Specialised Services

 

Key-Hole Laparoscopic Surgery

Laparoscopic surgery, also called minimally invasive surgery (MIS), keyhole surgery, or pinhole surgery is a modern surgical technique in which operations in the abdomen are performed through small incisions (usually 0.5–1.5cm).

The key element in laparoscopic surgery is the use of a laparoscope: a telescopic rod lens system, that is usually connected to a video camera. Also attached is a fiber optic cable system connected to a light source to illuminate the operative field. The abdomen is usually insufflated with carbon dioxide gas to create a working and viewing space. The gas used is carbon dioxide, as it can safely be removed by the respiratory system if absorbed through the tissues.

The main advantage to the patient of laparoscopic surgery over open procedure is that a smaller incision is required, thereby causing less pain and a thus quicker recovery. A number of operations can be performed by key-hole surgery.

These include:

  • Laparoscopic Radical Nephrectomy
    • Early cancer of the kidney is potentially curable by total removal of the affected kidney. A person can live and function normally with a single good kidney. Surgery to remove a kidney with cancer is called a radical nephrectomy.
    • Traditionally, a radical nephrectomy is performed with an open surgical incision. This results in significant pain and slow recovery from surgery. Laparoscopic or key hole radical nephrectomy has replaced open surgery as the surgery of choice for early kidney cancer. It has proven to give similar results in terms of cancer control and cure as the open operation but without the associated pain.
    • Laparoscopic radical nephrectomy mimicks all the steps of an open surgery. The diseased kidney is placed in a surgical plastic bag before being removed form the body by way of a small abdominal incision, just large enough for the kidney. Hence, a large surgical incision is avoided.
    • Laparoscopic radical nephrectomy is effective for kidney cancers as large as 10cm in diameter.
  • Laparoscopic Radical Partial Nephrectomy
    • Where it is possible, when treating kidney cancer, it is also preferable to remove part of a kidney rather than the entire kidney. This is known as a partial radical nephrectomy.
    • It is a more difficult procedure than a total nephrectomy and carries a higher risk of complications. In the past this type of procedure could only have been performed by an open operation but with modern technology it is possible to perform this procedure safely by key hole surgery. This is performed in much the same way as the laparoscopic total radical nephrectomy. The benefits of the key hole approach are less pain, a quicker recovery and discharge form hospital, as well as a very much smaller scar.
  • Laparoscopic Pyeloplasty
  • Laparoscopic Adrenalectomy
  • Laparoscopic Radical Prostatectomy
    • Laparoscopic prostatectomy envolves removal of the entire prostate gland via 5 small key-hole incisions. This is performed for early and localised prostate cancer when cure is possible.
    • Surgery for cure in early prostate cancer can be performed by open surgery, laparoscopic surgery or robotically assisted laparoscopic surgery. Results of open surgery are well established. The operation involves a moderate incision in the lower part of the abdomen.
    • Laparoscopic (key-hole) surgery achieves similar results. The advantage of laparoscopy is that the incisions are smaller and discharge from hospital is quicker, but thereafter the results are similar.
  • Laparoscopic Varicocoelectomy
    • Varicocoeles can also be treated by laparoscopy. Under general anaesthesia, three small incisions (5mm each) are made in the abdomen. Varicoceles on the right or left or both can be approached. The abnormal veins are identified and clipped and divided. Advantages of laparoscopic varicocele surgery over other techniques include:
    • Accurate identification of all the veins as the surgery is done under magnification during laparoscopy.
    • Varicoceles from both sides of the body can be corrected at the same time without needs for further surgical incisions.
    • Rapid recovery from surgery with minimal pain as the small 5mm wounds causes minimal damage to tissue.
    • Surgery is completed within 90 minutes, even in the case of varicoceles occurring on both sides. Patient can be discharged within a few hours after surgery and return to work within 48 to 72 hours.
  • Robotic Prostatectomy
    • Laparoscopic prostatectomy can be performed directly by the surgeon or with the assistance of a surgical robot. Robotic or robot assisted surgery assists the surgeon with a 3D view and simplifies the stitching steps involved in the operation. Otherwise, it is exactly the same as laparoscopic prostatectomy performed directly by the surgeon.

Treatment for Kidney and Urinary Stones

Treatment strategies include accurate diagnosis of the stone problem, assessment of potential complications that are related to stones, specific procedures to removed or dissolve stones and long term preventive measures to avoid stone recurrence.

A procedure to remove a stone would be indicated in the following situations:

  • a stone that is causing persistent pain
  • a stone that is causing a complication such as obstruction to the kidney, which may lead to kidney damage, infection and bleeding
  • a stone that is not likely to come out by it’s own and has potential to grow in size and cause complications

Specific procedures for stones:

  • Extra corpal shock wave lithotripsy (ESWL)
    • This is the treatment of choice for the majority of urinary and kidney stones. It does not involve any surgery or instruments placed into the body. After undergoing a general anaesthetic the patient lies on a bed and the treatment device is placed over skin overlying the stone.
    • Shockwaves are generated and passed from the machine into the patient’s body and eventually to the stone. The energy of the shockwave is absorbed by only the stone and results in fragmentation. A large stone can be broken down to very fine sand fragments. The fragments are removed during passage of urine.
    • Although the amount of energy is strong enough to fragment a hard stone, it would not cause damage to the surrounding kidney tissue as the shockwaves are well directed and monitored throughout the procedure by the urologist.
      The entire procedure takes less than an hour and is performed as day surgery. Following treatment, the patient is advised to consume at least 3L of fluids a day to encourage flushing of the sand fragments. Return to work is expected within 24-48 hours.
      Complications are very rare although mild pain and blood in urine is observed for 1-2 days after treatment.
  • Endoscopy and Laser surgery
    • Stones in the ureter (urine tube) may cause problems including acute and significant obstruction to the kidney. Shockwaves maybe used to treat this problem but another modality which is very suitable is ureteroscopy and lithotripsy either with a laser or pneumatic. The advantage of this procedure is that the fragments of the stone can be removed afterwards.
    • This procedure involves a short general anaesthesia. During this time, a fine tube called an ureteroscope is placed into the urine passage tube, to the bladder and ureter. The impacted stone is identified and broken down by laser or a fine jack hammer. Fragmentation with laser is very precise as is associated with minimal damage to the surrounding tissue. The fragments are later removed via the ureteroscope.
    • The entire procedure should not take more than 90 minutes and can be performed as day surgery in some cases. Mild discomfort and blood in urine is observed for 1-2 days after the procedure. Return to work is expected after 1-2 days.
    • Complications are not common. In some situations, a temporary plastic tube called a stent may be placed in the ureter, after the procedure to ensure good urine drainage from the kidney. The stent can be removed after 1-2 weeks.
  • Percutaneous surgery (PCNL)
    • This technique is employed for large kidney stones or staghorn stones that would have required an open surgical incision in the past.
    • Very large stones can be removed via a small, 1 cm cut on the skin overlying the kidney. A telescope is placed via this hole, which leads the urologist into the kidney containing the stone. The kidney stone is fragmented by an ultrasound machine or mechanical device to small fragments that can be removed via the 1 cm skin incision. There is minimal disruption to the kidney. Recovery from surgery is rapid as the surgical incision is small and causes minimal pain.
    • This procedure is done under general anaesthesia and usually requires a hospital stay of 2-3 days. Return to work is expected within 7-10 days.
  • Laparoscopy surgery for stone
    • Laparoscopic or keyhole surgery is being performed for kidney or urinary stones that are not amenable to treatment by ESWL, endoscopy and laser or PCNL surgery.
    • Laparoscopic procedures include laparoscopic ureterolithotomy (for ureter stones) and laparoscopic pyelolithotomy (kidney stones) that can be performed together with pyeloplasty.
    • These procedures are carried out under general anaesthesia and require a hospital stay of 2-3 days. 3 or 4 small 5–10mm incisions are made on the abdomen to expose and remove the stones. A internal fine plastic tube called a stent is usually placed in the urine tract after the surgery and is removed after 1-2 weeks.

Urodynamics

Urodynamics is a specialised study that is undertaken to help reach a diagnosis in patients with voiding difficulty or urinary incontinence. It involves the filling of the bladder through a catheter and the recording of the bladder response to filling. It is performed as an outpatient in a specialiased urodynamics facility with the aid of x-rays. A trained specialist and a nurse perform the procedure. It normally takes an hour to perform and afterwards patients are able to drive them selves home, if they so wish.

 
Top