LAPAROSCOPIC TRANSPERITONEAN URETEROLITHOTOMY …



RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES,

Bangalore, Karnataka.

ANNEXURE-II

PROFORMA FOR REGISTRATION OF SUBJECTS FOR

DISSERTATION

1. NAME OF THE CANDIDATE AND Dr.Prasannakumar Kamble

ADDRESS S/O M. R. Kamble

Near Post Office Tikota

At Post- Tikota

Tq/Dist- Bijapur 586130

ADDRESS FOR CORRESPONDENCE Dept of general surgery

M. S. Ramaiah Medical College

and Teaching hospital Bangalore

2. NAME OF INSTITUTION M. S. Ramaiah Medical College

and Teaching hospital Bangalore

3. COURSE OF STUDY AND SUBJECT M. S. General surgery

4. DATE OF ADMISSION TO COURSE 13-05-2009

5. TITLE OF THE TOPIC EVALUATION OF LAPAROSCOPIC

TRANSPERITONEAL URETEROLITHOTOMY

FOR LARGE LOWER URETERIC CALCULI

EVALUATION OF LAPAROSCOPIC TRANSPERITONEAL URETEROLITHOTOMY FOR LARGE LOWER URETERIC CALCULI

6. BRIEF RESUME OF THE INTENDED WORK:

6.1 NEED FOR THE STUDY:

One of the major disorder of the urinary system causing concern to the patient and the

Doctor is stone formation and the severity of the condition can be judged from the fact that 10% of the patients harboring the stone in kidney lose their kidney either by nephrectomy or as a result of subsequent destruction. The damaging effect of the stone may be result of obstruction with dilatation of the urinary tract leading to stasis and severe infection with resulted fibrosis.

There are many modalities in the management of the ureteric stones. In recent years, great advances have been made in the development of minimally invasive procedures for treating urinary stones including extracorporeal shock wavelithotripsy (ESWL), laser, and flexible ureterorenoscopy

For the management of the lower ureteric stones, It is recognized that the advent of new minimally invasive procedures for treating urinary stones, such as ESWL, flexible ureterorenoscopy, percutaneous surgery, and use of laser has resulted in a marked decrease in morbidity. Despite all these developments, however, open surgery will continue to be indicated in some patients. Laparoscopic ureterolithotomy is primarily indicated as a salvage procedure in the event of a failed ureteroscopy and urerteric stones where open surgery is contemplated.. It can be conducted by retroperitoneal and transperitoneal approach.

Laparoscopic treatment of ureteral stones, a minimally invasive procedure, is feasible, safe, and quite effective. Many studies have shown that laparoscopic ureterolithotomy represents a safe and effective treatment option for ureteral stones either as primary for large impacted stones or as a salvage procedure after failed shock wave lithotripsy or ureteroscopy. This procedure fulfills the advantages of minimal blood loss and analgesia requirements, good cosmetic appearance, short hospital stay and convalescence period. So this present study is undertaken to evaluation of laparoscopic transperitoneal ureterolithotomy in the management of large lower ureteric stones.

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6.2 REVIEW OF LITERATURE

From time immemorial man has undoubtedly been affected with stone disease. Richu 1968 refered to a stone that was found in the pelvis of an egyptia skeleton estimated to be over 7000 years old

Although there is abundant proof from the archeological discoveries and ancient documents about urolithiasis. There is little or no mention about the ureteric calculi until

medieval times. Hippocratus 470-400 bc had described the signs, symptoms and also the treatment of the calculi.

During the course of time many methods have been developed for the treatment of ureteric stones. From

conservative treatment to operative. From invasive treatment to minimally invasive methods.

Lower ureteric calculi were usually treated earlier by shock wave lithotripsy or ureteroscopy and which are not amaneable and large calculi are treated by open ureterolithotomy. Recently newertechnique which are minimally invasive are conducted like laparoscopic ureterolithotomy. It can be conducted by retroperitoneal and transperitoneal approach.

Technique

Patients with lower ureteric stone of size >2CM were primarily treated with laparoscopy. Both the affected units had good renal function on intravenous urogram.

Prior placement of the double J stent

Placement of double J stent prior to laparoscopy is not only fraught with difficulty but also takes away precious time of the operating room. It could safely be avoided since it does not help in either localization of the ureter or stone during laparoscopy. With the technique described subsequently, it takes very little time to place the double J stent safely once the stone is taken out from the ureter.

Port placement strategy

Patient was placed trendelenberg positon. Location of the stone on the body surface in relation with bony landmarks was marked to help placing the ports. Camera port was placed at the umbilicus with open technique. Dominant port of 10 mm was inserted under vision in the iliac fossa and the non dominant port of 5 mm at the suprapubic area.

Mobilization of the colon and reaching the ureter

As soon as colon was reflected, iliac vessels were identified and then it becomes easy to identify the ureter, and the stone bulge over the ureter. Ureter was then dissected distally staying away from the adventitia till the stone site was reached.

Localization of the stone by "Ureteral pinching"

Due to absence of tactilefeedback, exact site of incision over the stone sometimes becomes challenging. Pinching the ureter gently gave us the exact location of the stone. Using Maryland dissector, a non stone bearing part of the ureter could be pinched fully but the stone carrying part could not be pinched.

Once the stone was localized by 'ureteral pinching', pointed diathermy hook or an endoknife was used to incise the ureter over the stone. Maryland dissector was used to fish out the stone with closed forceps' tip or using its one prong only. The same dissector could be used to hold the stone and bag it in the glove finger, which was then attached with a clip to the parietal wall for its removal at the end of surgery

Laparoscopic stenting.

Double DJ stent is placed and confirmed

Suturing the Ureterotomy incision

Once the stent was in place,5-0 vicryl was used to close the ureterotomy with interrupted stitches and a tube drain was placed before closing the ports

6.4 AIMS AND OBJECTIVE OF THE STUDY :

To evaluate the transperitoneal ureterolithotomy by laparoscopy for the management of the large (>2cm) lower ureteric stones in consideration with

1. Mean operating time

2. Mean blood loss(Hb% fall)

3. Post operative pain(analgesic requirement)

4. Mean hospital stay

5. Mean convalescence period

MATERIALS AND METHODS

7.1 SOURCE OF DATA

Total of 50 patients with symptoms of large lower ureteric calculi and treated with

The transperitoneal ureterolithotomy by laparoscopy in M. S. RAMAIAH TEACHING HOSPITAL AND M. S. RAMAIAH MEMORIAL HOSPITAL BANGALORE during period of 1999 TO AUGUST 2011

7.2 MEHODS OF COLLECTION OF DATA

Patients with symptoms of large lower ureteric calculi or recurrent stones after previous open ureterolithotomy, failure of ureteroscopic removal of calculi, failure of ESWL, are assessed clinically , KUB X ray, USG abdomen and pelvis, hematologically and taken for LAPAROSCOPIC TRANSPERITONEAN URETEROLITHOTOMY. Patients were studied Intra operatively for duration of operation. Post operatively patients were investigated for Hb% fall, Assessed for analgesic requirement and followed up the patient to know the duration of hospital stay and after the discharge for duration to start his/her work .

SURGICAL TECHNIQUE

• Port placement- 10 mm port through the lower cup of umbilicus

5 mm port in the mid inguinal line in the right iliac fossae

10 mm port in the mid inguinal line in the left iliac fossae

• Mobilization of colon and reaching the dilated ureter

• Localization of the stone by the bulge in the ureter and gently pinching with the

instruments

• Ureterotomy and removal of the stone by cold knife (11 number)

• Placement of the double J stent

• Suturing the ureterotomy incision by 5.0 vicryl

• Drain inserted through one of the port

• Stone retrieval is by inserting the thumb of the rubber glove through the 10 mm port.

INCLUSION CRITERIA

1. Distal ureteric calculi (below the superior sacro iliac joint).>2CM in size

EXCLUSION CRITERIA

1. Distal ureteric calculi ................
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