Using Conventional Instruments to Perform Single Incision Laparoscopic Heminephroureterectomy in Children with Duplex Kidneys and Megaureters: The Crossed-Instruments (“Chopsticks”) Technique

Abstract

Introduction:

Poorly functioning dysplastic upper moiety in duplex kidney associated with ectopic ureteric insertion is a rare cause for urinary dribbling in children and upper moiety heminephroureterectomy is the treatment of choice. Such procedure has been commonly performed by conventional laparoscopy worldwide. Recently single incision laparoscopic surgery (SILS) has been developed as an evolution from conventional laparoscopy. We have previously described the crossed-instruments (“Chopsticks”) technique to perform SILS in children using conventional 3- and 5-mm instruments without additional costs for special instruments. ^{1 –3} This video (run time 7:22) demonstrated how single incision laparoscopic upper moiety heminephroureterectomy (SILHN) was performed using this technique in a 4-year-old girl who presented with urinary dribbling because of right renal duplex with dysplastic upper moiety, and ectopic insertion of upper moiety megaureter into urethra.

Materials and Methods:

Our technique to perform SILHN has been previously reported. ² An incision was made along the lower half of the umbilical ring. Subcutaneous tissue was mobilized to create a fascial surface for ports insertion. A 5-mm camera port was placed at 6 o'clock position. Then, 3- and 5-mm working ports were placed at the 3 and 9 o'clock positions respectively. Three millimeter straight instruments and a 5-mm vessel sealing device were used. The surgeon and the assistant stood on the left side of the operating table with the patient's right side being elevated. Most of the dissections were performed by the crossed-instruments technique so that the instrument on the surgeon's right hand operated on the left side of laparoscopic view and the left-handed instrument operated on the right side. Both intra- and extra-corporeal working space can be significantly widened with such maneuver.

Results:

Two girls, aged 7 and 4, underwent right-sided SILHN for urinary dribbling due to right renal duplex with dysplastic upper moiety, and upper moiety megaureter with ectopic ureteric insertion. Both procedures were successfully performed by two surgeons (Y.H.T. and J.D.S.) without conversion or additional ports. The operative time was 400 and 300 minutes in the first and second patient (this video) respectively. Five and eight doses of oral acetaminophen were taken for postoperative pain control. Tolerance to full diet was achieved at 60 and 72 hours after surgery. Both patients recovered smoothly without any complications and had immediate resolution of urinary dribbling after surgery.

Conclusions:

SILHN is technically challenging but feasible in children using conventional laparoscopic instruments. Operative time is expected to be cut short with accumulation of experience.

All the authors have no competing financial interests to disclose.

Runtime of video: 7 mins 22 secs