Transcript Laparoscopic Radical Cystectomy with orthotopic Neobladder

Laparoscopic Radical Cystectomy
with Orthotopic Ileal Neobladder
——Key Steps to Success
Huang Jian
The 2nd Affiliated Hospital
Sun Yat-Sen University, Guangzhou China
Introduction
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Laparoscopic radical cystectomy with
orthotopic neobladder (LRC-OIN) is
increasingly accepted by urologists.
It is no more the issue of feasibility but
the issue of improvement for this
procedure.
Discuss the techniques of key steps in
LRC-OIN
Haemostatic Instruments
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Harmonic scalpel
PK system
Bipolar forceps
LigaSure vessel sealing system
Electric hook
Hem-O-Lok
Hem-o-lok
PK System
LigaSureTM Vessel Sealing System
图1-2-10 结扎速血管闭合系统
Ultracision-Harmonic Scalpel
Patien’s position and trocar site
The Major Steps of the Procedure
Step 1: Pelvic lymphadenectomy
Step 2:Dissection of seminal vesicle and Denonvelia’s
fascia to expose the posterior aspect of prostate
Step 3: Exposing the anterior aspect of bladder and
prostate
Step 4:Dividing the lateral pedicles of the bladder and
the prostate
Step 5: Dividing the apex of the prostate and urethra
Step 6: Extracorporeal construction of Ileal neobladder
Step 7:Intracorporeal neobladder-urethra anastomosis
Step 1: Pelvic Lymphadenectomy with
electric hook and LigaSure
Techniques of Pelvic Lymphadenectomy
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Sequence: Lymphadenectomy before or after
cystectomy
extent: standard or extented
Using instrument: harmonic scalpel, PK system
bipolar clamp and electric scissors,
or electric hook and LigaSure
Attention:
blood vessel and obturator nerve injury
lymphatic leakage
tumor cell seeding
Step 2: Dissection of seminal vesicle
opening Denonvelia’s fascia
Step 3: Exposing the anterior aspect
of bladder and prostate
Step 4: Dividing the lateral pedicles
of the bladder and the prostate
 Nerve sparing
 Non nerve sparing
How to protect the neurovalscular bundle
Nerve sparing techniques
Non nerve sparing techniques
Step 5: Dividing the urethra
Step 2 to step 5: Cystectomy
Posterior aspect
Anterior aspect
Bilateral pedicles
Prostate apex and urethra
How to avoid rectum injury
Correctly localized seminal vesicle
 Opening the Denonvelia’s fascia and
separating rectum from prostate
 Dividing lateral peadicle close to the
prostate
 Transecting the urethra while pulling up
the prostate apex
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Different methods in dividing the
lateral paedicles
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LigaSure
PK Forceps
Endo-GIA
Harmonic scalpel
How to avoid the tumor seeding
 Avoidingbladder wall perforation
 Don’t transgressing the tumor boundaries,
 Blocking up the bladder neck before
transecting uretha
Step 6: Removal the spacimen
and neobladder construction
The technique of Extracorporeal formation of
neobladder
5 cm of midline subumbilical skin incision
 M shape ileal pouch
 Implantation of ureters directly to the
posterior wall of the pouch by means of
ureteral half nipple.
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Different techniques in formation of
neobladder
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Intracorporeally or extracorporeally
Reconstruction: Studer pouch, hemi-kock
pouch, T pouch, M pouch,
Implantation of ureters: ileal chimney, ileal
nipple, extramural serous-lined tunnels,
mucosal sulcus, ureteral nipple,
Studer pouch T pouch
ileal chimney
extramural serouslined tunnels
Hemi-kock pouch
ileal nipple
Mucosal sulcus
Ureteral nipple
Step 7: Neobladder- urethra anastomosis
Two running sutures technique
Tips and tricks
in Neobladder- urethra anastomosis
A traction stitch to relieve the tension
 Changing to head-up position
 Two running suture technique better than
interrupted, or running suture technique.
 Attention: the catheter out side the
neobladder
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Summary
The Surgical procedures of LRCOIN can be improved by reasonable
sequence, standard maneuver and
correct use of instruments.