Laparoscopic transperitoneal pyeloplasty post-Kasai procedure

Purpose Previous major laparotomy can make further surgical procedures challenging due to adhesions. We demonstrate an operative video of laparoscopic pyeloplasty in a patient who underwent Kasai procedure in infancy. Methods A right pelvi-ureteric junction (PUJ) obstruction was diagnosed in a 14-year-old boy who presented with intermittent pain. Transperitoneal laparoscopy confirmed marked bowel adhesions mainly in the right upper quadrant. The pelvis was approached via a trans-mesocolic window and a non-dependent PUJ with a dilated segment of the ureter above a crossing vessel was found. The ureter was carefully mobilized off the bowel adhesions and crossing vessels. The high insertion of the ureter was transfixed and divided. Pelvis was opened in the dependent part and ureter was spatulated. A dismembered pyeloplasty was then performed over 4.7 Fr JJ stent. Results The procedure was performed with minimal adhesiolysis and was uneventful. Postoperative ultrasound (US) in 3 weeks (pre-stent removal) showed resolution. He has been asymptomatic for 6 months postoperatively and is awaiting an US and Mercaptoacetyltriglycine (MAG3) scan. Conclusion Laparoscopic pyeloplasty is feasible in the setting of previous major abdominal surgery. Key points are to perform minimal adhesiolysis and to focus on the target area keeping the dissection close to the pelvis and always aiming for a dependent neo-anastomosis.