Transperitoneal laparoscopic nephrectomy in children: surgical technique with 3 trocars.

INTRODUCTION

The first videolaparoscopic nephrectomy in children was performed in 1992, and since then, little experience, and small series of pediatric patients have been reported. The technique, described by Clayman and accepted worldwide, requires the insertion of 4 or 5 trocars. Introduction of trocars is an important cause of complication in videolaparoscopic surgery. The authors report laparoscopic transperitoneal nephrectomy in children using only 3 trocars, to minimize risk of vascular injury or visceral perforation.

SURGICAL TECHNIQUE

The patient is placed in supine position with flank rotated at approximately 45(degrees). After pneumoperitoneum is established, the first trocar is introduced in umbilicus for the laparoscope. Under direct vision, the second trocar is placed at ipsilateral midclavicular line, and the third and last trocar in the epigastric region. Laparoscopic transperitoneal nephrectomy was performed in 3 children aged 7, 8, and 14 years old. Right nephrectomy was performed in 2 cases, and left nephrectomy in one. Mean operative time was 163 min (100 to 230 min), and no transfusion was necessary. Patients were discharged from hospital on day 2 to 4 after the procedure. There were no conversions to open surgery, and no intra or postoperative complications.

COMMENTS

Every trocar and instrument introduction into the abdominal cavity presents an important risk of vascular injury or visceral perforation. The risk per patient is naturally increased with the number of trocars utilized. Injuries during laparoscopic procedures can theoretically damage every intra- or retroperitoneal organ. The majority of these lesions will need immediate or delayed open surgery, due to hematoma formation, postoperative bleeding, abscess, or peritonitis. Transperitoneal videolaparoscopic nephrectomy in children can be performed using only 3 trocars. The technique allows a better cosmetic result, and reduces the risk of trocar introduction injuries, like vascular and visceral lesions.