ДВНЗ «Тернопільський державний медичний університет

імені І.Я. Горбачевського»

Deapartment of general and minimally invasive surgery

Study Guide for students

the fourth year — minimally invasive surgery

 

                                                           Lesson no. 6 (practical training) – 6 hours

Theme: 6. Nephrectomy. Indications, methods and technique of execution. Resection of kidney.

Indications, methods and technique of execution. Varix dilatation of spermatic cord. Technique of
execution of minimally invasive surgery. Minimally invasive methods of prostata gland adenoma treatment.
Minimally invasive methods of medical treatment of urethra and bladder. 

Object.  To study indications, methods and technique of execution of minimally invasive urinological
surgical interferences.

To acquaint students with basic instruments that are used for execution of minimally invasive urinological
surgical interferences (nephrectomy, resection of kidney, transurethral prostatic resection (TURP) etc.), to
study structure and function of some of them. To conduct demonstration surgical interferences.

To teach students how to prepare patients to minimally invasion urology interferences, to find out
contraindications to their implementation.

Professional orientation of students.

Laparoscopic urology – new method of effective treatment of different urinological diseases that make
possible to reduce a term of recovery of patients and do not leave cosmetic defects on the body after
operation’s execution. The modern state of technique allows to apply laparoscopy both for diagnostic aims
and for operative intervention, in particular nephrectomy, resection of kidney, transurethral prostatic
resection (TURP), operation concerning the extended vessels of testicle etc.

Methodology of implementation of practical work. Practical part of the lesson 9.00-12.00

Algorithm of communication of students with patients with any pathology that is examined in the theme
(communicative skills) :

Students must keep the following communicative algorithms:

1.      To greet and give one’s name.

2.      On face there must be a friendly smile, it allows to set to you confidence relations from the side of
patient.

3.      It should be explained in a pleasant form to a patient the aim of visit, theme and duration of
conversation and get his consent.

4.      If a patient just enters to the hospital it should be conducted a correct and quiet conversation with his
relatives and together with a attending medical doctor to report to them about a previous diagnosis,
purpose of hospitalization, realization of certain examinations, that are planned for execution in the future.

5.      Before realization of corporal methods of examination it should be explained to the patient what
examination will be executed, to specify on the unpleasant feelings and discomfort that a patient can feel
during this examination, to lay the stress on obligation of this examination in diagnostics of this disease and
to get his consent.

6.      In case of necessity of transporting to the place of inspection (survey room, rontgenological
department, manipulations room) to explain its necessity to the patient

7.      To prepare to realization of examination, to wash hands with warm water, to put on gloves, prepare
tools for execution of a diagnostic or medical manipulation

8.      To conduct a planned examination or medical manipulation.

9.      To explain the results of one or another inspection in correct and easily form understood by a patient
together with a attending medical doctor.

10.    To attract relatives of the patient to conversation and to explain to them in an accessible form the
results of these examinations and at presence of previous examinations to compare their results, also it is
necessary to find out if your explanations are clear for them.

11.    It is necessary only in the presence of attending medical doctor to ground expediency of operative
intervention for treatment of this pathology of the patient.

12.    After realization of surgical treatment only in the presence of attending medical doctor and at his
consent it should be reported the results of operative intervention to the patient and his relatives and also
about possibility of appearing of one or other early or future postoperational complications.

13.    Under conditions of examination of patient during a postoperational period it should be explained to

the patient how to execute correctly hygienic procedures and etc.

14.     To get in a polite form the consent of patient to participate in dressing.

15.    Together with a attending medical doctor to explain to the patient, and if it is necessary to the
relatives of the patient one or other actions concerning manipulations that are executed or are planned to
be executed in the future and also tactics of further treatment.

16.   Certainly it should be finished conversation with wishing the most rapid recovery to the patient.  

Break – 12.00-12.30

Seminar discussion of theoretical questions  – 12.30-14.00

1. Indications for the execution of laparoscopic nephrectomy.

2. Contraindications for the execution of laparoscopic nephrectomy.

3. Technique of execution of laparoscopic nephrectomy.

4. Indications for the execution of laparoscopic resection of kidney.

5. Contraindications for the execution of laparoscopic resection of kidney.

6.Technique of execution laparoscopic resection of kidney.

7. Indications for execution of transurethral prostatic resection (TURP).

8. Contraindications for execution of transurethral prostatic resection (TURP).

9. TURP syndrome.

10. Technique of execution of transurethral prostatic resection (TURP).

11. Minimally invasive methods of treatment of transurethral prostatic resection (TURP).

12. Minimally invasive methods of treatment of bladder’s diseases.

13. Minimally invasive methods of treatment of ureter’s diseases.

14. Technique of execution of laparoscopic operation in the case of varix dilatation of spermatic cord.

15. Indications for execution of laparoscopic operation in the case of varix dilatation of spermatic cord.

16. The main instruments that are used for execution of minimally invasive surgical urinological
interferences.

17. The points of putting of trocars depending on pathology.

18. The postoperational nursing.

19. The preparation of a patient before minimally invasive surgical interference.

20. The complications of minimally invasive surgical interference.

Break – 14.00-14.15

                                                             Hour of unsupervised work of students – 14.15-15.00

- analysis of tasks of licensed test exams «Krok 2»;

- evaluation of students who failed test controls the day before in «Moodle» system;

- practical skills passing by students with corresponding record in student's record card.

Examples of tests.
What diseases that need to extract the kidney for medical object are indicators for laparoscopic
nephrectomy?
a. renovascular hypertensia
b. chronic obstruction of urinary tracts with having a pain
c. all answers are right
d. chronic infection that is refractor for medical therapy
e. multicystic dysplasia of kidney

1. During laparoscopic nephrectomy before extracting the kidney from patient’s body it is putting
into:
a. endoscopic retractor
b. endoscopic basket
c. endoscopic container
d. fractional braker
e. vacuum reservoir

The absolute contraindications of laparoscopic nephrectomy does not include:

a. general peritonitis
b. peritoneal wall’s infection
c. coagulopathy
d. multicystic dysplasia of kidney
e. pyonephrosis

What is an advantage of retroperitoneal nephrectomy:

a. operation time reduction

b. direct access to kidney
c. a low level of traumatism
d. after operation period is less
e. all answers are right

What is an advantage of retroperitoneal nephrectomy:

a. operation time reduction
b. a low level of traumatism
c. an early access to the gates of kidney
d. after operation period is less
e. all answers are right

What is a disadvantage of retroperitoneal access by laparoscopic nephrectomy:

a. it’s not possible to put an extracted kidney into an endoscopic container
b. An early access to the gates of kidney
c. a direct access to kidney
d. all answers are right
e. a long-term period after operation

What is a disadvantage of retroperitoneal access by laparoscopic nephrectomy:

a. a direct access to kidney
b. a restricted work place
c. an early access to the gates of kidney
d. all answers are right
e. a long-term period after operation

What instrument is used for making a primary carboxyperetoneum during conducting a laparoscopic
nephrectomy:
a. aquacleaner
b. pusher
c. Veresh’s needle
d. trocar
e. Henher’s needle

Who was the first person who has conducted a laparoscopic nephrectomy?
a. Dayman in 1990
b. S. Al- Kadhi in 1988
c. M.Nelson in 1979
d. Karol Kaczynski in 2005
e. R. E Yautmann in 2008

The advantages of laparoscopic nephrectomy do not include:

a. a low level of traumatism;
b. a short period of hospital stay of patient (2—3 days),
c. a quick rehabilitation after operation
d. less time of operation duration
e. all answers are right

What is a purpose of wearing knee socks for pneumatic compression while conducting a laparoscopic
nephrectomy:
a. bleeding reduction
b. thromboembolism prophylaxis
c. centralization of circulation of the blood
d. all answers are right
e. increase of А/T

Which method helps to make a pneumoperitoneum by transperitoneal access to kidney

a. Kocher’s method
b. Tol’d’s method
c. Troyanov’s method
d. Pyrohov’s method
e. Hesson’s method

What a minimal number of working ports is needed to conduct a laparoscopic nephrectomy completely?
a. 1
b. 2
c. 3
d. 4
e. 5

What instrument is used for commissures dissecting while conducting a laparoscopic nephrectomy?
a. electric scissors
b. director
 c. electric knife
d. coagulator
e. all answers are right

On which line the peritoneum is dissected while conducting a laparoscopic nephrectomy?

a. Kocher’s line
b. Tol’d’s line
c. Troyanov’s line
d. Pyrohov’s line
e. Sitkovsiy’s line

What is a duodenum mobilization by Kocher while conducting a laparoscopic nephrectomy?

a. the duodenum taking in medial direction
b. the duodenum taking in lateral direction
c. the duodenum taking up
d. the duodenum taking down
e. the duodenum taking before in lateral direction and then in medial direction

Якими кліпсами кліпують ниркову артерію

a. 2-міліметровими
b. 11-міліметровими
c. 6-міліметровими
d. 20-міліметровими
e. 22-міліметровими

What clips are used for kidney artery clipsing

a. 2-mm
b. 11-mm
c. 6-mm
d. 20-mm
e. 22-mm

What minimal quantity of clips is put on proximal part of kidney artery while conducting laparoscopic
nephrectomy?
a. 1
b. 2
c. 3
d. 4
e. 5

What pressure has to be made in abdominal cavity for putting primary carboxyperetoneum on?
a. 3 mm mercury column;
b. 5 mm mercury column;
c. 20 mm mercury column;
d. 13 mm mercury column.
e. 50 mm mercury column.

Who was the first person who has conducted a laparoscopic adrenalectomy?
a. Gagner et al. in 1992
b. Dayman in 1990
c. Al- Kadhi in 1988
d. M.Nelson in 1979
e. Karol Kaczynski in 2005

What instrument is used for commissures dissecting while conducting a laparoscopic adrenalectomy?
a. director
b. electric scissors
c. electric knife
d. coagulator
e. all answers are right

What is an advantage of retroperitoneal method of laparoscopic adrenalectomy?

a. operation time reduction
b. a low level of traumatism
c. a quick adrenal gland mobilization
d. less after operation period
e. all answers are right

What angle is required for patient’s position while conducting laparoscopic adrenalectomy?
a. 60-70°
b. 45-60°
c. 35-40°
d. 25-30°
e. 40-45°

What is a purpose of wearing knee socks for pneumatic compression while conducting a laparoscopic
adrenalectomy?
a. bleeding reduction
b. thromboembolism prophylaxis
c. centralization of blood circulation
d. all answers are right
e. A/T increasing

What instrument is used for making a primary carboxyperetoneum during conducting a laparoscopic
adrenalectomy?
a. aqua-purator
b. pusher
c. Veresh’s needle
d. trocar
e. Henher’s needle

Which technique is used for making a pneumoperitoneum while laparoscopic adrenalectomy?

a. Kocher’s technique
b. Tol’d’s technique
c. Troyanov’s technique
d. Pyrohov’s technique
e. Hesson’s technique
Which pressure is required for abdominal cavity before trocars’ bringing in while laparoscopic
adrenalectomy?
a. 5 mm mercury column.
b. 20 mm mercury column.
c. 80 mm mercury column.
d. 40 mm mercury column.
e. 65 mm mercury column.

Where are the trocars put while laparoscopic adrenalectomy?

a. under the edge of costal margin on the side of involvement
b. under the edge of costal margin on the opposite side of involvement
c. along the Pyrohov’s line
d. in iliac parts
e. near the navel

Which pneumoperitoneum pressure is required for conducting a laparoscopic adrenalectomy?

a. 45 mm mercury column
b. 5 mm mercury column
c. 35 mm mercury column
d. 15 mm mercury column
e. 605 mm mercury column

Which access is used for conducting a retroperitoneal adrenalectomy?

a. lateral
b. medial flank
c. lateral flank
d. anterior
e. all answers are right

Which access is used for conducting a retroperitoneal adrenalectomy?

a. lateral
b. medial flank
c. posterior transversal access
d. anterior
e. all answers are right

What is an advantage of lateral flank access while retroperitoneal adrenalectomy?

a. permits to get a bigger work place
b. permits to reduce an operation term
c. risk of operative intervention is reducing
d. all answers are right
e. traumatic is reducing

What is a disadvantage of lateral flank access while retroperitoneal adrenalectomy?

a. risk of operative intervention is increasing
b. in the case of big tumours the visualization of adrenal gland vessels can be difficult
c. duration of operative intervention is increasing
d. all answers are right
e. all answers are wrong
What is an advantage of posterior transversal access while retroperitoneal adrenalectomy?
a. permits to get bigger work place
b. permits to reduce a term of operative intervention
c. risk of operative intervention is reducing
d. all answers are right
e. direct access to main adrenal gland vessels before starting manipulations with adrenal gland

The advantages of retroperitoneal access while retroperitoneal adrenalectomy include:

a. permits to reduce a term of operative intervention
b. risk of operative intervention is reducing
c. can be used in case with patient with obesity and abdominal operations in anamnesis
d. all answers are right
e. all answers are wrong

Lateral access while retroperitoneal adrenalectomy requires putting of the patient

a. in entire lateral position 10°
b. in entire lateral position 20°
c. in entire lateral position 25°
d. in entire lateral position 30°
e. in entire lateral position 90°

Which pressure is required for pararenial space while conducting retroperitoneal adrenalectomy?
a. 15 mm mercury column
b. 2 mm mercury column
c. 45 mm mercury column
d. 60 mm mercury column
e. 90 mm mercury column

With what instruments the peritoneum is taking to the medial direction while conducting retroperitoneal
adrenalectomy?
a. with insufflator
b. with swab
c. by means of adjoining tissues division
d. by means of dissection by blunt notch
e. all answers are right

How the Fascia Herot is cutting while conducting retroperitoneal adrenalectomy?

a. widely, in the medial direction
b. widely in the cephalad and caudalis direction
c. widely in the lateral direction
d. all answers are right
e. widely in the cephalad and lateral direction

How is the adrenal gland ablated while conducting retroperitoneal adrenalectomy?

a. by means of endoscopic container by the widest incision
b. by means of hermetic sterile bag
c. by means of endoscopic retractor
d. by means of endoscopic basket by the widest incision
e. all answers are right
What pressure of insufflation is required to examine the operation area for adequacy of hemostasis Before
trocars’ extraction while conducting retroperitoneal adrenalectomy?

a. 45 mm mercury column
b. 65 mm mercury column
c. 75 mm mercury column
d. 5 mm mercury column
e. 15 mm mercury column

Where the first trocar is placed while conducting laparoscopic operation in the case of varicocele?
a. in the left hypochondrium
b. in the right hypochondrium
c. in the region of umbilical cord
d. in the right inguinal region
e. in the left іnguinal region

What is placed into lumen of the first trocar while conducting laparoscopic operation in the case of
varicocele?
a. video-equipment
b. director
c. insufflator
d. coagulator
e. forceps

What is the main disadvantage of laparoscopic operation in the case of varicocele?

a. a high level of traumatism
b. a high frequency of hydrocele forming and relapse
c. duration of operation
d. all answers are right
e. a frequent bleedings

What do a high frequency of hydrocele’s forming and relapsing while conducting laparoscopic operation in
the case of varycocele attribute to?
a. a high level of traumatism
b. an insufficient visualization of lymphatic vessels during the operation
c. all answers are right
d. an insufficient hemostasis
e. all answers are wrong

Where two 5 mm trocars are placed while conducting laparoscopic operation in the case of varycocele?
a. on the white line
b. in hypochondriac region
c. in iliac and hypochondriac regions
d. in epigastric region
e. in two sides from the umbilical cord

What is the position of patient on the surgical table while conducting laparoscopic operation in the case of
varycocele?
a. on the back
b. on the left side
c. on the right side
d. on the abdomen
e. all answers are wrong

What instrument is used to create a primary carboxyperetoneum while conducting laparascopic operation
in the case of varycocele?
a. aqua-purator;
b. pusher;
c. Veresh’s needle;
d. trocar
e. Henher’s needle

The advantages of laparoscopic operation in the case of varycocele do not include:

a. all answers are wrong
b. a short term of patient’s staying in the hospital (1—3 days)
c. a quick recovering time after operation
d. less time for operation’s duration
e. all answers are right

What instrument is used to create a primary carboxyperetoneum while conducting laparascopic operation
in the case of varycocele?
a. aqua-purator;
b. pusher;
c. Veresh’s needle
d. trocar
e. Henher’s needle

Sources:

1.      Balalykin А. S. Endoscopic abdominal surgery. М.: Medicine, 1996, 152 p.

2.      Savelyev V. S., Buyanov V. М., Balalykin А. S. Endoscopy of organs of abdominal cavity. М.: Medicine,
1977, 247 p.

3.      Kotchnev О. S. Diagnostic and medical laparoscopy in emergency surgery. Kazan’, 1988, 151 p.

4.      Endoscopic surgery / I. V. Fedorov, E. I. Sigal, V. V. Оdintsov. – the 2-d ed.- М.: GEОТАR-MED, 2001.-
352 p.

5.     Illustrated manual of endoscopic surgery: teaching aid for surgeons/ Edited by S. I. Emelyanov – М.
«Medical Information Agency», 2004, 218 p.

1. Мaterials for preparation for practical training

 2. Мaterials for preparation for lecturess

3. Presentations of lectures

Author:                            
 

Discussed on the department meeting              Approved by cyclic methodical committee of surgical

“00”00 2014,  minutes of the meetings no. 1 subjects