Fig. 18.1
Ultrasound scan showing right ureterocele. Ureteric jet shows the location of orifice
Fig. 18.2
Cystoscopic view of right ureterocele
Fig. 18.3
Cystoscopic deroofing of ureterocele to advance ureteric stent
Fig. 18.4
View after deroofing ureterocele
Fig. 18.5
Subumbilical camera port site
Fig. 18.6
Balloon trocar inserted as subumbilical camera port
Fig. 18.7
Transvesical laparoscopic view after deroofing. Infant feeding tube is advanced into the ureter
Fig. 18.8
Locating left ureteric orifice to plan direction of submucosal tunneling
Fig. 18.9
Ureter is being carefully mobilised (after cirumferential incision of bladder mucosa)
Fig. 18.10
Ureteric stent is being transfixed to Ureter
Fig. 18.11
Ureter is held with dissector and dissected all around
Fig. 18.12
All bladder muscle fibre attachments to the ureter are divided using hook dissector with electrocautery
Fig. 18.13
Ureter is mobilised till perivesical fat is seen
Fig. 18.14
Hiatus has to be narrowed using 2-0 vicryl suture to prevent air leak
Fig. 18.15
Hiatus narrowed adequately
Fig. 18.16
Ureter margins being freshened is being excised with scissors
Fig. 18.17
Submucosal tunnel is being created with a dissector
Fig. 18.18
Once adequate length of submucosal tunnel is achieved, sufficient bladder mucosal incision is made for neoureteric orifice
Fig. 18.19
The ureteric stent with ureter is grasped with a dissector and routed through the submucosal tunnel
Fig. 18.20
Ureter is seen exiting through the new tunnel
Fig. 18.21
Ureteric end is sutured to mucosal edge using interrupted 4-0 vicryl suture
Fig. 18.22
Few more vicryl sutures are placed to fix the ureter
Fig. 18.23
View after reimplantation
Fig. 18.24
Mucosal defect at hiatus is closed
18.8.1.1 Problems in Transvesical Laparoscopic Surgeries
Fig. 18.25
Camera port slipped out of the bladder
Fig. 18.26
This can be prevented by a stay suture taken through the dome of the bladder or by using a balloon tip trocar (as shown in the inset)
Fig. 18.27
When the dissector is not in a desired direction while creating a submucosal tunnel, roticulating dissector is helpful
Fig. 18.28
When the dissector is not in a desired direction while creating a submucosal tunnel, roticulating dissector can be favourably rotated and tunnel can be made in the desired direction
Fig. 18.29
Collapse of the bladder (due to escape of air) may result in slippage of trocar
Fig. 18.30
Prevention of collapse of bladder with a stay (1 ethilon) taken through the dome and anterolateral wall of the bladder
Fig. 18.31
Gas leak through hiatus (which can result in perivesical emphysema and collapsing of bladder)
Fig. 18.32
Adequate closure of the hiatus prevents this leak
Fig. 18.33
Accumulation of blood stained urine preventing progress of surgery (as seen by Cystoscopy)
Fig. 18.34
Accumulated urine sucked out through foley catheter placed perurethrally
Fig. 18.35
Ultrasound scan done 3 months later shows good efflux from reimplanted ureter
Fig. 18.36
Postoperative MCU done 3 months later shows no reflux
18.9 Transvesical Reimplantation in VUR
Fig. 18.37
Gross right VUR
Fig. 18.38
Patient position for tranvesicoscopic ureteric reimplantation
Fig. 18.39
Retrograde placement of urethral dilator to guide camera port placement
Fig. 18.40
Trocar railroaded over the dilator
Fig. 18.41
Both ureters stented
Fig. 18.42
Bladder mucosa around ureteric orifice incised
Fig. 18.43
Neo meatus for right ureter made above the left ureteric orifice
Fig. 18.44
Right ureter being mobilised
Fig. 18.45
Right ureter mobilised
Fig. 18.46
Tunnel created for right ureter
Fig. 18.47
Right ureter grasped for tunneling
Fig. 18.48
Right distal ureter trimmed
Fig. 18.49
Neo ureteric orifice of right ureter reconstructed using 4-0 PDS
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