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The ‘double hitch’ manoeuvre in laparoscopic pyeloplasty – Early experience
Journal of Pediatric Urology (2013) 9, 524e526
The ‘double hitch’ manoeuvre in laparoscopic pyeloplasty e Early experience Abraham Cherian*, Hemant Nemade Department of Paediatric Urology, Great Ormond Street Hospital for Children NHS Foundation Trust, London WC1N 3JH, UK Received 10 December 2012; accepted 8 January 2013 Available online 23 February 2013
KEYWORDS Pyeloplasty; Children; Laparoscopic
Abstract Intra-corporeal anastomosis in laparoscopic pyeloplasty is laborious, time consuming and challenging. 14 children underwent laparoscopic dismembered pyeloplasty using a three port, transperitoneal approach over a one year period in whom a novel approach (“double hitch” manoeuvre) (Group-2, n Z 9) was used and operating times compared with the conventional “single hitch” (Group-1, n Z 5). The mean operating time in Group 1 (172.4 min) and in Group 2 (129.5 min) was significantly different. Mean follow up in Group1 and Group-2 was 14 and 6 months respectively. Utilisation of the “double hitch” manoeuvre in laparoscopic pyeloplasty reduces the operating time and probably makes it less laborious. ª 2013 Journal of Pediatric Urology Company. Published by Elsevier Ltd. All rights reserved.
Introduction One of the major deterrents in the wider adoption of laparoscopic pyeloplasty in children is because intra-corporeal anastomosis is considered labour intensive and time consuming. A novel technique to facilitate the operation is described: “double hitch” manoeuvre; potential benefits stated and operating times compared against the conventional “single hitch” technique [1].
Technique With the patient positioned in true lateral, a transperitoneal route using three, 5 mm ports gains access to the
pelvi-ureteric junction obstruction (PUJO). A 2/0-monofilament suture on a 40 mm-needle is introduced percutaneously through the anterior abdominal wall and a point, high on the pelvis is chosen for the first hitch stitch (“single hitch”). The pelvis is divided completely and the cranial end of the lower divided segment is transfixed (“double hitch”) with the same needle suture (Fig. 1). The “double hitch” elevates both divided segments anterior to the lower pole vessels (if present), aligned one beside the other (Fig. 2). The ureter is spatulated and anastomosis begins at the heel using continuous 5/0 PDS. One wall is first completed and a 4.7Fr JJ stent inserted percutaneously across the anastomosis over a guide wire. Remaining wall anastomosis is completed using a fresh 5/0 PDS starting again at the heel. The redundant cranial end of the lower
* Corresponding author. Tel.: þ44 207 405 9200; fax: þ44 207 813 8260. E-mail addresses: [email protected], [email protected] (A. Cherian). 1477-5131/$36 ª 2013 Journal of Pediatric Urology Company. Published by Elsevier Ltd. All rights reserved. http://dx.doi.org/10.1016/j.jpurol.2013.01.011
The ‘double hitch’ manoeuvre in laparoscopic pyeloplasty
Figure 1 Pictoral representation of the “double hitch”, which stabilises and elevates both segments to be anastomosed anterior to the lower pole vessels (LPV).
divided segment is then excised. The hitch stitch is removed, port sites closed, bladder drained for the first 48 h, and the patient then discharged home. The JJ stent is removed in 4e6 weeks time.
525
Figure 2 Right pyeloplasty; shows the heel stitch that begins the anastomosis, in progress when both segments (pelvis and ureter) have been stabilised and elevated by the “double hitch”(grey arrow).
showed improved drainage on post-operative MAG-3 renogram. The others are awaiting renograms. The Wilcoxon test demonstrated a significant difference in operating times between the two groups.
Discussion The study Operating times of all children who underwent laparoscopic dismembered pyeloplasty were noted on a retrospective one-year (2011e2012) review of a single surgeon experience. Pre-operative and follow up imaging, included ultrasound (US) and radioisotope studies (Tc99m Mag3).
Results The results are summarized in Table 1. No complications were noted. At follow up all patients in both the groups were asymptomatic and showed improvement in dilatation on US. All patients in Group-1 and 4 of 9 patients in Group-2
The “double hitch” manoeuvre offers several advantages at different stages of the procedure. Firstly, it provides stabilisation, approximation, alignment, elevation, and isolation from surrounding viscera of both segments to be anastomosed even in the presence of a lower polar vessel. Secondly, it aids accurate ureteric spatulation, as the ureter is stable and stationary, preventing rotation and spiral cuts. It further helps to assess the extent of spatulation required more accurately against the adjacent open pelvis. Thirdly, the heel stitch to begin the anastomosis, which is considered quite challenging can be precisely placed, as both segments are stationary and aligned. Approximation is tension free thus reducing the risk of cheese wiring and the first knot from coming undone. Fourthly, continuous
Table 1
Comparison of the two groups in this study.
Groups
No. pts
Left: right
Sex (M:F)
Presentation
Mean age (months)
Mean operating time (min)
Range-operating time (min)
P value
Mean follow up (months)
Group 1a
5
3:2
3:2
112.8
172.4
150e192
<0.001
14
Group 2b
9
6:3
6:3
Antenatal hydronephrosis 1, Pain 2, UTI 1, Incidental 1 Antenatal hydronephrosis 2, Pain 5, UTI 2
116.6
129.5
114e149
a b
Single hitch group. Double hitch group.
6
526
A. Cherian, H. Nemade
Table 2
Comparative studies of laparoscopic pyeloplasty.
No.pts Mean age (months) Mean operating time (minutes) Mean follow up (months) % Complications % Failures a
Ravish et al. [2]
Piaggio et al. [3]
Braga et al. [4]
Lee et al. [5],a
15 51.6 214 23 13 7
37 60 345 6.3 36 3
41 94.8 178 28 10 5
33 93.6 219 10 3.3 6.1
Yee et al. [6],a 8 363 15 12.5 0
Current sudy (Group 2) 9 116.6 129.5 6 e e
Robot assisted pyeloplasty.
and meticulous suturing between stabilised segments is accompanied by economy of movements and minimal tissue handling. Lastly, as both laparoscopic working instruments are free, they can be used to manipulate the stent into the right place. The ability to raise and lower both segments by adjusting the tension on the hitch facilitates every stage of the procedure. Comparative studies to illustrate operating times from other published literature are highlighted (Table 2) [2e6]. We conclude that this manoeuvre reduces operating time and probably makes it less labour intensive. We also propose that it has the potential to minimize the learning curve for beginners and augment the skills of an expert. The technique should appeal to both paediatric and adult surgeons whether transperitoneal, retroperitoneal or even if robot assisted approaches are employed.
Conflict of interest None.
Funding None.
Supplementary video related to this article can be found at http://dx.doi.org/10.1016/j.jpurol.2013.01.011.
References [1] Tan HL, Roberts JP. Laparoscopic dismembered pyeloplasty in children: preliminary results. Br J Urol 1996;77(6):909e13. [2] Ravish IR, Nerli RB, Reddy MN, Amarkhed SS. Laparoscopic pyeloplasty compared with open pyeloplasty in children. J Endourol 2007;21:897. [3] Piaggio LA, Franc-Guimond J, Noh PH, Wehry M, Figueroa TE, Barthold J, et al. Transperitoneal laparoscopic pyeloplasty for primary repair of ureteropelvic junction obstruction in infants and children: comparison with open surgery. J Urol 2007;178: 1579. [4] Braga LH, Lorenzo AJ, Ba ¨gli DJ, Mahdi M, Salle JL, Khoury AE, et al. Comparison of flank, dorsal lumbotomy and laparoscopic approaches for dismembered pyeloplasty in children older than 3 years with ureteropelvic junction obstruction. Urol 2010 Jan; 183(1):306e11. [5] Lee RS, Retik AB, Borer JG, Peters CA. Pediatric robot assisted laparoscopic dismembered pyeloplasty:comparison with a cohort of open surgery. J Urol 2006;175:683. [6] Yee DS, Shanberg AM, Duel BP, Rodriguez E, Eichel L, Rajpoot D. Initial comparison of robotic-assisted laparoscopic versus open pyeloplasty in children. Urology 2006;67:599.
The ‘double hitch’ manoeuvre in laparoscopic pyeloplasty e Early experience Abraham Cherian*, Hemant Nemade Department of Paediatric Urology, Great Ormond Street Hospital for Children NHS Foundation Trust, London WC1N 3JH, UK Received 10 December 2012; accepted 8 January 2013 Available online 23 February 2013
KEYWORDS Pyeloplasty; Children; Laparoscopic
Abstract Intra-corporeal anastomosis in laparoscopic pyeloplasty is laborious, time consuming and challenging. 14 children underwent laparoscopic dismembered pyeloplasty using a three port, transperitoneal approach over a one year period in whom a novel approach (“double hitch” manoeuvre) (Group-2, n Z 9) was used and operating times compared with the conventional “single hitch” (Group-1, n Z 5). The mean operating time in Group 1 (172.4 min) and in Group 2 (129.5 min) was significantly different. Mean follow up in Group1 and Group-2 was 14 and 6 months respectively. Utilisation of the “double hitch” manoeuvre in laparoscopic pyeloplasty reduces the operating time and probably makes it less laborious. ª 2013 Journal of Pediatric Urology Company. Published by Elsevier Ltd. All rights reserved.
Introduction One of the major deterrents in the wider adoption of laparoscopic pyeloplasty in children is because intra-corporeal anastomosis is considered labour intensive and time consuming. A novel technique to facilitate the operation is described: “double hitch” manoeuvre; potential benefits stated and operating times compared against the conventional “single hitch” technique [1].
Technique With the patient positioned in true lateral, a transperitoneal route using three, 5 mm ports gains access to the
pelvi-ureteric junction obstruction (PUJO). A 2/0-monofilament suture on a 40 mm-needle is introduced percutaneously through the anterior abdominal wall and a point, high on the pelvis is chosen for the first hitch stitch (“single hitch”). The pelvis is divided completely and the cranial end of the lower divided segment is transfixed (“double hitch”) with the same needle suture (Fig. 1). The “double hitch” elevates both divided segments anterior to the lower pole vessels (if present), aligned one beside the other (Fig. 2). The ureter is spatulated and anastomosis begins at the heel using continuous 5/0 PDS. One wall is first completed and a 4.7Fr JJ stent inserted percutaneously across the anastomosis over a guide wire. Remaining wall anastomosis is completed using a fresh 5/0 PDS starting again at the heel. The redundant cranial end of the lower
* Corresponding author. Tel.: þ44 207 405 9200; fax: þ44 207 813 8260. E-mail addresses: [email protected], [email protected] (A. Cherian). 1477-5131/$36 ª 2013 Journal of Pediatric Urology Company. Published by Elsevier Ltd. All rights reserved. http://dx.doi.org/10.1016/j.jpurol.2013.01.011
The ‘double hitch’ manoeuvre in laparoscopic pyeloplasty
Figure 1 Pictoral representation of the “double hitch”, which stabilises and elevates both segments to be anastomosed anterior to the lower pole vessels (LPV).
divided segment is then excised. The hitch stitch is removed, port sites closed, bladder drained for the first 48 h, and the patient then discharged home. The JJ stent is removed in 4e6 weeks time.
525
Figure 2 Right pyeloplasty; shows the heel stitch that begins the anastomosis, in progress when both segments (pelvis and ureter) have been stabilised and elevated by the “double hitch”(grey arrow).
showed improved drainage on post-operative MAG-3 renogram. The others are awaiting renograms. The Wilcoxon test demonstrated a significant difference in operating times between the two groups.
Discussion The study Operating times of all children who underwent laparoscopic dismembered pyeloplasty were noted on a retrospective one-year (2011e2012) review of a single surgeon experience. Pre-operative and follow up imaging, included ultrasound (US) and radioisotope studies (Tc99m Mag3).
Results The results are summarized in Table 1. No complications were noted. At follow up all patients in both the groups were asymptomatic and showed improvement in dilatation on US. All patients in Group-1 and 4 of 9 patients in Group-2
The “double hitch” manoeuvre offers several advantages at different stages of the procedure. Firstly, it provides stabilisation, approximation, alignment, elevation, and isolation from surrounding viscera of both segments to be anastomosed even in the presence of a lower polar vessel. Secondly, it aids accurate ureteric spatulation, as the ureter is stable and stationary, preventing rotation and spiral cuts. It further helps to assess the extent of spatulation required more accurately against the adjacent open pelvis. Thirdly, the heel stitch to begin the anastomosis, which is considered quite challenging can be precisely placed, as both segments are stationary and aligned. Approximation is tension free thus reducing the risk of cheese wiring and the first knot from coming undone. Fourthly, continuous
Table 1
Comparison of the two groups in this study.
Groups
No. pts
Left: right
Sex (M:F)
Presentation
Mean age (months)
Mean operating time (min)
Range-operating time (min)
P value
Mean follow up (months)
Group 1a
5
3:2
3:2
112.8
172.4
150e192
<0.001
14
Group 2b
9
6:3
6:3
Antenatal hydronephrosis 1, Pain 2, UTI 1, Incidental 1 Antenatal hydronephrosis 2, Pain 5, UTI 2
116.6
129.5
114e149
a b
Single hitch group. Double hitch group.
6
526
A. Cherian, H. Nemade
Table 2
Comparative studies of laparoscopic pyeloplasty.
No.pts Mean age (months) Mean operating time (minutes) Mean follow up (months) % Complications % Failures a
Ravish et al. [2]
Piaggio et al. [3]
Braga et al. [4]
Lee et al. [5],a
15 51.6 214 23 13 7
37 60 345 6.3 36 3
41 94.8 178 28 10 5
33 93.6 219 10 3.3 6.1
Yee et al. [6],a 8 363 15 12.5 0
Current sudy (Group 2) 9 116.6 129.5 6 e e
Robot assisted pyeloplasty.
and meticulous suturing between stabilised segments is accompanied by economy of movements and minimal tissue handling. Lastly, as both laparoscopic working instruments are free, they can be used to manipulate the stent into the right place. The ability to raise and lower both segments by adjusting the tension on the hitch facilitates every stage of the procedure. Comparative studies to illustrate operating times from other published literature are highlighted (Table 2) [2e6]. We conclude that this manoeuvre reduces operating time and probably makes it less labour intensive. We also propose that it has the potential to minimize the learning curve for beginners and augment the skills of an expert. The technique should appeal to both paediatric and adult surgeons whether transperitoneal, retroperitoneal or even if robot assisted approaches are employed.
Conflict of interest None.
Funding None.
Supplementary video related to this article can be found at http://dx.doi.org/10.1016/j.jpurol.2013.01.011.
References [1] Tan HL, Roberts JP. Laparoscopic dismembered pyeloplasty in children: preliminary results. Br J Urol 1996;77(6):909e13. [2] Ravish IR, Nerli RB, Reddy MN, Amarkhed SS. Laparoscopic pyeloplasty compared with open pyeloplasty in children. J Endourol 2007;21:897. [3] Piaggio LA, Franc-Guimond J, Noh PH, Wehry M, Figueroa TE, Barthold J, et al. Transperitoneal laparoscopic pyeloplasty for primary repair of ureteropelvic junction obstruction in infants and children: comparison with open surgery. J Urol 2007;178: 1579. [4] Braga LH, Lorenzo AJ, Ba ¨gli DJ, Mahdi M, Salle JL, Khoury AE, et al. Comparison of flank, dorsal lumbotomy and laparoscopic approaches for dismembered pyeloplasty in children older than 3 years with ureteropelvic junction obstruction. Urol 2010 Jan; 183(1):306e11. [5] Lee RS, Retik AB, Borer JG, Peters CA. Pediatric robot assisted laparoscopic dismembered pyeloplasty:comparison with a cohort of open surgery. J Urol 2006;175:683. [6] Yee DS, Shanberg AM, Duel BP, Rodriguez E, Eichel L, Rajpoot D. Initial comparison of robotic-assisted laparoscopic versus open pyeloplasty in children. Urology 2006;67:599.