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The good news is there are useful skills, techniques, and state-of-the art technologies that urologists can incorporate into their practices to improve outcomes.
"Most community urologists don't have the volume of laparoscopic procedures available to allow them to keep up their skill level," said Dr. Landman said at the Winter Urologic Forum here. "Now there are new and existing technologies that can help surgeons overcome some of the challenges of performing laparoscopy, allowing them to offer the benefit of this minimally invasive procedure to their patients."
Energy technologies, for example, can be powerful tools for creating hemostasis. For vessel-sealing capabilities, the Harmonic ACE (Ethicon Endo-Surgery, Cincinnati), LigaSure (Valleylab, Boulder, CO), and new devices such as the Enseal (SurgRx, Redwood City, CA), to name a few, are useful tools, according to Dr. Landman. However, before use, he suggests that surgeons understand the applications, limitations, and thermal spread of each instrument.
The use of laparoscopic ultrasound is another critical component that offers tre-mendous advantages to the laparoscopic surgeon. It is used increasingly in urologic laparoscopy because it allows surgeons to assess tissues and identify vessels. When using the duplex component of the ultrasound, the surgeon is able to characterize blood flow to both normal and neoplastic tissues. It is also used in advanced laparoscopic kidney surgeries to confirm ischemia.
"Laparoscopic ultrasound provides a good visual aid to the operating field during the procedure once the surgeon learns what the images mean and how to orient the device," Dr. Landman said. "I suggest collaborating with a radiologist during a procedure to learn how to use it, which is what I did."
Tools for beginners
For those not completely comfortable with pure laparoscopy, Dr. Landman suggested using the hand-assisted laparoscopy. With this technique, the surgeon has the tactile sensation and the retraction that a hand can provide while still maintaining a minimally invasive approach.
"I think the hand-assisted techniques have really allowed the community urologist to pass along the benefits of laparoscopy to their patients," said David Albala, MD, professor of urology and director of minimally invasive urological surgery at Duke University Medical Center, Durham, NC. "With this technique, it's possible to develop the skills for a laparoscopically hand-assisted nephrectomy when a urologist is only performing three or four nephrectomies a year. It's very learnable."
Incorporating tools, such as a fixed retractor system like an Endoholder (Codman, Raynham, MA) with a Padron Endoscopic Exposing Retractor (J. Jamner, Hawthorne, NY), also allows the surgeon to use both hands during the procedure. Another tool that can help with the challenge of suturing is Lapra-Ty clips (Ethicon Endo-Surgery). According to Dr. Landman, these clips are easy to use and minimize the need for knot tying.
The daVinci robot (Intuitive Surgical, Inc., Sunnyvale, CA) offers a three-dimensional optics system that makes visualization of the operative field more intuitive during laparoscopic procedures.
"Laparoscopic instruments are counterintuitive and lack the additional degrees of freedom that the wristed robot provides," Dr. Landman explained. "These will become more commonplace in ORs across the country as they become more affordable."