Wednesday, November 9, 2011

Widgets

Robotic-assisted laparoscopic ureterolithotomy OP Report

PREOPERATIVE DIAGNOSES: 2 cm left proximal ureteral stone, 6 mm left lower pole renal stone.

POSTOPERATIVE DIAGNOSES: 2 cm left proximal ureteral stone, 6 mm left lower pole renal stone.

OPERATION PERFORMED: Robotic-assisted laparoscopic ureterolithotomy, intraoperative ureteroscopy with basketing of renal stone.

ANESTHESIA: General endotracheal.

FLUIDS: 2000 mL of crystalloid.

ESTIMATED BLOOD LOSS: 50 mL.

URINE OUTPUT: Not measurable.

COMPLICATIONS: None.

SPECIMENS: Stone sent for metabolic evaluation.

DRAINS:
• 16-French urethral catheter.
• 15-French round Blake drain.

DISPOSITION: Patient was taken to the recovery room in stable condition.

OPERATION:
Patient was brought to the operating room. The patient was identified by myself. The patient was intubated in the supine position. The patient was then placed in the left flank up position. The patient was prepped and draped in the standard sterile fashion. A surgical time-out was performed. The films were reviewed. A urethral catheter was inserted prior to starting the procedure.

A 1.1 cm incision was made above the umbilicus. Veress needle was inserted. Saline drop test confirmed good position. The belly was insufflated to 15 cm of water. A 12 mm Visiport was then inserted into the belly. There was no evidence of any Visiport or Veress needle injury.

Thereafter, two 8 mm trocars were inserted, one in the left upper quadrant and one in the left lower quadrant. A 5 mm trocar was inserted in the lower midline. The patient was placed in the steep left-sided up position. The Da Vinci surgical system was docked.

The colon was mobilized off of the anterior surface of the kidney all the way up to the spleen. After mobilizing off the colon, we elevated the retroperitoneal fat, scored Gerota's fascia, identified the ureter, and dissected up towards the main renal hilum. Just at the level of the lower pole, we could see a transition point where the ureter became from a point of being fairly narrow to very large. I used vessel loops above and below this area of narrowing, so that I could occlude the stones and wouldn't migrate in a retrograde direction.

I then incised the anterior surface of the ureter. The stone was impacted in here. I gently milked it out after getting around it. The stone came out in its entirety. The patient did have a fairly raw-looking ureter and that's not surprising given the degree of impaction that the patient had.

I then inserted the ureteroscope through my 5 mm accessory trocar. Cannulated the ureter and got all the way up into the kidney. Panendoscopy revealed the lower pole 6 mm renal stone. This was grasped, basketted, and removed in it's entirety.

There were no other stones in the kidney on intraoperative ureteroscopy.

At this point, flexible cystoscopy was performed. There was no evidence of any intravesical bladder abnormalities whatsoever. I did insert a stent, 6-French variable length that had a good curl in the bladder and traversed across the ureterolithotomy defect. The ureterolithotomy was then closed in 2 layers using interrupted 3-0 Vicryl sutures on an RB-1 needle. At the end of the case, I gave indigo carmine as well as Toradol. There was no evidence of any urinary extravasation in the field.

A 15-French Blake drain was inserted through the lower midline trocar. I placed a 10 mm EndoCatch for extraction of the specimen. Mastisol and Steri-Strips were used after removing all of the trocars. Of note, the midline trocar had a 0 Vicryl suture on a UR-6 needle used to close the fascia.

No comments:

Post a Comment

Total Pageviews