A boy with Pelvi-uretric junciton obstruction managed laparoscopically
Master R.S., 7 years old boy came with pain in left side of belly. Ultrasound showed swelling of left Kidney (hydronephrosis). Ureter, bladder and right kidney were normal. A DTPA scan was done to find out about drainage of left kidney and also percentage function. It showed Pelvi-ureteric junction obstruction and a preserved function in the left kidney. Since the child was symptomatic he was planned for a pyeloplasty.
A Laparoscopic pyeloplasty was performed successfully and the child recovered uneventfully. A double J stent was also placed across the anastomosis and this was removed by cystoscopy after 6 weeks. A repeat DTPA scan at 6 months showed good drainage for left kidney and ultrasound showed reduction of swelling.
DTPA scan showing retention of isotope in Left kidney, right kidney
has cleared off well.
Delayed images of DTPA scan showing retention of tracer even at 2.5
hours after starting the test.
Picture of the child taken at 2 weeks, note only two stitch marks DTPA scan after 6 months showing good drainage from left kidney
and normalisation of curve.
Laparoscopic Surgery and Laparoscopic pyeloplasty
Pediatric Laparoscopy or laparoscopic surgery in children is a new and upcoming specialty and it has been possible due to availability of miniaturized equipment, small telescopes and above all well trained doctors. The concept of laparoscopy in children is very appealing and is being applied to more and more surgical problems in kids.
For laparoscopy, initially a small hole is made in the belly button or navel to put a telescope and also to infuse a harmless gas (generally carbon dioxide) into the belly. This inflates the belly and gives working space to the surgeon. Then through small holes, instruments are put to perform the procedure. These instruments for kids are really small—the tip size is just 3 mm. A camera is attached to the telescope and is used to watch the procedure on a monitor in a magnified and more precise way. At the end of the surgery, the instruments are removed from the belly and one or two stitches are put within the skin to finish the procedure. These stitches need not be removed. It is amazing how extensive procedures can be performed with 3-4 key hole punctures.
Laparoscopic pyeloplasty is one of the most challenging reconstructive surgeries in laparoscopy. It involves dissection of the pelvi-ureteric junction, excision of junction and excess pelvis and then re-stitching the junction back properly. It takes 3-4 hours as each suture is critical and takes a lot of time. But all this is compensated by a fast recovery and less pain post-operatively. There are hardly any stitch marks on the belly. Laparoscopic pyeloplasty is possible only in children more than one year of age due to the limitation of the space.
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