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Keywords:

  • adhesions;
  • kidney cancer;
  • prior abdominal surgery;
  • robotic partial nephrectomy;
  • robotics

Abstract

  1. Top of page
  2. Abstract
  3. INTRODUCTION
  4. PATIENTS AND METHODS
  5. RESULTS
  6. DISCUSSION
  7. CONCLUSIONS
  8. CONFLICT OF INTEREST
  9. REFERENCES

Study Type – Therapy (case series)

Level of Evidence 4

OBJECTIVE

  • • 
    To evaluate our experience with robotic partial nephrectomy in patients with previous abdominal surgery and evaluate the effect of previous abdominal surgery on perioperative outcomes. We also describe a technique for intraperitoneal access for patients with prior abdominal surgery utilizing the 8 mm robotic camera for direct-vision trocar placement.

PATIENTS AND METHODS

  • • 
    From a prospective cohort of 197 consecutive patients who underwent robotic renal surgery at a single academic institution, a total of 95 patients underwent transperitoneal robotic partial nephrectomy (RPN).
  • • 
    Patients with and without previous abdominal surgery were compared. Patients with prior abdominal surgery were subcategorized into two groups: upper midline or ipsilateral upper quadrant scar or lower abdominal, contralateral, or minimally-invasive scar.
  • • 
    Demographic and perioperative variables were compared between the surgery and no surgery groups. Access was obtained using a Veress needle or Hassan technique.
  • • 
    We utilized a technique of direct vision placement of the initial trocar on our 10 most recent cases, using an 8 mm robotic camera placed through the obturator of 12 mm clear-tipped trocar.
  • • 
    Lysis of adhesions was performed as needed to allow for placement of additional robotic ports.

RESULTS

  • • 
    A total of 95 patients underwent transperitoneal RPN, of which 41 (43%) had a history of prior abdominal surgery and six had upper midline or ipsilateral upper quadrant scars.
  • • 
    There were no statistically significant differences between patients with previous abdominal surgery and patients with no previous abdominal surgery in BMI (30.4 vs 29.4 kg/m2), median tumor size (2.5 cm vs 2.3), median total operative time (246 vs 250 min), median warm ischemia time (21 vs 16 min), median EBL (150 vs100 ml), clinical stage, transfusion rate, or complications.
  • • 
    A total of six patients underwent 7 previous upper midline or ipsilateral upper quadrant surgeries, including open cholecystectomy-2 patients (33%), open partial gastrectomy-2 patients (33%) and exploratory laparotomy-1 patient (17%).
  • • 
    Complications in this group were an enterotomy during lysis of adhesions that was repaired robotically without sequelae and a mesenteric hematoma during Veress needle placement. A total of 35 patients underwent 16 other prior abdominal surgeries, including abdominal hysterectomy-10 patients (29%), umbilical/inguinal hernia repair-9 patients (26%) and appendectomy-7 patients (20%). There were no access related injuries in the 10 cases in which the robotic 8 mm camera was used for initial trocar placement.

CONCLUSIONS

  • • 
    Transperitoneal robotic partial nephrectomy is feasible in the setting of prior abdominal surgery. The majority of these patients can have their procedure performed safely without an increase in complications.
  • • 
    Direct-vision intraperitoneal placement of initial trocar may be achieved by using an 8 mm robotic camera, without the need to switch between conventional and robotic cameras.

INTRODUCTION

  1. Top of page
  2. Abstract
  3. INTRODUCTION
  4. PATIENTS AND METHODS
  5. RESULTS
  6. DISCUSSION
  7. CONCLUSIONS
  8. CONFLICT OF INTEREST
  9. REFERENCES

Patients with a history of prior abdominal surgery are at an increased risk of intra-abdominal adhesions [1,2] which may complicate successful completion of transperitoneal laparoscopic or robotic procedures. Previous groups have evaluated the effect of prior abdominal surgery on transperitoneal laparoscopic upper tract procedures [3–7]. The impact of prior abdominal surgery on robotic prostatectomy has also been evaluated [8]. However, to our knowledge, the impact of previous abdominal surgery on robotic upper urinary tract procedures, such as robotic partial nephrectomy (RPN), has not been examined.

Partial nephrectomy is an established treatment for small renal masses less than 4 cm in size [9,10]. Laparoscopic partial nephrectomy (LPN) has demonstrated comparable cancer control and functional outcomes to open PN while potentially improving convalescence and perioperative outcomes [11–14]. However, LPN is technically challenging, requiring advanced laparoscopic skills for tumor excision and intracorporeal sutured reconstruction under the time constraints of warm ischemia. RPN has emerged as an alternative to LPN that may help with some of these technical challenges [15–21].

We evaluated the effect of previous abdominal surgery on perioperative outcomes in patients undergoing RPN via a transperitoneal approach. Using a large, prospectively collected database of RPN patients, we sought to answer the following questions:

  • 1) 
    What is the epidemiology of previous abdominal surgery at an experienced robotic center performing routine RPN?
  • 2) 
    What are the bowel and vascular complications associated with previous abdominal surgery during RPN?
  • 3) 
    What steps can be taken to minimize the morbidity of RPN in patients with previous abdominal surgery?

PATIENTS AND METHODS

  1. Top of page
  2. Abstract
  3. INTRODUCTION
  4. PATIENTS AND METHODS
  5. RESULTS
  6. DISCUSSION
  7. CONCLUSIONS
  8. CONFLICT OF INTEREST
  9. REFERENCES

Using a prospectively maintained, IRB approved database, we identified 197 consecutive patients who underwent robotic renal surgery from January 2004 to September 2009, of which 100 patients underwent RPN. Five patients underwent a retroperitoneal approach for RPN, leaving a total of 95 patients who underwent a transperitoneal RPN. Patients from four surgeons at our institution were included in the analysis. The da Vinci S surgical system (Intuitive Surgical Inc., SunnyVale, CA) was used in all operations.

Access to the peritoneal cavity for RPN was obtained via a Veress needle or Hasson technique [22]. In those patients with previous abdominal surgery (Fig. 1), the Veress needle was placed in the ipsilateral abdominal quadrant farthest from the previous incision. After placing the Veress needle into the peritoneal cavity, pneumoperitoneum was established. Certain safety steps were used to confirm entry into the peritoneal cavity, including absent gas or blood at aspiration of a syringe through the Veress needle, injection of 5 cc saline that could not be aspirated, low initial intraperitoneal pressure and no rapid increase in intraperitoneal pressure at the commencement of insufflation. Direct-vision placement of the initial tocar was performed in our 10 most recent cases using an 8 mm robotic camera placed through the obturator of a 12 mm nonbladed optical trocar (Fig. 2). In cases in which peritoneal access using a Veress needle was unsuccessful, open trocar placement was performed utilizing the Hassan technique. Initial adhesiolysis was performed with laparoscopic scissors as needed to allow for placement of additional ports. A rigid nephroscope with a working channel can also be used for adhesiolysis through initial tocar prior to placement of other trocars. The remaining ports were placed as shown in (Fig. 3) and RPN was performed. Our technique of RPN has been previously described [23].

image

Figure 1. Patient with midline scar from prior abdominal surgery prior to placement of ports for RPN.

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image

Figure 2. a, Robotic 8 mm camera placed through obturator of 12 mm clear-tipped trocar for direct-vision placement of the initial optical trocar. b, External view of direct-vision technique of gaining initial trocar access with 8 mm robotic camera through obturator of 12 mm optical trocar. The trocar is manually twisted to gain peritoneal entry under direct vision. c, Camera view of direct-vision placement of the initial trocar utilizing 8 mm camera.

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image

Figure 3. Port placement for robotic partial nephrectomy.

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Patients undergoing RPN were grouped according to whether or not they had undergone previous abdominal surgery. Patients with prior abdominal surgey were subcategorized as having an upper midline or ipsilateral upper quadrant scar or as having a lower abdominal, contralateral, or minimally invasive scar. Patient demographics and perioperative outcomes were compared between the surgery and no surgery groups. Statistical comparisons of continuous variables were performed using the Median test. Categorical variables were compared using Fisher’s exact test. A 5% significance level was used for all tests and all analyses were performed using commercially available software.

RESULTS

  1. Top of page
  2. Abstract
  3. INTRODUCTION
  4. PATIENTS AND METHODS
  5. RESULTS
  6. DISCUSSION
  7. CONCLUSIONS
  8. CONFLICT OF INTEREST
  9. REFERENCES

During the study period a total of 197 robotic renal procedures were performed, of which 95 patients underwent transperitoneal RPN. A total of 41 (43%) patients undergoing RPN had a history of prior abdominal surgery and six had upper midline or ipsilateral upper quadrant scars. The types of abdominal surgeries patients had previously undergone are listed in Table 1. A total of six patients underwent seven types of previous upper midline or ipsilateral upper quadrant surgeries, including open cholecystectomy-2 patients (33%), open partial gastrectomy-2 patients (33%) and exploratory laparotomy-1 patient (17%). A total of 35 patients underwent 16 different types of other prior abdominal surgeries, including abdominal hysterectomy-10 patients (29%), umbilical/inguinal hernia repair-9 patients (26%), and appendectomy-7 patients (20%). The time between the initial abdominal surgery and RPN was more than one year in all patients.

Table 1.  Types of previous abdominal surgeries in 41 patients who underwent transperitoneal RPN with a prior history of abdominal surgery
Previous abdominal operationNo. of procedures (%)
  • *

    Total Number of patients who underwent more than one prior abdominal procedure is 17 (49%).

  • **

    Total Number of patients who underwent more than one prior abdominal procedure is 3 (50%).

Lower abdominal, contralat, min-invasive* (No. of Pts. = 35) 
 Abdominal total/partial Hysteretomy10 (29%)
 Umbilical/Inguinal Hernia Repair9 (26%)
 Appendectomy7 (20%)
 Cesarean Section2 (6%)
 Open Cholecystectomy, contralateral3 (9%)
 Laparoscopic Cholecystectomy5 (14%)
 Colectomy/Partial Colectomy3 (8%)
 Robotic Adrenal/Renal surgery3 (9%)
 Exploratory Laparotomy1 (3%)
 Robotic prostatectomy3 (9%)
 Diagnostic Laparoscopy1 (3%)
 Abdominal paraganglioma5 (14%)
 Open Partial/Radical Nephrectomy3 (9%)
 Enterocutaneous Fistula Surgery1 (3%)
 Tubal ligation3 (9%)
 PCNL1 (3%)
Upper midline or ipsilat upper quadrant** (No. of Pts. = 6) 
 Open Partial Gastrectomy2 (33%)
 Open Cholecystectomy2 (33%)
 Exploratory Laparotomy1 (17%)
 Open Nephrectomy (Chevron)1 (17%)
 Abdominal Aortic Aneurysm Repair1 (17%)
 Splenic Artery Repair1 (17%)
 Drainage of Pancreatic Cyst1 (17%)

Table 2 lists baseline patient characteristics and perioperative outcomes for robotic partial nephrectomy in patients with prior surgery compared to patients with no surgery. There were no statistically significant differences between groups in age, sex, or BMI, median tumor size, or operative time. Patients with previous abdominal surgery were more likely to require adhesiolysis (41% vs 15%, P = 0.005). Adhesiolysis in patients with previous upper midline or ipsilateral upper quadrant surgery took a mean time of 32 min. Patients with prior abdominal surgery had a trend toward longer median warm ischemia time (21 vs 16 min) and median EBL (150 vs100 ml), although this did not reach statistical significance. There were no statistically significant differences in perioperative variables with stratification of patients with prior surgery into the two subcategories based on scar location (data not shown).

Table 2.  Patient characteristics and perioperative outcomes for transperitoneal RPN based on prior surgery status
VariablesAll Surgeries (n = 41)No Surgery (n = 54)P value
  1. IQR, Interquartile Range; BMI, Body Mass Index; LOS, Length of Stay; EBL, Estimated Blood Loss.

Median Age, years (IQR)61 (52–70)59 (50–65)0.406
Male Gender, n (%)24 (58.5)38 (70.3)0.279
Median BMI, kg/m2 (IQR)30.4 (25.2–36.3)29.4 (26–33.6)0.412
Median Tumor size, cm (IQR)2.5 (1.5–3.3)2.3 (1.7–3.0)0.540
Median Operative Time, min (IQR)246 (203–307)250 (214–299)1.000
Median Warm Ischemia time, min (IQR)21 (11–25)16 (0–25)1.000
Median LOS, days (IQR)2 (1–3)2 (1–3)0.513
Median EBL, cc (IQR)150 (69–250)100 (50–200)0.144
Adhesiolysis, n (%)17 (41)8 (15)0.005
Pathologic stage   
 Benign12150.174
 pT1a2330 
 pT1b28 
 pT200 
 pT3a41 

Intra-operative and postoperative complications are listed in Table 3. Access related complications occurred in two patients with previous upper midline or ipsilateral upper quadrant surgery: an enterotomy during lysis of adhesions that was repaired robotically without sequelae and a mesenteric hematoma during Veress needle placement. There was no conversion from transperitoneal RPN to open partial or robotic radical nephrectomy. Complications in patients with a previous lower abdominal, contralateral, or minimally-invasive scar consisted of a postoperative urine leak – two patients (6%), bleeding – three patients (9%), and pulmonary embolism – one patient (3%). However, there was no statistically significant difference in complications between groups. There was no statistically significant difference in the proportion of medical vs surgical complications between groups. There were no access related injuries in the 10 cases in which the robotic 8 mm camera was used for initial trocar placement.

Table 3.  Complications of patients with prior abdominal surgeries who underwent transperitoneal RPN
ComplicationsAll Surgeries (n = 41)No Surgery (n = 54)Other scar location (n = 35)Upper midline or ipsilat. upper quadrant scar (n = 6)P value
  • *

    Enterotomy occurred during lysis of adhesions; repaired robotically without sequelae.

  • Both urine leaks resolved spontaneously after stenting.

  • §

    One patient with platelet dysfunction required reexploration for delayed rupture of a hepatic subcapsular hematoma, with completion nephrectomy. Bleeding resolved in two patients after transfusion.

  • Re-exploration nephrectomy (1), angioembolization (1), and transfusion with spontaneous resolution (1).

Intraoperative     
 • Enterotomy*1 (2.4%)001 (16.7%)0.432
 • Mesenteric hematoma1 (2.4%)001 (16.7%)
Postoperative     
 • Urine leak2 (5%)02 (6%)00.184
 • Bleeding3 (7%)3 (6%)3 (9%)§01.000
 • Pulmonary embolism1 (2%)01 (3%)00.432
 • Urinary retention03 (6%)000.256

A subset analysis was performed of the five patients who underwent retroperitoneal RPN, which demonstrated a median tumor size of 2.2 cm, operative time of 259 min, warm ischemia time of 23 min, EBL of 75 ml, and length of stay of 2 days. Three of five patients (60%) had undergone prior abdominal surgery, including one patient with an upper midline and ipsilateral lower abdominal scar. There were no postoperative complications with the retroperitoneal approach.

DISCUSSION

  1. Top of page
  2. Abstract
  3. INTRODUCTION
  4. PATIENTS AND METHODS
  5. RESULTS
  6. DISCUSSION
  7. CONCLUSIONS
  8. CONFLICT OF INTEREST
  9. REFERENCES

Previous abdominal surgery is associated with formation of intra-abdominal adhesions [1,2,4], which may complicate successful completion of transperitoneal laparoscopic or robotic procedures. Previous abdominal surgery has traditionally been considered a relative contraindication to laparoscopy, and has been associated with increased operative times and complication rates [5,6]. Postmortem studies have shown that the most common cause of peritoneal adhesion formation is prior surgery [1]. As complex urological procedures are increasingly being performed using robotic and laparoscopic techniques, the number of patients with a prior history of abdominal surgeries undergoing such procedures is likely to increase [24]. Previous groups have evaluated the effect of prior abdominal surgery on transperitoneal laparoscopic upper tract procedures [3–7]. Robotic prostatectomy has also been evaluated in the setting of prior abdominal surgery [8]. However, to the best of our knowledge, our study is the first to examine the impact of previous abdominal surgery on transperitoneal RPN.

The impact of previous abdominal surgery on non-urological laparoscopic procedures has been evaluated by several gropus. Earlier abdominal surgery did not have an impact on the postoperative stay or complication rates in patients who underwent laparoscopic cholecystectomy [25,26]. Approximately 5% of procedures were converted to an open procedure, with dense adhesions preventing trocar placement being the most common reason [25]. Women undergoing laparoscopy for gynecologic procedures who had undergone prior laparotomy were also at a greater risk for access related complications [27]. In patients undergoing laparoscopic tubal ligation, complication rates were almost twice as high in patients with previous abdominal surgery [28].

The impact of previous abdominal surgery on transperitoneal laparoscopic upper urinary tract procedures has been evaluated by several groups [3–7]. Some studies suggested higher complication rates in patients with prior abdominal surgery [29], while others showed no increase in complications in patients with a history of open abdominal or prior renal surgery [4,7]. In a study by Seifman et al. of 190 patients undergoing laparoscopic upper tract surgery, 76(40%) had undergone prior abdominal surgery [7]. Patients with prior abdominal surgery had an increased risk of complications (16% vs 4%), which may have contributed to a longer mean hospital stay (3.8 vs 2.6 days). An upper midline scar/ipsilateral upper quadrant scar was associated with a greater access complication rate (12% vs 0%) but not a higher operative complication rate (21% vs 13%). When patients with previous surgery had a complication, the complication was more often operative than medical. In contrast, when patients without previous surgery had a complication, it was more likely to be medical than operative.

There are few reports on the effects of previous surgery on robotic surgery outcomes. Nazemi et al. published a study on 49 patients who underwent robotic surgery (25 had robotic radical prostatectomy) and found no difference in operative time, EBL, and complications when comparing those who had previous abdominal surgery vs no surgery [30]. They found a higher incidence of peritoneal adhesions in patients with previous surgery (54% vs 10%). Almost a third (30%) of all patients had a history of previous surgery with the majority of the cases being hernia repairs or appendectomies.

In a study by Siddiqui et al. of 3950 patients who underwent transperitoneal robotic radical prostatectomy, 1049 (27%) patients had a history of abdominal or inguinal surgery [8]. As in our study, there were no differences in EBL, total operative time, body mass index between groups. Adhesiolysis was more likely to be required in patients with prior abdominal surgery (23% vs 8%, P < 0.001). There were 4 access-related vascular injuries from Veress needle insertion, all of which were managed conservatively, with safe completion of the robotic prostatectomy within 2 weeks. Bowel injury occurred in 5 patients, 3 of which had a history of previous abdominal surgery requiring extensive adhesiolysis.

Our study is the first to analyze the impact of prior abdominal surgeries on perioperative outcomes after RPN. The incidence of peritoneal adhesions requiring adhesiolysis in our prior surgery group was (42% vs 15%) in patients without prior abdominal surgery, with achieved statistical significance (P = 0.005). Our rate of previous surgery of 43% is higher than the 30% and 27% rates reported by Nazemi et al. and Siddiqui et al., respectively, and is likely higher than what is seen in the community setting. This may be in part due to the fact that some patients are referred to us specifically because of a complex past surgical history. There was one enterotomy that occurred during lysis of adhesions in a patient with a prior major abdominal surgery and extensive adhesions, which was repaired robotically without sequelae. Some postoperative complications such as urine leak and pulmonary embolism occurred in patients with prior abdominal surgery, while bleeding occurred in both groups. However, our data do not show a statistically significant increase in complications in patients who have undergone previous abdominal surgery and there was not a statistical correlation in the location of the abdominal scar with operative complications. Also, our study did not show any increased proportion of medical complications in the no surgery group, contrary to what had been found by Seifman et al. [7] It is somewhat surprising that previous abdominal surgery did not seem to be associated with a statistically significant increase in operative times. Once the initial port was successfully placed, placement of other ports were relatively straightforward, even in most cases in which limited adhesiolysis was required. The direct vision port placement technique with the 8 mm camera further reduced potential delay in placing ports in the setting of prior abdominal surgery. Another possible explanation is that there could be a selection bias for more complex partial nephrectomy cases being done with an open extraperitoneal approach if dense adhesions were anticipated from prior abdominal surgery as opposed to attempting robotically for easier tumors, which might nullify extra time spent during adhesiolysis.

We used standard techniques for obtaining intraperitoneal access. Although many devices and techniques have been developed to decrease the morbidity of access injuries, no device is perfectly safe and there is no consensus regarding the optimal choice. Radially expanding trocars may be associated with fewer trocar injuries compared with bladed trocars [31,32]. Even the Hassan cannula can cause a major vascular injury at laparoscopy [33]. Lecuru et al. described the feasibility and safety of initial blind intraperitoneal access [27]. Patients with prior abdominal surgery had a higher rate of complications compared to patients without prior surgery. Audebert et al. determined the rate of umbilical adhesions at laparoscopy to be significantly higher in women with previous laparotomy [34]. They recommended preliminary inspection with a microlaparoscope through the left upper quadrant and insertion of the umbilical trocar under direct vision. Vilos et al. recommended left upper quadrant access in those with suspected periumbilical adhesions [35].

The use of an optical access trocar technique for initial access was described by Thomas et al. in 1283 urological laparoscopic surgeries [36]. Trocar injuries occurred in 4 patients (0.31%), but were recognized in 3 patients. They concluded that optical access trocars may result in fewer access-related complications or at least improved recognition if they do occur. We sought to recapitulate this technique using a robotic platform. The standard robotic 12 mm camera prevents the traditional application of this technique, as the camera is too large to fit through the obturator of an optical trocar. Therefore, setup of a separate conventional laparoscopic camera would be required in order to utilize this technique. We describe a modification of this technique utilizing the 8 mm robotic camera for direct-vision trocar placement that allows the vision trocar technique to be replicated using a robotic platform without the need for a separate laparoscopic setup. There were no access related injuries in the 10 cases in which the robotic 8 mm camera was used for initial trocar placement.

Limitations of our study include a single institution analysis with relatively low number of patients and the retrospective nature of the study. Other potential causes for adhesions, such as radiation therapy and inflammatory disorders, were not considered in this analysis. This study is based on a large cohort of patients at a major tertiary referral center. We also included multiple surgeons with varying level of experience and learning curve could potentially influence the results. In our study, operative experience did not decrease the complication rate, possibly due in part to liberalizing our criteria for patient selection as our experience increased. Consequently, the results may not be applicable to the urologic community at large. Our study focused on a transperitoneal approach for RPN, although we did include a subset analysis of patients who underwent a retroperitoneal RPN and we have previously described our experience with a retroperitoneal approach for robotic kidney surgery [37]. Patients who underwent a retroperitoneal approach had similar perioperative outcomes. A retroperitoneal approach for RPN is feasible and may be another potential strategy for patients with prior abdominal surgery, particularly for posterior tumors. Our 8 mm robotic camera had a slightly darker view than the standard 12 mm robotic camera, so we only used it to obtain initial access and switched to the 12 mm camera for the rest of the case to optimize visualization. However, with upcoming improvements in the 8 mm robotic camera quality over time, it may be more practical to continue to use the 8 mm camera for the rest of the case. Our 8 mm robotic camera had been purchased for pediatric cases. For institutions that do not already have the 8 mm camera, it is debatable as to whether the ability to perform direct trocar placement warrants the purchase of a separate 8 mm robotic camera.

CONCLUSIONS

  1. Top of page
  2. Abstract
  3. INTRODUCTION
  4. PATIENTS AND METHODS
  5. RESULTS
  6. DISCUSSION
  7. CONCLUSIONS
  8. CONFLICT OF INTEREST
  9. REFERENCES

Robotic partial nephrectomy is feasible in the setting of prior abdominal surgery. The majority of these patients can have their procedure performed safely without an increase in complications, although there is a trend toward increases warm ischemia time and EBL. We describe a novel technique of an 8 mm robotic camera for direct-vision placement of the initial 12 mm trocar, which may be beneficial in patients with prior abdominal surgery. Physicians and patients should discuss potential risk of RPN in the setting of prior abdominal surgery and discuss alternative treatment options in order to minimize the risk of injury from previous surgery.

REFERENCES

  1. Top of page
  2. Abstract
  3. INTRODUCTION
  4. PATIENTS AND METHODS
  5. RESULTS
  6. DISCUSSION
  7. CONCLUSIONS
  8. CONFLICT OF INTEREST
  9. REFERENCES