室内尼古斯隆德卡因peterwiklund27 intracorporeal neobladder27体内新蓝色.pdfVIP

Intracorporeal
Neobladder


Peter
Wiklund


Karolinska
Institute


Patient
selection


Patients
with
significant
co‐morbid
conditions
should
be
cleared
after
consultation
with


the
specialists
in
medicine,
especially
for
their
cardiopulmonary
status.
In
our
opinion


patients
not
suitable
for
a
robotic
approach
are
patients
with
decreased
pulmonary


compliance
that
would
not
tolerate
Trendelenburg
position.
Furthermore,
patients
with


a
history
of
previoutensive
abdominal
surgery
may
be
a
relative
contraindication.



Preoperative
preparation


Broad
spectrum
intravenous
antibiotics
are
given
prior
surgery
and
a
stoma
site
is


marked.
Contrary
to
some
other
studies
we
do
not
use
a
pneumatic
leg
compression


system
due
to
risk
of
decreased
vascular
perfusion
during
the
procedure.
We
start
the


patients
on
low‐molecular
weight
heparin
(4,000
units)
the
evening
before
surgery
and


until
the
patient
is
fully
mobilized.
After
induction
of
general
endotracheal
anesthesia
a


naso‐gastric
tube
and
urinary
catheter
are
inserted.
The
patient
is
placed
in
lithotomy


position
with
arms
adducted
and
padded.
The
table
is
placed
in
25°
Trendelenburg


position
during
the
cystectomy
and
lymph
node
dissection.
For
the
urinary
diversion
the


Trendelenburg
position
is
decreased
to
15°.
Shoulder
pads
should
be
avoided
due
to


high
risk
for
plexus
damages.



Equipment



The
technique
is
challenging,
requiring
conventional
laparoscopic
infrastructure
as
well


as
an
assistant
with
high
skills
in
conventional
laparoscopy.
Standard
laparoscopic


surgical
equipment
with
some
extra
instruments
is
required
(Ligasure
(Tyco
healthcare),


surgical
endoscopy
clip
applicators
5
–
10
mm,
laparoscopy
endo‐catch
bags,


laparoscopy
stapler
for
intestinal
stapling).



Surgical
Steps


Surgical
Step
Lens
Right
Left
Robotic
Fourth
Right


Robotic