentially less laborious, quicker, predictable, and teachable. Single incision trans-peritoneal nephrectomy has been previously described in children [3,4]. The retroperitoneal route employed in three adult patients using a different device has been reported [5]. To the best of our knowledge, our report is the first of its kind in children using the retro-
3 peritoneal prone approach. We are encouraged by our initial experience and short learning curve, and foresee the use of this technique in other settings.
Conflict of interest None.
Funding None.
References [1] Edwards JP, Ho AL, Tee MC, Dixon E, Ball CG. Wound protectors reduce surgical site infection: a meta-analysis of randomized controlled trials. Ann Surg 2012;256:53e9. [2] Garg S, Gundeti M, Mushtaq I. The single instrument port laparoscopic (SIMPL) nephrectomy. J Pediatr Urol 2006;2: 194e6. [3] Barbancho DC, Fraile AG, Va ´zquez FL, Bramtot AA. Single-port nephrectomy in infants: initial experience. J Pediatr Urol 2011;7:396e8. [4] Johnson KC, Cha DY, DaJusta DG, Barone JG, Ankem MK. Pediatric single-port-access nephrectomy for a multicystic, dysplastic kidney. J Pediatr Urol 2009;5:402e4. [5] Butterworth C, Gkougkousis E. Single port laparoscopic nephrectomy via a retroperitoneal approach. Br J Med Surg Urol 2010;3:128.
Please cite this article in press as: Cherian A, De Win G, Single incision retro-peritoneoscopic paediatric nephrectomy: Early experience, Journal of Pediatric Urology (2014), http://dx.doi.org/10.1016/j.jpurol.2013.12.018