1 Urology Journal UNRC/IUA Vol. 1, 1-4 Winter 2004 Printed in IRAN DEFINITION Laparoscopy is to study peritoneum cavity via a camera entered abdominal cavity through abdominal wall following induced pneumoperi- toneum. Ordinary surgery processes are per- formed during laparoscopic surgery but with less lesions and faster improvement comparing toAccepted for publication Laparoscopic Era Modern Status of Laparoscopic Surgery in the Urology of Iran and World SIMFOROOSH N*, BASIRI A, MAGHSOODI R, SHAFI H Urology and Nephrology Research Center, Shaheed Labbafinejad Hospital, Shaheed Beheshti University of Medical Sciences, Tehran, Iran First, we would like to introduce laparoscopic procedures conducted at Labbafinjad Medical Center, some of which were performed for the first time in Iran and some others were conducted for the first time worldwide, by which Iran has been known as a leading country among Mediterranean countries in laparoscopic urology. 1. Laparoscopic ileocystoplasty (to extend bladder by ileum with intestinal anasto- mosis) simultaneously with laparoscopic Malon to control stool incontinence (First case in the world) (9 cases) 2. Laparoscopic urethrocystoplasty (First case in the world) (2 cases) 3. Radical laparoscopic prostatectomy by an innovative technique with no suture (20 cases) 4. Laparoscopic antireflux in children by Lich method (40 cases) 5. Laparoscopic retroperitoneal and pelvic lymphadenectomy (6 cases) 6. Laparoscopic pyeloplasty (to repair pelvic obstruction) (50 cases) 7. Laparoscopic donor Nephrectomy (170 cases) 8. Laparoscopic Nephrectomy (65 cases) 9. Laparoscopic adrenalectomy (11 cases) 10. Laparoscopic adrenalectomy (15 cases) 11. Laparoscopic surgery of retrocaval ureter (1 cases) 12. Laparoscopic removal of ureteral and pelvic stones (140 cases) 13. Nephropexy (1 cases) 14. Varicocelectomy (102 cases) 15. Laparoscopic repair of hydrocele and hernia (28 cases) 16. Laparoscopic therapy of renal cyst (25 cases) 17. The detection and treatment of ectopic testis (247 cases) 18. Partial adernalectomy (1 case) 19. Histrosalpingoanorectomy (1 case) MODERN STATUS OF LAPAROSCOPIC SURGERY IN THE UROLOGY OF IRAN AND WORLD open surgery. The variety of mentioned proce- dures indicated that approximately all open abdominal urological surgeries could be conduct- ed by laparoscopy, provided that there is due practice. Laparoscopic urologic procedures have some advantages including: 1. They prevent large incisions in abdominal uro- logic surgeries, which are cosmetically impor- tant and prevent hernia and infection at the place of incision. 2. They reduce immediate and chronic postoper- ative incision pain (especially at flank posi- tion). In contrast to open surgeries, no pain or a very little pain is felt in laparoscopic proce- dures. 3. Faster return to the normal life and work due to less pain and immobility is possible, which leads to better economical outcome for fami- lies and society. In general, modern surgery tends to decrease pain and invasion and laparoscopy has found its place among minimally invasive procedures as an approach, which replaces urological open surger- ies in lots of cases. INTRODUCTION AND HISTORY The idea of minimal stress and invasion has been come in mind since a long time ago. The use of tube and speculum in medical sciences refers to ancient Greek civilizations. New endoscopy was innovated in 1805 by Bozzini who tried to observe urethra and vagina by the light of candle through a tube.(1) By the invention of cystoscope by Nitze in 1875, edoscopic surgery (to observe urethra and bladder and perform sur- gery by endoscope) was started and developed parallel to open surgery.(2) In 1901 Von Ott reported first examination of abdominal cavity by light concentration provided by a mirror con- nected to speculum. One year later Killing reported a laparoscopic surgery performed on an alive dog by a cystoscope after blowing filtered air.(3) The first human laparoscopy was conduct- ed by Jacobeus in 1910 via a cystoscope4. In 1929, passing through two separate trocars was viable and in 1933, Co2 was applied to produce pneumoperitoneum. Consistent control of Co2 pressure during laparoscopy was reported in 1944 by Palmer.(5) Although modern laparoscopy was developed in Europe by gastroenterologists, obstetricians were the most beneficiaries of laparoscopy and were the pioneers. Though the first laparoscopy was performed via a cystoscope, its first practical urological application was reported in 1976 to detect cryptorchidism.(6) Wickham extracted ureteral stone by laparoscopy in 1979.(7) Eshghi used laparoscope to remove staghorn stone through skin in 1985.(8) Animal urologic laparoscopies were conducted by Winfield in 1990 and Schuesster reported the first retroperitoneal lymphadenecetomy to treat prostate cancer in 1991.(9, 10) Performing laparo- scopic varicocelectomy by Donvan, Winfield, and Haywood and nephrectomy by Clayman were reported at the same year.(11,12,13) Later on, sev- eral procedures (bladder diverculitis, retroperi- toneal lymphadenectomy, urethrolease, bladder neck suspension, renal cyst, pyeloplasty, radical nephrectomy, ileocystoplasty, radical cystectomy, radical prostatectomy, and antireflux) were pre- formed and reported by urologists and researchers. Although there are many reports on laparoscopic urological surgeries, this method has not totally adapted in most centers, so it needs further developments to achieve its real position. Undoubtedfully, lots of laparoscopic technologi- cal aspects and instruments would be developed in future, so that applying this technique would be much easier and would be expanded to other procedures too. Furthermore, less dependency on instruments could lead to less expensive laparoscopy. For example, consistent metal instruments and trocars are used in our center instead of disposable ones. PRINCIPALS OF LAPAROSCOPIC SURGICAL PROCEDURES Proper selection of patients, knowledge of relat- ed complications, familiarity with laparoscopic techniques and availability of laparoscopic equip- ments and their directions are essential in laparoscopic procedures. In this article, we would like to review how to prepare a patient and select him for laparoscopic surgery. 2 MODERN STATUS OF LAPAROSCOPIC SURGERY IN THE UROLOGY OF IRAN AND WORLD PATIENT'S SELECTION AND PREPARATION Precise physical examination and history tak- ing are considered as important steps at the beginning of the work. A history of sever cardiac or respiratory disease is a limited factor for the procedure. Sever adhesion by previous abdomi- nal or pelvic surgeries is relatively considered as a contraindication in laparoscopic surgeries, though not always (especially for skilled sur- geons). A history of generalized peritonitis, sever obesity, large hiatal hernia and incarcerated her- nia are contraindications as well. Congenital and acquisitioneal umbilical disorders (hernia, urachal cyst, purulent discharge) should be stud- ied, so that in case of presence, trocars should not be inserted around umbilicus. In the cases of aortic aneurism, it is better not to insert the nee- dle and trocar in the midline. They should be inserted with direct vision. Mainly it is prefer- able to insert the first trocar with direct vision in order to prevent entrance complications. In a report a comparison was made in more than 12000 laparoscopic surgeries between the method of blind insertion of Veress trocar needle and the method of inserting the first trocar open- ly, it was found that the complications were much less (50%) in the second method.(22) Definite con- traindications for laparoscopy are as follows: 1. Generalized peritonitis 2. Infection of abdominal wall 3. Intestinal obstruction 4. Uncorrected coagulation disorders Patient should be aware of this procedure and should be asked for permission for any open sur- gery if needed. Intestinal preparation is needed and it is preferred to use liquid diet 48 hours postoperatively in addition to 300gr MgOH in order to repair primarily any intestinal complica- tion. In the cases of intestinal segment surgeries Neomicine 2gr and oral Metromidazole 2gr should be administered in 2 doses a night before surgery with an interval of 4 hours (a survey is being conducted in this center on the necessity of preoperative intestinal preparation if ileum is going to be involved). Any drug that disturbs blood coagulation (like aspirin and anti inflam- matory drugs) should be stopped provided that coagulation time becomes normal. Routine tests are available and depending on the type of pro- cedure and its extension, transfusion may be requested. IV antibiotic is administered 30 min- utes before surgery and continued for 2 days or more depending on the type of procedure. Open surgery instruments should be always prepared to be used for a laparoscopic patient who may need open surgery during the procedure. PREPARATION FOR PROCEDURE Foly catheter and NG tube should be applied to empty bladder and gastric cavities during laparoscopy. Patient's legs should be tied by elas- tic bandage or pneumatic socks should be used to prevent postoperative emboli. Penis and scro- tum should be bandaged separately to prevent any pneumomoscrotum and pneumofalus. Liquid should be received through the vessels of neck as much as possible to let the hands be free, for the use of arm boards impedes the movement of sur- geon and his assistants. Like other abdominal surgeries, abdominal and genital parts are prepped with iodine. Some researchers believe that in case of long procedures 5000 units SC Heparin should be injected 6 hours preoperative- ly and 12 hours postoperatively till the patient resumes his movement. Usually, the surgeon and scrub nurse are posi- tioned near the patient in contrast to pathology and assistant surgeon positioned next to the patient at pathology side. Laparoscopic instru- ments (TV and Co2 blower) are positioned near the patient's feet and above his both sides, it is better to use 2 TVs, so that the surgeon and his assistant could easily observe the surgery field and the level of abdominal Co2 pressure. Before beginning the procedure, all needed instruments should be controlled to assure their accurate working, It is essential to control the following instruments: 1. Co2 blower 2. Indicator system (camera, endoscope, TV, light source) 3. Suction and washing unit 4. Cuter 3 MODERN STATUS OF LAPAROSCOPIC SURGERY IN THE UROLOGY OF IRAN AND WORLD IMPORTANT POINTS IN ANESTHESIA AND LAPAROSCOPY Analgesia, amnesia and muscle relaxation are important factors in laparoscopy. Though epidur- al anesthesia is preferred by some surgeons and patients for some short-term surgeries such as tubal ligation general anesthesia is considered as the preferable method for laparoscopy. Since there is a risk of vomiting and aspiration due to increased abdominal pressure and Trendelenburg position, intubation of the trachea is recommended. Important anesthetic complica- tions are not so common in laparoscopy. However, less important complications such as headache, vomiting, muscles pain, shoulder pain and dizziness may be occurred which is due to the used drugs. N2O is not preferred by sur- geons, because it causes intestinal expansion and consequently difficulty during the procedure (applying N2O for 2 hours leads to 100% increase in intestinal gas volume in 70% of cases). N2O also causes postoperative vomiting and pneu- mothorax if pleura is opened. Patient should be totally relaxed because the smallest improper movements could lead to insertion of trocar in intestines or large vessels. The administration of anti-H2-receptor (Cimetidine) and Metoclopramide in patients who are at high risk of aspiration (those with excess body fat, hiatal hernia and diabetes) could prevent this complica- tion and minimize aspiration of gastric acidic contents. The neck veins are preferred for water, electrolytes, and blood transfusion. It is essential to monitor blood O2 saturation to prevent hypoxia... THE INSERTION OF ESPECIAL LAPARO- SCOPIC NEEDLE (VERESS NEEDLE) Veress needle is inserted to fill peritoneum cav- ity with Co2 in order to insert the first trocar. The needle could be disposable or durable. Needle No.14 has a diameter of 1.2 mm and a length of 70 to 120 mm. The needle has an outer cover with a sharp tip and an axis with a blunt tip. The central or inner margin of the needle is pushed on the handle of scalpel to assure that by pushing central and blunt part, the needle would be retracted and by omitting the pressure, it would be quickly returned to its place. Patient is positioned at 10 to 20 degrees in a way that the head would be at a lower level than the pelvis. The place of inserting needle should be exactly above or under umbilicus which is bilaterally retracted upwards by 2 grasping pencets in a way that the abdominal wall would be kept away from inner organs, then a small curved incision is incised on the skin by a scalpel, through which, the needle is inserted ver- tically toward peritoneum. The insertion of nee- dle through fascia and peritoneum is sensible and to assure it, a syringe of 5 mm N.S is con- nected to the needle. Then the syringe is aspirat- ed to assure the lack of blood or intestinal con- tents (yellowish liquid) outflow. Next, N.S is injected and aspirated. If the fluid was injected in peritoneum cavity, it could not be aspirated. When syringe is disconnected from the needle particularly if abdominal wall is retracted upward, needle's remaining drops would rapidly enter the peritoneum. Afterwards, the blower of Co2 is connected to the needle and the gas is blown by an amount of 1 lit/min. Abdominal pressure should be lower than 10 mmHg before the flow of Co2. If the pressure is higher and no Co2 flow is seen (flow=0) or if the pressure rapidly reaches 15 mmHg (with an amount of one lit/min), the sur- geon should retract the needle back a little. If the pressure is high again, needle should be pulled out before gas blow reaches 200 mm and the sur- geon should try the needle once again. It should be confirmed that the needle is insert- ed in peritoneum and the gas is flowed, even if the needle was inserted for several times. One sign of inserting Veress in abdominal cavity is that natural dullness of liver would be omitted in percussion during gas flow and the abdomen is gradually extended. The abdomen is filled with gas till the pressure reaches 15 mmHg and then the trocar is inserted. THE INSERTION OF THE FIRST TROCAR Regarding the fact that inserting the first tro- car, which is performed blindly like Veress, is of great importance, a small incision (1 cm) is made above or bellow umbilicus and then an incision is cautiously made in fascia. The surgeon holds a 10 mm trocar in his right hand and his assistant bilaterally retracts the umbilicus upwards and 4 MODERN STATUS OF LAPAROSCOPIC SURGERY IN THE UROLOGY OF IRAN AND WORLD lifts abdominal wall so that when the surgeon pushes the trocar inside the peritoneum, umbili- cal wall is kept away from inner organs by two grasping pencets . The insertion of the trocar is associated with a special sound. To insert the tro- car more inside the abdomen, it should be pushed toward an imaginary line started from umbilicus toward a point between promontorium and bladder. Before the insertion, Co2 pressure could be temporary increased to 20 mmHg and maximally to 25 mmHg, so that a maximum dis- tance between abdominal wall and inner organs is obtained. Following the first trocar insertion, other tro- cars are inserted in a proper place according to the type of procedure and by observing the sys- tem. THE INSERTION OF THE FIRST TROCAR BY DIRECT OBSERVATION AND WITHOUT THE USE OF VERESS A 1 cm incision is usually made above umbili- cus. Fascia is incised a little by a scalpel. Peritoneum is opened 1 cm or less while abdom- inal wall is kept away from the inner organs. Then 1 mm trocar is inserted by direct observa- tion (without scalpel). To prevent Co2 leakage from the place of the first trocar entrance, fascia incision should be a little smaller than trocar diameter and a spiral pluge should be seen at the surface of trocar (new trocars are mostly grooved). Then the lense and other trocars are inserted by a direct observation. This method excluds the blindly performed processes and their complica- tions in laparoscopy and facilitates teaching urol- ogy to assistants and fellowships. The following method is used in case of Veress insertion. Considering practical laparoscopic experiments performed at UNRC, the use of Veress has been omitted and the first trocar is always inserted in abdomen with a direct observation, which leads to 2 important advantages: 1. It prevents blindly insertion of Veress to omen- tum, intestines and great vessels particularly in children, besides it precludes the detach- ment of peritoneum form fascia and gas leak- age in peritoneum. 2. The abdomen is filled with gas by trocar much faster than Veress; thus, applying trocar is time-saving. TROCAR EXTRACTION By the end of laparoscopy and before the extraction of trocars, the field of procedure is examined with low pressure (5 mmHg) for any hemorrhage, and then it is washed by 200 to 500 ml N.S and 500mg Cephazoline. The drain of any brown-yellowish material or blood (a sign of intestinal injury) should be noticed very carefully. If none of them were observed, the liquid would be sucked. Some sur- geons do not extract this liquid to decrease adhe- sion of intestines to the passage of trocars and to decline infection. The small trocar is extract- ed first, the place of which is observed by laparo- scope to detect any hemorrhage. The largest tor- car is extracted finally and its place is covered by the finger till the gas is emptied, then the mar- gins of fascia are joined together by an 8 like suture, remember that before fastening the suture the gas should be completely emptied. Skin passage of trocars should be sutured by 4.0 chromic or 5.0 vicryl subcutaneously and then the incision is covered by a light piece of gauze. POSTOPERATIVE CARES Postoperative cares are dependent on the type of procedures as in small procedures like varico- cele or laparoscopic diagnosis of UDT performed at outpatient departments, liquid diet is adminis- tered in the afternoon and normal diet is given a day after. The patient could start walking 6 hours later. In the case of large procedures and suspected hemorrhage the repetition of Hb, Na, and K tests seems to be essential. If the patient suffers form sever pain, a narcot- ic drug would be administered every 6 hours; however, Acetaminophen could be helpful on next day. If abdominal pain lasted or increased after 24 hours, intestinal perforation should be care- fully suspected and studied. If shoulder pain which is particularly felt after large procedures (due to remaining abdominal gas and diaphragm stimulation), is continued specially in adults, patient should be examined by ECG and chest scan for any cardiac complication or pulmonary emboli. Antibiotics are usually administered for 5 MODERN STATUS OF LAPAROSCOPIC SURGERY IN THE UROLOGY OF IRAN AND WORLD 2 days or occasionally more, depending on the type of procedure. If the patient suffers from delayed abdominal pain, hernia or infection of the region of surgery should be doubted. Echymosis of abdominal wall particularly in lower parts after vast pelvic operations are com- mon and improved spontaneously. In case of increased echymosis and decreased blood Hb, abdominal CT scan should be ordered for the detection of any hematoma. Hydrocele is observed after long procedures due to the gath- ering of washing liquid. This would be improved spontaneously and by tight fastening of testis bandage and resting for one to two weeks. LAPAROSCOPIC COMPLICATIONS Performing laparoscopy by skilled surgeons is not associated with considerable complications, though at learning stage more complications may occur, which are gradually decreased. Complications are reported to be about 4% and mortality rate to be 0.03%. Laparoscopic compli- cations have several major parts: those which have occurred during inserting Veress and insert- ing trocar and in pneumoperitoneum stage, as well as vascular complications which are devel- oped by applying some surgical instruments, and those complications occurred at the stage of tro- car extraction which include vascular complica- tions (the most common), gaseous emboli, hypotension, cardiac rhythmic disorders, hypox- ia, hypercapnia, acidosis, aspiration, pneumotho- rax, pneumomediastinum, pneumopericardium, subcutaneous emphysema, visceral injuries, peripheral nerve injuries, intestinal complica- tions, and the rise of creatinine. The familiarity with the technique and accurate consideration to preventive measures are the best ways of pre- venting complications and decreasing them in laparoscopic procedures (as in open surgeries). Even though if any complication occurs, timely diagnosis and treatment would be of great impor- tance. The elimination of Veress, blind insertion of first trocar and the insertion of first trocar with direct vision could omit most essential com- plications especially for surgeons use laparoscopy newly. LAPAROSCOPY APPLICATIONS IN UROLOGY By traditional use of cystoscope for diagnosis and treatment and through endoscope, surgical urology entered the new world of surgical endoscopy. Moreover, by performing bladder tumor and prostate TUR, the attitude of urolo- gists toward treating diseases was changed and finally by the progress of technology, urethral entrance and ultimately renal entrance became practical via precise instruments, through which renal and urethral tumors and stones were treat- ed. In 1976 a new gate was opened toward mod- ern world of treating urologic diseases, that was by performing laparoscopy to detect UDT. Gradually, the practice of different laparoscopic techniques was confirmed as a surgical fact. In 1991, Schuessler reported the first surgical laparoscopy through which pelvic lymphadenecto- my was conducted in a patient with prostate can- cer. Radical nephrectomy for renal cancer was carried out by Clayman, who broke off the kid- ney by merciliter and extracted it./ Consequently performing large procedures through some small openings became a reality.(10, 13) This procedure was appreciated by many urologists; however, some others opposed it because it lasted for 9 hours. Yet, the time of radical nephrectomy was gradually reduced to reach the time of open sur- gery or a little more. It was indicated that laparoscopy could be an actual rival and an appropriate replacement for open surgery. In accordance with different reports on laparoscop- ic nephrectomy outcomes, this procedure has been introduced as a substitution for open sur- gery, for it prevents large and painful flank inci- sion which leads to hernia and postoperative sever pain. To date, nephrectomy is routinely conducted in lots of centers and it has replaced large procedures in big centers as a standard of care. One thousand cases of laparoscopic radical prostatectomy have been recently reported in Europe. Schuessler was the first in the USA to perform this procedure; however, he concluded that it was incomparable to open surgery. One year later, following a report of 300 cases of laparoscopic radical prostatectomy by Vacnsine from France, the procedure was once again car- ried out by Gill from the USA, which was lasted for 3-4 hours and urethral catheter was removed 6 MODERN STATUS OF LAPAROSCOPIC SURGERY IN THE UROLOGY OF IRAN AND WORLD after 2-5 days.(14) Twenty cases of laparoscopic radical prostatectomy were conducted in Iran at Labbafinejad Medical Center during the last year. Postoperative urine control and stenosis of anastomosis were the same as open surgery, but with lower hemorrhage and sooner return to nor- mal life. Laparoscopic repairing procedures are also common. First laparoscopic surgery and pyeloplasty was performed in 1993. It outran endopyelotomy in a way that its outcomes were similar to those of open surgery. Fifty cases of pyeloplasty have been already conducted in this center (fig. 1) with satisfied outcomes. The first case of laparoscopic cystoplasty was report- ed by Gill in 2000.(16) The first laparoscopic cystoplasty was carried out in this center in 2002. Nine cases of ileocystoplasty and one ureterocystoplasty have been already conducted. The most complicated procedures were per- formed by Gill et al at Cliolind Clinic which included radical cystectomy and ileal conduit, 11 cases of which were conducted in 2001, followed by 5 cases of radical cystectomy and orthotopic patch. Gill et al were introduced as a unique group in laparoscopic surgery field and were awarded best prize in laparoscopy at the urology congress.(17) Nephrectomy due to benign lesions was carried out for the first time by Clayman in 1991. In 1993 laparoscopy was performed in Iran at Labbafinejad Medical Center to diagnose and 7 FIG. 1. Aberrant vessels in a patient with UPJ FIG. 3. Postoperative photo of a patient who underwent RPLND laparoscopic retroperitoneal lymphadenetomy with 3 trocars. The scar of pre- vious open orchidectomy is observed underneath. FIG. 4. Renal cyst in a 2-year child who under- went laparoscopy FIG. 2. Laparoscopic lymphadenectomy for testicu- lar tumor; lymph nodes between aorta and vena cava has been totally removed. MODERN STATUS OF LAPAROSCOPIC SURGERY IN THE UROLOGY OF IRAN AND WORLD treat UDT and varicoclectomy.(18) Although, learning how to conduct laparoscopy is more dif- ficult and time-consuming, it is practical by obtaining more skill. This center is an obvious example which initiated its laparoscopic activities by a limited experience with diagnostic laparoscopy. Larger procedures such as ader- nalectomy, RPLND (fig. 2, 3), urethral stone and renal cyst (fig. 4) were conducted by gradual obtaining of experience at the first 4 years. Laparoscopic progresses were such fast that lots of mentioned surgeries were performed routinely during the last 2 years and some others such as ureteroplasty and ileocystoplasty with intra- abdominal anastomosis and appendix diversion toward abdominal wall were also carried out for the first time worldwide which were accepted at USA Urologic Congress for the first time from Iran and were represented in April 2003.(20,19) To date, all international journals of urology are filled with successful reports of laparoscopic procedures, which indicates the increasing progress in urology. It could be claimed that laparoscopy is now the first surgical alternative. 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