Category: Laparoscopy: Upper Tract - Benign
Introduction & Objective :
Laparoscopic pyelolithotomy is performed for both stones in the renal pelvis as well as those in the calyces when a concomitant pyeloplasty is required. While larger pelvic stones are often easily removed after pyelotomy, smaller calculi require flexible renoscopy to locate and remove them. Issues with conventional technique are: leakage of irrigating fluid out of the pyelotomy, instability of the scope within the pelvicalyceal system, difficulty in scope re-entry through the pyelotomy and the inherent risk of losing stones within the peritoneal cavity.
We describe a simple technique to circumvent challenges of combined laparoscopy and intra-renal endoscopy.
An eleven-year-old boy presented with bilateral flank pain. Intravenous urography revealed bilateral 7mm renal calculi with concomitant left pelvi-ureteric junction obstruction. The right renal stone was cleared with extracorporeal shock wave lithotripsy. Left laparoscopic pyelolithotomy and pyeloplasty were performed after informed assent and consent.
Pneumoperitoneum was achieved and three 5mm, 10cm long optical trocars were placed. Once the renal pelvis was dissected, a wide stitch was taken with 2-0 polypropylene on the pelvic well above the pelvi-ureteric junction. The stitch was hitched to the abdominal wall using a trocar site closure device (Endo Close, Covidien). A limited pyelotomy was made distal to the stitch, forming the superior apex (corner) of the traditional diamond cut on the renal pelvis made for pyeloplasty. The iliac port trocar was advanced directly into the hitched pyelotomy. The flexible scope (16.5F Olympus) was deployed through the trocar. For pyelolithotomy in adults, either a 15cm long trocar at the iliac port or a dedicated port may be placed for the purpose.
The system prevented excessive loss of irrigant, stabilized the pyelotomy for re-entry and hastened controlled stone removal. The flexible scope thus arranged, provided excellent vision and handling with minimal irrigation. The patient had an uneventful convalescence and was discharged on the second postoperative day. He has remained stone and symptom-free for 2 years after the operation.
The corner-hitch trocar technique increased time-efficiency by preventing loss of irrigant and stones into the peritoneal cavity. It allowed a stable platform for flexible scopy with the trocar acting as a fulcrum. There was decreased tissue handling at the pyelotomy; the trocar stayed in place while the scope could remove stones either whole or fragmented by laser. This technique is particularly useful for removing small stones prior to laparoscopic pyeloplasty.
Ranil Boaz– Assistant Professor, Christian Medical College, Vellore, Vellore, Tamil Nadu, India
Cornerstone Wann– Assistant Professor, Vellore, Tamil Nadu, India
Chandrasingh Berry– Professor, Vellore, Tamil Nadu, India
Antony Devasia– Professor, Vellore, Tamil Nadu, India
Christian Medical College, Vellore
Vellore, Tamil Nadu, India