Laparoscopic heminephrectomy in horseshoe kidney
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We have done 5 such cases and published also, video can be found in youtube. this was presentation in local meeting about our first case.
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Laparoscopic heminephrectomy in horseshoe kidney
- 1. Laparoscopic Heminephrectomy in Non Functioning Right Moiety of Horse Shoe Kidney Dr. Santosh Kumar Agrawal Dr. Saurabh Sudhir Chipde Department Of Urology and Renal Transplantation Shri Aurobindo Institute of Medical sciences and Mohak Hi-Teck Speciality Hospital, Indore, India
- 6. Introduction Horse shoe kidney is the most common fusion anamoly of the kidney (1 in 400) Prenchymatous isthmus Inferior mesentric artery vlcsnap-2013-06-28-10h21m32s58.png
- 7. Introduction The most common associated finding in horseshoe kidney is uretero-pelvic junction obstruction, which occurs in up to 35% of cases and is often the cause of problems. Kidney stones develop in 20% to 60% of patients and may be associated with obstruction and recurrent infections.
- 8. Laparoscopic surgery in patients with horseshoe kidney is technically challenging procedure and has not been frequently reported. Anatomic variations like lower renal location, aberrant vessels, wide variation in vascular supply and the isthmus necessitate special consideration during laparoscopic surgery.
- 9. There are about 24 case report of laparoscopic heminephrectomy for various indications in published literature using various approaches. eg. Trans peritoneal, retroperitoneoscopic and hand assisted laparoscopic heminephrectomy.
- 10. Unmarried female – 20 years old Severe pain in right lumber region since last 2 month Lump in right lumber region USG- grossly hydronephrotic right moiety of horse shoe kidney with papery thin parenchyma. Normal left moiety. Index case
- 11. DTPA scan – Non Visualized Right Kidney NCCT Abdomen – Creatinine- 0.8mg/dl Other blood parameters normal Index case
- 13. DTPA scan – Non Visualized Right Kidney NCCT Abdomen – Creatinine- 0.8mg/dl Other blood parameters normal Index case
- 16. Operating time: 2hrs 35 minutes ( from skin incision for the first port) Blood loss: 140 ml Drain removed on 2nd post operative day Discharged on 3rd post operative day At 6 month follow up – patient is doing well Results
- 17. There are 3 factors mainly which pose challenges during laparoscopic heminephrectomy 1. Abnormal vasculature 2. division of isthmus 3. Lower location of kidney
- 18. CT angiography has been advised to study abnormal vasculature in HSK prior to laparoscopic surgery. Isthmus has been dealt using various technique in reported literature. Division with staplar,harmonic scalpel and bipolar electrocatery are the commonest method.
- 19. In poorly functioning kidney due to PUJ obstruction, vessels are usually thin caliber and atretic and there is clear demarcation between hydronephrotic sac and parenchymatous isthumus. Ligasure can be used to devide the vessels and junction. Demarcation.
- 20. Laparoscopic hemi-nephrectomy is good option in cases for nonfunctioning hydronephrotic moeity in horse shoe kidney. Ligasure can be used for dealing the vessels if they are small caliber and isthmus can be dealt with same. Conclusion
- 22. Video
- 23. • 35 years /female • Post hysterectomy VVF • Cystoscopy – supratrigonal single VVF, well away from ureteric orifice
- 24. Port position
- 26. { Case 1
- 46. Thank you
Editor's Notes
- . Laparoscopyhas revolutionized surgery for renal diseases and have become widely available for several different ablative and reconstructive operations. Laparoscopic surgery for anamalous kidneis are increasingly been reported. . There are about 24 case report of laparoscopic heminephrectomy in published literature using various approaches for eg. Trans peritoneal, retroperitoneoscopic and hand assisted laparoscopic heminephrectomy. Laparoscopic heminephrectomy in patients with horseshoe kidney is technically challenging procedure and has not been frequently reporte
- A 20 year old unmarried female presented in urology outpatient department with complaints of pain in right lumber region since last 2 month. Pain was severe and was present most of the time. There was no history of fever and urinary complaints. On per abdominal examination, mild tender lump was present in right lumber region. Ultrasonography of abdomen revealed grossly hydronephrotic kidney with thinned out renal parenchymaof of right renal moity and normal left renal moiety.non contrast CT scan of abdomen done in outside hospital confirmed the presence of horse shoe kidney with hydronephrotic kidney with thinned out parenchyma. DTPA scan revealed non-visualized right kidney. Serum creatinine was 0.8 mg%. Rest of the blood investigation were within normal limit. Patient was planned for right laparoscopic heminephrectomy.
- Patient was operated in general anesthesia with endotracheal tube intubation with 700 flank up position three ports were used . pneumoperitoneuma was created with veress needle.10 mm camera port was inserted at umbilicus. One 5 mm working port was put in right mid clavicular line below costal margin and one 10 mm working port was put 4 finger breadth below and lateral to umbilical port in mid clavicualar line. 30 degree 10mm telescope was inserted. Right colon was reflected off the right moiety with the help of hook cautery. It is imported to enter into proper plane between mesentric fat and gerota’s fascia. Entire right colon from hepatic flexure to cecum was reflected medially this expose the upper and lower pole of kidney nicely. It is important to identify isthmus clearly after dissection of lower pole. Usuallly there is clear demarcation between parenchymal isthumus hydronephrotic sac. This junction is difficult to identify in heminephrectomy in case od renal tumor. After plane was devoloped between the meadial side of sac and duodenum was kocherized . Thios exposes IVC and on futher dissection we can identify psoas muscle.
- At surgery, the patient was placed in a right lateral position, and 3 ports were placed. The camera port was placed just above the umbilicus followed by one 10 -mm port along the lateral border of the rectus muscle. One 5-mm port was put 4 finger breadth above the camera port in midline. The colon was mobilized, and the upper pole of the kidney was dissected. Multiple vessels were clipped with a Hem-o-lock and divided. The upper pole was freed laterally and posteriorly. Gonadal vessels were identified and traced upwards. The kidney was mobilized at the lower pole. The kidney was dissected medially, and the upper part of the isthmus was identified. The ureter was identified and divided after clipping. Gonadals were identified and divided after clipping. The upper and lower poles of the kidney were lifted to visualize the isthmus. The isthmus was isolated and clipped with a 15-mm Hem-o-lok (and was divided with a Harmonic scalpel.