Page 9 - World Association of Laparoscopic Surgeons - Journal

M El-Shazly et al

TECHNIQUE The mean numerical pain score was 5.5 preoperatively
and decreased to 0.5 after 1 month postoperatively. After
Under general anesthesia, patients were positioned in the
6 months, the mean numerical pain score was 1.7. This was
lateral position. Transperitoneal access was established
statistically caused by the occurrence of recurrence in one
using veress needle or open (Hasson technique). Primary
case after 6 months.
port (10 mm) was inserted on the lateral border of rectus
The mean operative time was 95 minutes (range 60-135).
abdominis muscle opposite the umbilicus. Two working
The mean operative duration for the three cases that
ports (5 mm) were inserted after establishment of
had sclerotherapy prior to laparoscopic decortication was
pneumoperitoneum on the anterior axillary line: One just
115 minutes. The mean operative duration of the thirteen
below the costal margin and the other just above anterior
cases that had laparoscopic decortication as a primary
superior iliac spine. Longitudinal incision was done in the
management was 72 minutes. The difference is statistically
posterior peritoneum on the line of Toldt followed by
significant using Statpac version III (using t-test: t was 5.2,
medialization of ascending or descending colon using
degree of freedom 14, two tailed probability 0.0001).
scissor and Maryland dissector. Gerota’s fascia was then
dissected to expose the kidney. Aspiration of the cyst was
DISCUSSION
done using aspiration needle inserted through skin under
Renal cysts can be classified to simple (Bosniak type I
laparoscopic guidance. Excision of the cyst wall (unroofing)
and II) or complex (Bosniak type III and IV) cysts with risk
was then done. Cauterization of the edges and wadding the
of malignancy according to Bosniak classification. 11
cavity with omentum was performed to decrease the
The ideal management of symptomatic simple renal cyst
possibility of recurrence. Omentum was fixed to the cyst
should be less invasive and effective with low recurrence
edges with intracorporeal sutures and clips. A drain is left
rate. Aspiration only or aspiration sclerotherapy is less
for 1 day only. Removal of ports and closure of port sites
invasive, however the recurrence rate is relatively high. 6,7
were performed.
Open surgery offers the best success rate and lowest
RESULTS recurrence rate among the different modalities; however, it
is invasive procedure with the comorbidities of flank
The demographics and operative data are summarized in
incision. Laparoscopy offers effective treatment with high
Table 1.
success rate and low recurrence rate comparable to open
The operation was successfully completed laparos-
surgery with the advantage of being less invasive modality
copically in all cases with no conversion to open surgery. 9,10
of management.
There were no major perioperative complications. One case
Different laparoscopic techniques are reported: Simple
only developed ileus postoperatively and stayed for 4 days.
decortication using monopolar diathermy or scissors,
This was due to some colonic adhesions that required more
marsupialization, decortication with omental wadding and
dissection. Hospital stay was 2.4 days (range, 2 to 4 days).
different approaches; transperitoneal, extraperitoneal and
The mean blood loss was 50 ml (range 60-135 minutes). 12,13
less have been described.
Fifteen cases improved significantly after operation in a
Inspite of the advancement of different laparoscopic
mean follow-up of 1.5 years. One case had recurrence after
techniques, the reported recurrence rate is still up to 19%
6 months. Unfortunately, he developed colon cancer and 14
regardless the technique used.
refused any further intervention.
Transperitoneal and retroperitoneal approaches are
comparable regarding to improvement of pain, clinical
Table 1: The demographics and operative data
success and radiological findings. Transperitoneal approach
Demographics and Results has the advantages of larger working space, anatomical
operative data
landmarks and has the disadvantages of longer operative
Mean age (range) 52 years (range 27-68 years) 15
Males 7 duration and need to mobilize colon. We preferred the
Females 9 transperitoneal approach as it is our preferred approach and
Cyst size (mean largest 14.5 (range 11-19 cm) it allows accessibility to the omentum for decortication with
dimension of cyst)
Approach All transperitoneal omental wadding.
Mean operative 95 minutes (range 60-135 minutes) Recurrence after laparoscopic decortication could be
duration
Mean blood loss 50 ml (range 30-80 ml) explained by incomplete resection of the cyst wall. The
Mean hospital 2.4 days (range 2 to 4 days) residual secreting cyst wall can become adherent to
stay (range) surrounding tissues with development of a new cyst.
Recurrence 1
To prevent recurrences, different techniques have been
2
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