Use of Dundee Jamming Knot to Initiate Continuous Suture in Pediatric Retroperitoneoscopic Pyeloplasty

Abstract

Introduction:

Retroperitoneoscopic pyeloplasty ^1,2 is a procedure that requires suturing delicate structures in a small working space using delicate suture material. The distance between the spatulated ureter and the most dependent portion of the renal pelvis adds some difficulty to suturing. Continuous suture saves time and promotes a good seal of the structures. ³ For continuous suture in small spaces, a short thread is more appropriate. The use of a long thread makes suturing difficult and time-consuming. In contrast, the use of short thread for distant structures is difficult and often almost impossible. An alternative is the use of an external sliding knot. In this case, however, the thread would be lengthy and could not be used for the continuity of the suture. A new suture and additional manipulation of the structures will be necessary. In this video, we demonstrate the technique to approximate the spatulated ureter and the most dependent portion of the renal pelvis using continuous suture with an external component (Dundee Jamming Knot ^{4 –6} ). This knot is tied inside the cavity, but has an external component previously tied as shown in the video.

Materials and Methods:

Ureteropelvic junction obstruction was diagnosed in a 2-year-old girl who underwent right retroperitoneoscopic pyeloplasty. The patient was placed in left lateral decubitus position. Three trocars were used. A 5 mm camera port and two 3.5 mm trocars were installed as shown in the video. The retroperitoneal space was created. A stay suture was passed at the ureteropelvic junction. The ureter was opened and spatulated and the pelvis was opened in its most dependent portion. A 6-0 PDS^® thread previously prepared with the external component of the Dundee Jamming Knot was passed through the angle of the spatulated ureter and the most dependent part of the renal pelvis, easily approaching the structures. Then the anterior portion of the anastomosis was performed. A Double-J catheter was passed and had its appropriate position confirmed. The posterior portion of the anastomosis was performed and the remainder of the renal pelvis was closed. No external drainage was done.

Results and Conclusions:

The patient had an uneventful recovery and was discharged home on postoperative day 2. The ureteral stent was removed 4 weeks after surgery. Ultrasonography after 5 weeks suggests good pyelic drainage and the patient was asymptomatic. This technique saves time, reduces manipulation of the involved structures, generates less friction in relation to the external sliding knot and allows immediate start of the continuous suture using thread of appropriate size for the working space. This technique can also be used in other situations requiring approximation of structures with some distance.

Acknowledge:

Massaud-Ribeiro, L. MD, MSc

No competing financial interests exist.

Runtime of video: 3 mins 29 secs