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WHAT IS LAPAROSCOPY?
Laparoscopy means looking into the abdomen and examining it via a special telescope connected with a camera system. With the help of this optic and camera system one can perform necessary surgical interventions, which are called laparoscopic surgery. During a laparoscopic surgery 3 to 4 tubules called trochars are placed via the abdominal skin to open a way into the abdominal cavity and CO2 gas is given, so that the abdominal cavity is bloated up with a necessary pressure to create a suitable place for surgery in the abdomen. A suitable high resolution telescope providing approximately 10 times magnification is then placed into the abdomen through one of the trochars and the camera-images are reflected onto the screen. Other procedure-specific manual instruments in different shapes and functions, designed and developed in years specially for laparoscopic procedural needs are introduced through other trochars and the surgery is performed.
HISTORY
Laparoscopy has been defined at starting of 1900s. Firstly, abdominal cavity of animals had blown up with miscellaneous gases by helping of telescope put in, it has been attempted with diagnostic purpose. Afterwards, as of 1970s laparoscopy showed improvement by dizzying speed. History of laparoscopy went to about 100 years before and its usage of therapeutic purpose in our country was very late. Laparoscopy has been started to apply at urology as of end of 1990s in Turkey and at this 10-year process made very important progress. Reasons of later coming of laparoscopic surgery to our country may be deemed as being newly sufficient of technical facilities and training of this surgical technique developed in abroad is more difficult and taking up longer time than open surgery.. Now if patient has no situation to be an obstacle at urology (to be mentioned) for some operations, laparoscopy is offered as first choice to patients.
WHICH OPERATIONS CAN BE MADE AS LAPAROSCOPIC AT UROLOGY?
At urologic surgery, usage areas of laparoscopy are very broad. Laparoscopic surgery, especially at uro-oncologic surgery has been submitting very important advantages to patients and physicians.
PROSTATE
Prostate Cancer: Laparoscopic Radical Prostatectomy
KIDNEY
Kidney cancer: Laparoscopic Radical Nephrectomy
Laparoscopic Partial Nephrectomy
Non-functional Kidney: Laparoscopic Simple Nephrectomy
Kidney outlet obstruction: Laparoscopic Pyeloplasty (Ureteropelvic Narrowing)
Kidney Cyst: Laparoscopic Cyst Excision
SUPRARENAL-ADRENAL GLAND
Adrenal cancer: Laparoscopic Surrenalectomy
TESTIS
Testis cancer: Laparoscopic Retroperitoneal Lymph Node Dissection
Undescended Testis: Laparoscopic Orchidopexy
Diagnostic Laparoscopy
BLADDER
Bladder cancer: Laparoscopic Radical Cysctectomy and Urinary diversion
Bladder diverticulum: Laparoscopic diverticulectomy
Cystocele: Laparoscopic sacrocolpopexy
WHAT ARE ADVANTAGES OF LAPAROSCOPIC SURGERY?
There are very important advantages of operation by this system proved with miscellaneous studies. There are;
- Less bleeding during operation
- Less pain after operation
- Much shorter convalescence after operation
- Returning within shorter time to daily activities and business life
- In terms of cosmetic when it compares with open surgery, there is much smaller cicatrix on patient’s skin.
WHAT ARE DISADVANTAGES OF LAPAROSCOPIC SURGERY?
In spite of there is no disadvantage of laparoscopic surgery treatment from the point of patient, for a patient group not operating is suitable . Thus, it is required to take care of choice of suitable patients. Disadvantage of this system from the point of surgeons is long and hard of learning process.
Contraindications of laparoscopic surgery definitely:
- Incurable bleeding diseases,
- Intestinal obstructions,
- Active infections at abdominal wall,
- Cancers spread to peritoneum
Contraindications of Laparoscopy application as relative:
- Obesity
- Previous big intraabdominal operations
- Pregnancy
- Serious respiratory failure
- Serious arrhythmia
- Heart diseases
Laparoscopic surgery complications (possible problems dependend on operation)
The most important thing at laparoscopic surgery is physician’s well-educated and experienced at this subject. Complication rates connected to laparoscopic surgery are very low levels by correct patient choice of a well-read and well-educated surgeon. Complication rate is approx. 3-5 % at laparoscopic surgery. The most frequent complications are bleeding and passing to open surgery by miscellaneous reasons. Besides there is complication of excessive increasing of intraabdominal pressure possible to be caused troubles of patient’s respiratory and heart operating very decreased by developing of technical equipment during operation. Today patients living this annoyance, has already respiratory distress and cardiac insufficiency before operation.
INFORMATION RELATED TO SOME LAPAROSCOPIC OPERATIONS USED OFTEN AT UROLOGY
Patient preparation before laparoscopic surgery
Urological laparoscopic operations are performed under general anesthesia. So routine preoperative examinations of chest X-ray, electrocardiography (ECG) and some blood tests necessary for the preparation of the patient for general anesthesia are performed. When the patient has an additional disease, he/she is referred to a consultant for advanced evaluation so that any additional risk of surgery and general anesthesia could be determined and precautions taken. If these examinations show that the patient is suitable for surgery, the patient is admitted to hospital a day before the operation, colon cleaning to minimize operational risks is achieved at that night by giving him/her medicines. Prophylactic antibiotics are also given. He/she should not eat/drink anything for the last 6 hours before the operation to minimize the risk of aspiration during anesthesia. Intravenous fluids are added to prevent dehydration in this period.
Patient Follow-up after laparoscopic surgery
The patient after operation is followed for a time in reanimation room. During this follow-up, After following of blood pressure, pulse rate, respiratory, liquid quantity from surgical drainage, it is seen the patient is stabile, afterwards the patient is taken to service bed.
It may be felt a light pain or discomfort feeling on operation area. Along blood pressure, pulse rate, respiratory, fever follow-up, a pain killer diagnosis can be applied upon patient’s request. Next day it is passed to nutrition from mouth with intestinal motility control by your physician’s suggestion. Urinary catheter generally is taken evening or morning (at laparoscopic radical prostatectomy, catheter between 15-21st day) after operation. The patient is walked, afterwards if drainage is not working it is taken. After evaluation of patient’s general situation, after operation 1 or 2 days the patient is discharged.
First day after operation it generally is preferred nutrition with liquid or soft food. Next period it is passed to normal nutrition.
Laparoscopic Radical Prostatectomy
The prostate gland plays a very important place in the male production, it provides liquidation of seminal fluid and helps to maintain the vitality of sperms within the semen, but it begins to became larger after about 40 years of age. If this enlarging has benign causes, this is called benign prostate hyperplasia (BPH). As one gets older, this commonly seen BPH may cause urinary obstruction by causing narrowing of the outlet of the urinary bladder and urinary canals and related symptoms like difficulties during urination, slowing down or interruptions of the urinary flow, incomplete emptying of the urinary bladder or frequent nocturnal urination may develop. Malignant tumor of the prostate is prostate cancer, which is the most common cancer seen in male population. Prostate cancer is curable if diagnosed early, so yearly screening with prostate examination and serum prostate specific antigen (PSA) levels is advised over the age of 50.
Treatment of prostate cancer varies according to the stage of the disease and according to the age and general health status of the patient; surgery, anti-hormonal treatment (medical treatment), radiotherapy, cryotherapy or brachiotherapy maybe the treatment choices. If suitable for the patient and if cancer is limited to the gland, surgical treatment is given in the medical literature to be the most effective choice
5 small holes (varying between 5 to 10 millimeter diameter) in the abdominal region are necessary for the placing of the tubules (trochars). The hole in the umbilical region is for the tubule (trochar) passing carbon dioxide gas into the abdomen. This gas pushes the abdominal wall upwards and to sides, so that we can view inside easily with the help of a telescope connected to a camera system, which is let there through the same tubule. The space created this way also enables us to operate freely. Findings are evaluated and the operation is performed using the necessary manual instruments mentioned above.
Laparoscopic surgery has been performed commonly for the treatment of prostate cancer since 1999. Laparoscopic radical prostatectomy has many advantages of laparoscopy like less blood loss, less pain after the operation, shorter hospitalization and shorter time needed to return normal diet end daily activities compared with the classical surgery, and also shorter time is needed till the catheter is taken out, which is placed after the surgery to assure urinary passage from the bladder to the penis. Cancer control is also equal to the classical open surgery with a large incision. Urinary incontinence and penile hardening commonly seen after classical operations are rare complications after laparoscopic surgery performed by an experienced surgeon.
LAPAROSCOPIC NEPHRECTOMY
Nephrectomy with a classical surgery needs an incision up to 10-15 cm. If the tumor is large the 11th or 12th costal bone should be resected in addition to the large incision mentioned above. Muscles and nerves damaged because of such a resection cause pain and numbness for a long time. This also causes delayed healing. At present laparoscopic nephrotomy is the standard practice in all centers with an experienced surgeon in this procedure.
What is laparoscopic nephrectomy, when is it performed?
Laparoscopic nephrectomy is a minimal invasive (causing less trauma) surgical procedure to excise the kidney. Simple laparoscopic nephrectomy is performed when there is an infection, stone, obstruction, congenital hypoplasia or kidney dysfunction secondary to vascular obstructions because of for example hypertension. Laparoscopic radical nephrectomy on the other hand is an excellent treatment method to excise kidney tumors up to a 12-15 cm diameter, if they are localized within the kidney. Unlike classical surgery, only a few 0.5 to 1 cm incisions are enough to place the telescope and special manual equipments and the kidney is excised with the help of them. Surgery lasts about 45 min. in simple laparoscopy but may last up to 4 hours in radical laparoscopy when there is a big tumor adherent to the peripheral tissues. In a laparoscopic kidney operation via three holes (a 1.2 cm, 1.0 cm, and 0.5 cm) the cancerous or dysfunctional kidney maybe excised totally or only the tumor maybe excised (laparoscopic partial nephrectomy) and the patient maybe discharged after 1 or 2 days.
What are advantages of application of nephrectomy as laparoscopic?
• Not being risk of intestine injury when it is operated as retroperitoneal
• Short term staying on hospital and speed recuperation
• After operation much less pain and much less using necessity for analgesic medicine
• Returning in short term to normal daily activities
• Positive cosmetic appearance because of small operation incision
LAPAROSCOPIC ADRENALECTOMY
The diagnosis and treatment of adrenal gland diseases need special attention. Owing to the minimal surgical damage, less pain and rapid healing effects laparoscopic surgery has became the standard surgical choice in adrenal surgery all around the world. Laparoscopic surgery maybe performed for adrenal tumors up to 10 cm. In the case of a functional (hormonally active) tumor causing hypertension called pheocromocytoma medication to achieve blood pressure control should be started under a supervision of an internal medicine or endocrinology specialist at least 2 weeks before the operation. A urinary catheter is placed to follow the urine amount excreted during the operation, under the anesthesia and during the first 24 hours postoperatively. The patient is positioned laying 45° to a side. Open surgery incisions for adrenal tumors could be seen in full size, but for laparoscopic surgery only a 1.5 cm incision is needed and the other 2 to 3 holes are smaller incisions approximately about 0.5 to 1 cm. Excised adrenal tumor is put into a small bag during the operation and taken out from the largest hole after bleeding control of the operation side.
What are advantages of laparoscopic adrenalectomy?
• In spite of a big operation incision, three or four each small surgical incision cicatrix
• Not being herniation risk from surgical incision like open surgery
• Long term pain risk is very low demand on cutting muscle layers and nerves during surgical incision
• Less pain after operation
• Short term staying on hospital – generally 1st or 2st day is discharged from hospital
• Speed recuperation and returning in short time to daily activities
At technicals of radiological imaging of an organ for diagnosis of adrenal (adrenal gland, surrenal) diseases, surgical treatment of adrenal gland as laparoscopic is applied with success with therapy measures before operation and improvements at anesthesia.
LAPAROSCOPIC PYELOPLASTY
What is UPJ narrowing, how is it diagnosed?
Kidney outlet obstruction (ureteropelvic narrowing-[UPJ narrowing) is the narrowing of the canal transiting urine from the kidney to the bladder, in such a case the kidney cannot empty the excreted urine fully and if not diagnosed and treated the kidney may loose its function after a time. This is a congenital disease and may manifest itself in the childhood with loin pain at that side and frequent lower or upper urinary tract infections.
In spite of this situation is determined with ultrasonography at that kidney, USG is not enough alone for operation decision. Definitive diagnosis could only be made with a method evaluating the flow of urine functionally from the kidney to the urinary canal. One of these method performed classically for this purpose is intravenous pyelography (IVP, kidney X-ray with medication). Here medication not enough emptied medication and pooled medication in the enlarged kidney pelvis should be visualized. The medication given for the IVP is an opaque substance visible with the X-ray and is given to the patient intravenously to follow the excretion of the substance from the kidneys. With serial X-ray films the function of the kidneys, collective systems and bladder is evaluated. An IVP showing UP-narrowing is not enough for definitive diagnosis and MAG-3 or DTPA scintigraphy with diuretics ( reno gram with diuretics) should be performed. After it is put upj narrowing diagnosis to a a patient, offered therapy methods are open or laparoscopic pyeloplasty operations.
Laparoscopic surgery also can be applied for child patients. For this operation again as mentioned above 3 trochar holes in 0.5-1 cm sizes are opened via the abdominal skin and the operation is performed. Preoperative preparation and postoperative care is the same as for other laparoscopic surgeries.
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