The application of laparoscopic ultrasound-guided intervention in renal hybrid surgery: case report

Introduction

Yamakawa first introduced the concept of laparoscopic ultrasound (LUS) in laparoscopic surgery (1). LUS offers the advantage of flexibly exploration of organs or lesions from multiple angles, unrestricted by the abdominal wall or intestinal gas. This capability addresses the lack of tactile perception in robotic surgery and greatly assists various intra-abdominal procedures (2).

Transabdominal ultrasound-guided balloon occlusion of the abdominal aorta has been utilized in open obstetrics surgeries for the treatment of menacing placenta praevia and placenta implantation, albeit exclusively in open surgical settings (3,4). However, there is a notable absence of reports detailing the application of intervention techniques with LUS guidance throughout the entire surgical process.

The preferred surgical approach for localized renal tumors is partial nephrectomy, wherein the arterial supply is routinely and temporarily occluded by clamping the renal artery to prevent bleeding during tumor resection and suturing (5). At our center, we have previously explored hybrid partial nephrectomy with digital subtraction angiography (DSA) guidance in a hybrid operation room. By using a balloon catheter inserted into the renal artery, we achieved a balloon catheter achieved a comparable intraoperative blood flow occlusion effect to traditional clamping techniques (6). However, hybrid procedures heavily rely on DSA equipment and are limited to scarce hybrid operating rooms. This approach involves radiation exposure, poses inconvenience, may incur higher costs, and is challenging to generalize.

Our center explored an innovative approach to partial nephrectomy for localized renal tumors by utilizing LUS guidance instead of traditional DSA guidance in hybrid surgery. With approval from the ethics committee, we conducted procedures using LUS-guided renal artery balloon catheter occluded hybrid partial nephrectomy (UBo-HPN) from April 2022 to May 2022. We present this case in accordance with the CARE reporting checklist (available at https://tau.amegroups.com/article/view/10.21037/tau-24-22/rc).

Case presentation

Methods

Clinical data of three cases of UBo-HPN patients performed at Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology from April 2022 to May 2022 were prospectively included. Patients’ age, gender, comorbidities [rated according to the age-adjusted Charlson Comorbidity Index (7)], as well as tumor size and location were recorded preoperatively. Intraoperative data recorded included operative time, warm ischemia time (WIT), LUS-guided renal artery balloon placement time, estimated blood loss (EBL), and complications. Changes in the hemoglobin and serum creatinine (sCr) at 48 hours preoperatively compared with postoperatively were also recorded.

All procedures performed in this study were in accordance with the institutional review board of Tongji Hospital (No. 2020S138) and with the Helsinki Declaration (as revised in 2013). Written informed consent was obtained from the patients for publication of this case report and accompanying images, and an additional informed consent form for the hybrid surgery was signed (Appendix 1). A copy of the written consent is available for review by the editorial office of this journal.

For LUS-guided intervention process, an ultrasound surgeon (Y.Y.) wearing a surgical attire mediated the process. Intraoperative scanning and monitoring were conducted using a Hitachi ARIETTA 70 ultrasound diagnostic instrument. The UST-5418 four-direction LUS probe, featuring a 38-mm scanning range of the line array probe, can be adjusted with 90° bends in the four directions of up/down/left/right and underwent preoperative sterilization. The ultrasound scanning frequency was 2–13 MHz, and color Doppler flow imaging (CDFI) was utilized to evaluate the tumor blood flow signal.

LUS was introduced into the abdominal cavity through two robotic or laparoscopic trocars positioned either above or below the umbilicus. The below-umbilicus trocar is situated two transverse fingers below the umbilicus in the anterior midline, while the above-umbilicus trocar is placed at the level of the renal artery, also in the anterior midline (Figure 1).

Figure 1 LUS was introduced into the abdominal cavity through two robotic assistant trocars above or below the umbilicus (blue dots), with the below-umbilicus trocar located two transverse fingers below the umbilicus in the anterior midline, and the above-umbilicus trocar located at the level of the renal artery at the level of the anterior midline. The lines on the cephalic and pedicled sides represent the lower edge of the ribs and the pubic symphysis. The red dot represents the optic trocar and the two purple dots represent the trocars for the robotic instruments. LUS, laparoscopic ultrasound.

The method of manipulating the LUS during vascular interventions was as follows:

• LUS was inserted into the below-umbilicus trocar for long-axis imaging of the abdominal aorta, abdominal trunk, and superior mesenteric artery, as well as for the entire journey of short-axis imaging of the renal artery (Figure 2A). It is inserted into the above-umbilicus trocar for the complete long-axis imaging of the renal artery and short-axis imaging of the abdominal aorta (Figure 2B).
• When searching for renal artery openings, LUS can be swept along the abdominal aorta in a downstream direction or retrograde from the renal hilum.
• In cases of multiple renal arteries, the diameters of individual renal arteries are typically thinner than normal, and the locations of accessory renal artery openings need to be carefully determined, often through a combination of intraoperative LUS imaging and preoperative CT angiography (CTA) imaging.

Figure 2 LUS-guided renal artery intervention and CDFI. (A) Image of the guide catheter within the long axis of the AA; (B) the short-axis image of the AA and the opening of the RRA (arrow shows the guiding catheter); (C) the short-axis image of the AA and the opening of the RRA (arrows show the guidewire); (D) after the balloon is inflated (arrows); (E) before the balloon is inflated, the ultrasound shows that there was a rich blood supply to the tumor; (F) after the balloon is inflated, the tumor blood flow signal disappears. AA, abdominal aorta; RRA, right renal artery; T, tumor; LUS, laparoscopic ultrasound; CDFI, color Doppler flow imaging.

In two of the three cases, the surgical approach involved robot-assisted laparoscopic partial nephrectomy, while laparoscopic partial nephrectomy was performed in one case. During the UBo-HPN procedure, firstly, perirenal fat surrounding the renal tumor was removed to expose the tumor mass, without dissecting the anatomical structures including the renal hilum, the Toldt’s line, and mesentery.

Surface ultrasound guidance was employed for precise femoral arterial puncture, with the puncture point located approximately one transverse finger below the inguinal ligament. Following the puncture, a vascular sheath was inserted. Systemic heparinization was initiated with an initial dose of 3,000 U of heparin, followed by supplemental doses of 1,000 U administered hourly. This regimen was implemented to minimize the risk of thrombotic events during the procedure.

The LUS probe was inserted through an appropriate trocar, allowing for thorough examination of the renal artery in both long- and short-axis views to locate its opening. Subsequently, a guidewire and a 5-F guiding catheter were navigated into the renal artery via the femoral artery, external iliac, common iliac, and abdominal aorta under full LUS surveillance (Figure 2C). Once positioned, the guiding catheter was retracted, and a 5.5-F Fogarty balloon catheter was advanced along the guidewire until its tip reached the target renal artery. The balloon catheter was then inflated with an appropriate amount of saline to occlude the renal arterial flow (Figure 2D). CDFI confirmed the complete disappearance of arterial blood flow signal in the tumor area.

Following tumor resection and wound closure, the balloon catheter was deflated under LUS surveillance. The restoration of renal arterial blood flow was confirmed by CDFI. After observing the wound for at least 1 min to ensure hemostasis, the balloon catheter and femoral artery vascular sheath were removed, and an arterial closure device was employed. Twenty mg of cavitriol was immediately administered to neutralize the residual heparin. Four thousand one hundred U of low molecular weight sodium heparin was administered 3 hours postoperatively to mitigate the risk of deep vein thrombosis.

Results

The ages of the three patients ranged from 32 to 55 years old, including one male and two females, without clinical symptoms. The age-adjusted Charlson Comorbidity Index for these three patients ranged from 3 to 4. One patient had a 5-year history of systemic lupus erythematosus, and another patient had mild liver function abnormalities and was diagnosed with hepatitis B. The maximum diameter of the tumors ranged from 1.9 to 3.7 cm. Two of the tumors were located in the left kidney, and one was in the right kidney. All patients had no history of abdominal surgery.

All three patients underwent successful UBo-HPN surgeries, with total operation times ranging from 95 to 120 min (average 105 min), including a WIT of 13 to 19 min. The LUS-guided renal artery balloon placement time took 11 to 32 min. EBL ranged from 50 to 300 mL.

In all cases, CDFI confirmed that the LUS-guided vascular interventional technique achieved a complete occlusion of the renal artery, and the restoration the blood flow to the affected kidney was reconfirmed after deflation.

Postoperative review at 48 hours showed a decrease in hemoglobin of 10, 8, and 7 g/L in the three patients, while sCr decreased by 9, 17, and increased by 3 µmol/L, respectively. Two patients had a pathological diagnosis of renal clear cell carcinoma, and one had a leiomyolipoma, with negative surgical margins in all patients (Table 1).

Patients were discharged after removal of drainage tube and 1 day of observation. All patients received follow-up appointments every 3 to 6 months. None of the three patients experienced significant postoperative surgical or intervention-related complications during hospitalization or follow-up.

Discussion

Ultrasound technology has evolved beyond routine diagnosis, ushering in a new era of ultrasound-guided interventions that play a significant role in clinical care and precision treatment. Compared to fluoroscopy, ultrasound offers portability and eliminates radiation exposure, making it an attractive option for guidance. Ultrasound-guided procedures such as fistulation, ablation, thrombolysis, nerve block, and musculoskeletal rehabilitation have become the mainstream of ultrasound intervention (8-12). Additionally, reports have highlighted the successful occlusion of the blood flow in the abdominal aorta and other large vessels using transabdominal ultrasound during open surgery of aggressive placenta praevia and bone tumors (3,4,13,14). In contrast, hybrid surgery has predominantly relied on DSA equipment.

Since transabdominal ultrasound can be interfered with the intestinal gas and the abdominal wall, the quality of visceral arterial imaging is far inferior to that of DSA. In contrast, LUS allows for direct scanning against the organ surface without the interference of the intestinal gas and the abdominal wall. To our knowledge, this study represents the first exploration of LUS-guided abdominal vascular intervention, demonstrating its efficacy in clearly visualizing visceral arteries.

The outstanding features of LUS-guided hybrid surgery lie on the precise localization comparable to that of DSA, while avoiding radiation exposure, saving the potential cost of the DSA equipment, and circumvention of the limitations associated with hybrid operating rooms. In addition, for patients with renal insufficiency, LUS eliminates the risk of damage to residual kidney function posed by radiographic contrast agents.

LUS has emerged as a valuable tool in guiding vascular interventions, offering several distinct advantages:

• Clear visualization of vascular structures: LUS can clearly display the abdominal aorta, major branches, and the renal artery openings. By positioning the LUS probe through multiple trocars at the appropriate angles, surgeons can achieve precise visualization, aiding in accurate instrument placement.
• Real-time monitoring of interventional procedures: LUS enables continuous monitoring of guidewire, catheter, and balloon catheter placement. Surgeons can observe the inflation and deflation of the balloon catheter in real-time, ensuring optimal positioning and effectiveness of the intervention.
• Confirmation of vascular flow: CDFI for LUS allows for the visualization of disappearance and reappearance of the renal arterial flow signals, confirming the effectiveness of occlusion and restoration of renal blood flow (Figure 2E,2F).
• Facilitation of complex surgical cases: LUS also helps in the surgical treatment of some complicated cases of renal tumors, such as completely endogenous renal tumors.

While LUS offers significant advantages in vascular intervention, several limitations should be considered. LUS-guided intervention is not suitable for people with peripheral arterial disease, arterial entrapment, and other contraindications to intervention (15). It is not suitable for cases with a tortuous renal artery alignment, which may lead to prolonged placement time or failure. It requires ultrasonographers to be proficient in the techniques of vascular puncture and vascular intervention technique, and may be associated with a long learning curve. Till now, there is still a short time of device exchange when placing LUS probes, which may be overcome with the introduction of robotic ultrasonography in the future (16).

Conclusions

LUS is effective alternative to DSA for guiding abdominal vascular interventions and supporting partial nephrectomy. LUS offers the distinct advantages of multi-angle visualization and real-time monitoring under radiation-free condition.

Acknowledgments

Funding: This work was supported by the National Natural Science Foundation of China (No. 81402098), the Project of China Urological Tumor Research Fund (No. 2023041) funded by China Primary Health Care Foundation, and the Key Program of Tongji Hospital Research Fund (No. 2022A09).

Footnote

Reporting Checklist: The authors have completed the CARE reporting checklist. Available at https://tau.amegroups.com/article/view/10.21037/tau-24-22/rc

Peer Review File: Available at https://tau.amegroups.com/article/view/10.21037/tau-24-22/prf

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://tau.amegroups.com/article/view/10.21037/tau-24-22/coif). The authors have no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. All procedures performed in this study were in accordance with the institutional review board of Tongji Hospital (No. 2020S138) and with the Helsinki Declaration (as revised in 2013). Written informed consent was obtained from the patients for publication of this case report and accompanying images. A copy of the written consent is available for review by the editorial office of this journal.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

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