Материал: Oxford American Handbook of Urology ( PDFDrive )

652 CHAPTER 16 Urological surgery and equipment

Laparoscopic surgery

Virtually every urological procedure can be done laparoscopically. It is particularly suited to surgery in the retroperitoneum (nephrectomy for benign and malignant disease and for kidney donation at transplantation, pyeloplasty for UPJO), but is also suited to pelvic surgery (lymph node biopsy, radical prostatectomy).

Reconstructive surgery requiring laparoscopic suturing and using bowel is technically very challenging, but is possible. Laparoscopic surgery offers the following advantages over open surgery:

•Reduced postoperative pain

•Smaller scars

•Less disturbance of bowel function (less postoperative ileus)

•Reduced recovery time and reduced hospital stay

Contraindications to laparoscopic surgery

•Severe COPD (avoid use of CO2 for insufflation)

•Uncorrectable coagulopathy

•Intestinal obstruction

•Abdominal wall infection

•Massive hemoperitoneum

•Generalized peritonitis

•Suspected malignant ascites

Laparoscopic surgery is difficult or potentially hazardous in the morbidly obese (inadequate instrument length, decrease range of movement of instruments, higher pneumoperitoneum pressure required to lift the heavier anterior abdominal wall, excess intra-abdominal fat limiting the view); those with extensive previous abdominal or pelvic surgery (adhesions); those with previous peritonitis leading to adhesion formation; in those with organomegaly; in the presence of ascites; in pregnancy; in patients with a diaphragmatic hernia; and in those with aneurysms.

Potential complications unique to laparoscopic surgery

These include gas embolism (potentially fatal), hypercarbia (acidosis affecting cardiac function—e.g., arrhythmias), post-operative abdominal crepitus (subcutaneous emphysema), pneumothorax, pneomomediastinum, pneumopericardium, barotraumas.

Bowel, vessel (aorta, common iliac vessels, IVC, anterior abdominal wall injury), and other viscus injury are not unique to laparoscopic surgery, but are a particular concern during port access. Perforation of small or large bowel is the most common trocar injury. Rarely, the bladder is perforated.

Failure to progress with a laparoscopic approach or vessel injury with uncontrollable hemorrhage requires conversion to an open approach. Postoperatively, bowel may become entrapped in the trocar sites, or there may be bleeding from the sheath site.

An acute hydrocele can develop from irrigation fluid accumulating in the scrotum. It resorbs spontaneously. Scrotal and abdominal wall bruising commonly occurs.

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656 CHAPTER 16 Urological surgery and equipment

Scrotal exploration for torsion and orchiopexy

Indications

Scrotal exploration is used for suspected testicular torsion.

Technique

A midline incision is used, since this allows access to both sides so that they may both be fixed within the scrotum. Untwist the testis and place in a warm, saline-soaked swab for 10 minutes.

If it remains black, remove it, having ligated the spermatic cord with a transfixion stitch of absorbable material. If it pinks up, fix it. If uncertain about its viability, make a small cut with the tip of a scalpel. If the testis bleeds actively, it should be salvaged (close the small wound with an absorbable suture). If not, it is dead and should be removed. Whatever you do, fix the other side, since the predisposing “bell clapper” deformity tends to be bilateral.

Fixation technique

Some surgeons fix the testis within the scrotum with suture material, inserted at 3 points (3-point fixation). Some use absorbable sutures and others, nonabsorbable sutures. Those who use the latter argue that absorbable sutures may disappear, exposing the patient to the risk of retorsion.1

Those who use absorbable sutures argue that the fibrous reaction around the absorbable sutures prevents retorsion and argue that the patient may be able to feel nonabsorbable sutures, which can be uncomfortable. The sutures should pass through the tunica albuginea of the testis, and then through the parietal layer of the tunica vaginalis lining the inner surface of the scrotum.

Others say the testis should be fixed within a dartos pouch,2 arguing that suture fixation breaches the blood–testis barrier, exposing both testes to the risk of sympathetic orchiopathia (an autoimmune reaction caused by development of antibodies against the testis).

For dartos pouch fixation, open the tunica vaginalis, bring the testis out and untwist it. Develop a dartos pouch in the scrotum by holding the skin with forceps and dissecting with scissors between the skin and the underlying dartos muscle. Enlarge this space by inserting your two index fingers and pulling them apart. Place the testis in this pouch.

Use a few absorbable sutures to attach the cord near the testis to the inside of the dartos pouch to prevent retorsion of the testes. The dartos may then be closed over the testis and the skin can be closed in a separate layer.