THE EVOLUTION OF RETROPERITONEAL LAPAROSCOPY
DURGA D GAUR
Associate Professor, Department
of Urology, Bombay Hospital Institute of Medical Sciences, Bombay, India.
Laparoscopy is being universally used to indicate endoscopic inspection
of the peritoneal cavity. However, it is etymologically not correct. In Greek
language, the word ‘lapara’ means flank. Therefore, only the procedure for inspecting
the structures in the lumbar region i.e. retroperitoneoscopy, should be called
laparoscopy. However, since Jacobeus first used the term laparoscopy in 1910,
for the inspection of the peritoneal cavity using a cystoscope, it is still
being used to indicate its historical significance rather than its literal meaning.
The term laparoscopy is now commonly used for both the intraperitoneal and the
extraperitoneal endoscopic procedures, but to specify them, it is preceded by
the adjectives of transperitoneal and retroperitoneal. However, some continue
to call them laparoscopy and retroperitoneoscopy.
As retroperitoneal organs are routinely exposed by an extraperitoneal approach
at an open operation, retroperitoneal laparoscopy automatically becomes the
procedure of choice for endoscopic exploration of these organs. Though, transperitoneal
laparoscopy has been performed for more than 50 years, mainly as a result of
the pioneering work done by Semm in the field of operative laparoscopic gynaecology,
retroperitoneal laparoscopy could not become popular because of the uniformly
poor results in the past.
The reason for the failure of retroperitoneal laparoscopy in the past was the
copycat attitude of the workers in this field. They tried to perform retroperitoneoscopy
the same way as laparoscopy was being performed without realizing that there
was no preformed space in retroperitoneal area. Quite naturally, they failed
to create a satisfactory pneumoretroperitoneum merely by insufflation through
a Veress needle.
Some progress was made only after the realization that some type of disruptive
force to break up the tough fibrous trabeculae and dense areolar and fibro-fatty
tissue in the retroperitoneum was necessary to allow creation of a satisfactory
pneumoretroperitoneum. Bartel in 1969 first reported endoscopic
visualization of the pelvic retroperitoneum with a mediastinoscope4 and some
5 years later, Wittmoser performed a retroperitoneal endoscopic lumbar sympathectomy.
The technique called ‘lumboscopy’ was extensively used and popularized by Sommerkamp
(1974) for exposing the kidney for renal biopsy.
However, it was a direct vision semi-open technique, requiring specially designed
long slender suction cannula, clip applicator, aspiration needle, biopsy forceps
and endoscopic scissors. It was a simple and economical procedure as no endocamera,
telescope or pneumoinsufflation was required. However, it could not be widely
accepted due to the field of vision and the access being limited.
Retroperitoneal laparoscopy, using a laparoscope and pneumoinsufflation, was
only started in 1979 by Wickham, for performing a ureterolithotomy.
However, subsequent attempts at retroperitoneal laparoscopy by Wickham and Miller
(1983) were not encouraging due to their inability to create a satisfactory
Thinking in the line of using some disruptive force to open up the retroperitoneal
space, Bay-Nielsen and Schultz (1982) and Clayman et al (1985) performed retroperitoneal
endoscopic ureterolithotomy, by using a laryngoscope and an Amplatz sheath respectively.[9,10]
The laparoscope was used by Eshghi et al (1985) to monitor percutaneous transperitoneal
removal of a staghorn calculus in a pelvic kidney. Weinberg and Smith (1988)
performed a nephrectomy in a pig by sucking it out through a nephrostomy with
an endoscopic ultrasonic aspirator.[11,12] They had to perform
prior embolization of the renal artery and the vein for obtaining haemostasis.
It was Clayman’s historical report of a transperitoneal laparoscopic nephrectomy
in 1991 that created world wide interest in laparoscopic surgery of the retroperitoneal
organs. Clayman et al had also performed a retroperitoneal laparoscopic nephrectomy,
but their subsequent nephrectomies were mostly performed transperitoneally,
as they considered the retroperitoneal approach to be very unsatisfactory.[13,14]
Retroperitoneal laparoscopy only took off after Gaur reported his innovative
balloon technique of dissection of the retroperitoneal space prior to pneumoinsufflation
in 1992.[15,16] The impact of this discovery was so great
that compared to less than a dozen articles on retroperitonesocopy published
during the last 80 years, more than a dozen appeared in the world literature
within a year.[17-31]
PROGRESS IN RETROPERITONEAL SURGERY DURING THE LAST DECADE
In spite of this sudden surge in the retroperitoneal laparoscopic activity,
the urologists were unable to compete with the general surgeons and the gynaecologists.
This is shown by the fact that so far their contribution has been a mere 6%
of the total number of laparoscopic articles published in the world medical
There are two explanations for this gross disparity between the urological and
the non-urological laparoscopic activity. One is that most urological laparoscopic
procedures have a steep learning curve, especially if performed by the retroperitoneal
approach. The urologist has to perform a relatively larger number of procedures
to have the same degree of confidence as his counterparts in other specialties,
where most of the work consists of simpler procedures on the appendix, gall
bladder and the fallopian tubes.
The other reason is that, while an average laparoscopic urologist is mostly
searching for an indication, his colleagues in general surgery and gynaecology,
generally have a big waiting list for a procedures like cholecystectomy, appendectomy,
herniorrhaphy, fundoplication and tubectomy.
There is one more reason for the smaller number of laparoscopic urological procedures
being performed. While the role of laparoscopy in gynaecology and general surgery
has been long established, its role for many urological procedures is still
UROLOGICAL PROCEDURES OF DOUBTFUL VALUE
Retroperitoneoscopic urological procedures like renal biopsy, varicocoelectomy,
pelvic lymphadenectomy, renal cyst decortication, nephropexy and colposuspension
were more frequently being performed earlier. However, most of these have either
been discontinued or much less frequently performed. The reasons being that
there are not many indications for such procedures or the long-term results
are not satisfactory or alternative less invasive therapeutic procedures are
ESTABLISHED RETROPERITONEOSCOPIC PROCEDURES
Nephrectomy for benign disease
Though, Gaur et al first published the report of simple nephrectomy by the retroperitoneal
laparoscopic approach, Clayman et al had performed it earlier.
Since then retroperitoneal laparoscopic nephrectomy has become established as
a minimally invasive procedure of choice for patients who have symptomatic benign
non-functioning kidney.[32-34] The efficiency, efficacy and
safety of the procedure is reflected in a recent series of 185 retroperitoneal
laparoscopic simple nephrectomies by Hemel et al. They had an operative time
of 100 minutes, an open conversion rate of 10.3% and major complication rate
of 3.78%. With more experience in this field even a tubercular
nonfunctioning kidney can not be considered a contraindication any more.[36,37]
The first retroperitoneoscopic adrenalectomy was reported by Uchida et al and
since then it has been performed by using both the posterior and the lateral
approach.[33,34,38] Most surgeons agree that the upper limit
of the size of the adrenal tumour for retroperitoneoscopic removal should not
exceed 5 or 6 cm due to the high incidence of malignancy in larger tumours.[39,40]
There are advocates who even suggest retroperitoneoscopic partial adrenalectomy.
Sasagawa et al and Suzuki et al have used a stapler and an ultrasonic knife
respectively for performing the procedure.[41,42] The results
of retroperitoneoscopic and transperitoneal laparoscopic adrenalectomy have
been compared by Fernandez-Cruz et al who found no difference in operative time,
analgesic requirement, hospital stay and return to normal activity.
The results of transperitoneal laparoscopic, lateral retroperitoneoscopic and
the posterior retroperitoneoscopic approaches have been compared by Baba et
al who found that the posterior approach was most effective for retroperitoneoscopic
adrenalectomy in regard to the simplicity of the vascular control.
The efficacy, efficiency and safety of the posterior retroperitoneoscopic approach
has been shown in a recent series of 142 adrenalectomies by Waltz et al. They
had an operative time of 101 minutes, success rate of 95% and there were no
major complications. However, Gill et al and Suzuki et
al claim that a lateral retroperitoneoscopic approach is equally effective,
simple and safe.[46,47]
RETROPERITONEOSCOPIC UROLOGICAL PROCEDURES STILL TO BE ESTABLISHED
Reconstructive urological procedures
Reconstructive retroperitoneoscopic surgery has not yet been widely accepted
because of the inherent problems in laparoscopic suturing and the problems of
manipulation due to limited space available. Due to this reason, non-dismembered
pyeloplasty procedures for ureteropelvic junction obstruction like, exopyelotomy
and Fenger-plasty were initially performed.[48,49] However,
very soon they were followed by retroperitoneoscopic dismembered pyeloplasty.[50-52]
The efficiency and efficacy of the procedure has been shown by Eden et al to
be quite with a mean operative time of 164 minutes, open conversion rate of
4% and success rate of 95%.
Retroperitoneal laparoscopic radical nephrectomy is slowly gaining popularity
for the treatment of T1-T2 NOMO renal tumours since it was first reported by
Kinukawa et al in 1995. Clayman et al study have shown
that the results of laparoscopic radical nephrectomy for T1-T2 renal tumours
up to 10 cm were quite comparable with those of open radical nephrectomy series.
They had no port site recurrence in any patient. Gill
et al have not only shown identical results but these authors also claim that
T1-T2 NOMO tumours even as large as 12 cm can be safely removed by the retroperitoneal
Gill et al have used a novel endoscopic approach for excising a cuff of bladder
for this purpose and have recently compared the results of retroperitoneoscopic
radical nephroureterectomy and the open procedure.[57,58]
Their conclusion was that laparoscopy was superior in regard to surgical time,
blood loss, specimen weight, resumption of oral intake, narcotic analgesia requirements,
hospital stay, return to normal activities and convalescence. In an attempt
to further simplify the procedure, Salomon et al use a small iliac incision
for distal ureterectomy and excision of the cuff of bladder and Igarshi et al
employ a gasless hand assisted retroperitoneoscopic technique.[59,60]
Nephron sparing surgery
Gill et al reported retroperitoneal laparoscopic partial nephrectomy using a
double loop apparatus and argon beam coagulator for acquiring haemostasis.61
Various modalities for achieving haemostasis during this procedure like ultrasound,
radiofrequency, microwave, cable-tie, fibrin glue, biological glue, hydro jet
and electrosurgical snare have been used from time to time.[62-67]
Though retroperitoneal laparoscopic renal cryoablation, is a much simpler nephron-sparing
procedure, is safe and effective but its long term results are still awaited.
The real indication for retroperitoneal laparoscopic ureteral surgery is a salvage
ureterolithotomy as an alternative to an open procedure in patients where URS
and ESWL have failed. However, Gaur has even recommended the retroperitoneoscopic
approach as a primary procedure, if one feels that the chances of failure with
the existing minimally invasive procedures could be high due to size of the
stone, degree of its impaction or a co-existing ureteral anomaly.
It is also an excellent approach for ureterolysis, treatment of ureteral stricture
or retrocaval ureter.
Renal stone surgery
After Gaur et al reported the first retroperitoneal laparoscopic pyelolithotomy
in 1994, only a few papers appeared in the medical literature.[70-72]
On account of its being less invasive to the renal parenchyma and having a better
chance of total stone clearance, it may be given priority over percutaneous
nephrolithotripsy in select group of patients with large renal stones.
With advances in technique and instrumentation, retroperitoneal laparoscopic
pyelolithotomy might become an acceptable minimally invasive alternative for
patients with staghorn stones in due course of time.
Live donor nephrectomy
Though, retroperitoneoscopic live donor nephrectomy was performed sometime back,
it could not become popular mainly due to the problem of limited space.
Gasless retroperitoneoscopy assisted live donor nephrectomy being a simpler
procedure is slowly gaining acceptance.[75,76] Even a hand
assisted standard retroperitoneoscopic live donor nephrectomy has recently been
Schuessler et al reported the first laparoscopic radical prostatectomy in 1992
and Guillonneau et al later popularized the technique using the transperitoneal
laparoscopic approach.[78,79] The retroperitoneal laparoscopic
surgeons are not far behind and Bollens et al have even performed it retroperitoneoscopically
and have since reported 42 procedures with a reasonable mean operative time
of 317 minutes.
It is hoped that it would soon be possible to universally perform almost all
reconstructive and ablative urological procedures by the retroperitoneal laparoscopic
However, this would require perfection in the already existing tissue approximation
techniques, tissue retrieval methods, tissue ablation techniques, haemostasis
techniques, intraoperative imaging techniques, 3-D video imaging, virtual reality,
telerobotics and miniaturized robotics.[81-82] The invasiveness
of the retroperitoneal laparoscopic procedure would be further reduced by the
use of needlescopes and microlaparoscopic instruments, which are at present
only being used for the transperitoneal procedure. This
is because of the problem of needlescopic access to the retroperitoneal space
and it is hoped that soon this barrier would also be overcome.
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