Laparoscopic Radical Proststectomy
Once the patient’s suitability is confirmed for laparoscopic radical prostatectomy then the patient is explained about the procedure –the possible complications, outcome. The risk of conversion to an open procedure is explained thoroughly.
Specifically, if the patient’s safety or the oncologic integrity of the operation is jeopardized, the attending surgeon may decide to convert the procedure to the open surgical technique.
The preoperative and preanesthesia screening to determine suitability for a complex laparoscopic procedure is identical to that performed prior to open surgery. The patient is started on liquid diet one day prior to proposed date of surgery.The patient is given tab dulcolax 4 in evening and 4 in night time with fleet enema at bedtime.
On the day of surgery, a preoperative enema is performed, sequential compression stockings are placed, and a large-bore intravenous line is begun with preoperative antibiotics that cover both genitourinary and skin flora.(We start Cefoperazone and sulbactum and amikacin combination)
Regardless of the technique used, the patient is placed in the supine position with his head down. This head-down position allows for gravity to facilitate the natural retraction of the pelvic tissues.
To start with, a periumbilical incision is made to provide access for the initial laparoscopic port. A Veress needle is used to establish pneumoperitoneum and to facilitate the laparoscopic survey of the abdomen.
Carbon dioxide is then insufflated into the abdomen to achieve pneumoperitoneum. The initial access is replaced by a 12-mm radially dilating laparoscopic trocar.
The patient is placed supine with the arms at the sides and the legs spread apart and in an extreme Trendelenburg position. One surgeon and one assistant perform the operation, with a right-handed surgeon standing on the left side of the patient.
Five ports are placed in a diamond configuration,
(1) a 10-mm telescope port at the umbilicus,
(2) a 10-mm port at the McBurney point,
(3) a 5-mm port at the midpoint between the umbilicus and the pubis symphysis in the midline,
(4) a 5-mm port at the midpoint between the left anterior superior iliac spine and the umbilicus, and
(5) the final 5-mm port at the right pararectal line at the level of the umbilicus. The abdomen is initially inspected, and a pelvic lymphadenectomy is performed, if required.
The procedure is begun anteriorly, and the peritoneum is incised to enter the space of Retzius, thereby causing the bladder to fall posteriorly. The endopelvic fascia is incised, and the levator muscle is pushed laterally to free the prostate gland. This is followed by ligation of the dorsal vein. The next step is incision of the bladder neck.with incision of the peritoneal fold between the rectum and bladder and the dissection of the seminal vesicles posteriorly. The seminal vesicles are retracted anteriorly, and the Denonvilliers aponeurosis is incised (the globular pad of fat shows the right plane of the dissection). The dissection is carried distally to the level of the rectourethral muscle, separating the prostate anteriorly from the rectum posteriorly.
Finally, the lateral pedicles are dissected, and the urethra is transected to free the prostate gland with the seminal vesicles.
The final step of the surgery is construction of the urethrovesical anastomosis. We perform continuous running suturing of the urethrovesical junction. The procedure is completed with testing of the anastomosis with filling of the bladder with 300 ml of normal saline and placing a drain in pelvis.
The advantages of the transperitoneal approach include familiarity with anatomy, adequate space for dissection, and the presence of several reference points to aid the surgeon in orientation. Maximum mobility of the bladder is achieved in this approach, which helps provide a tension-free urethrovesical anastomosis.
Disadvantages of the transperitoneal approach include communication of the anastomotic site to the peritoneal cavity with the potential for peritoneal urine leak and ascites. The transperitoneal approach also increases the risk of bowel injury, ileus, and adhesions.