RU2739115C1 - Method for laparoscopic treatment of extended postradiation strictures and obliteration of the lower one-third of ureter - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention refers to medicine, particularly to operative urology. Laparoscopic ureter is excised and cut off along border of stricture or obliteration within healthy tissue, ureter is mobilized proximally by 7-10 cm depending on thickness of muscular layer and fatty tissue. A urinary bladder wall is incised to form an anastomosis without tension. Tightening the ureteral catheter from the urinary bladder is followed by measuring the length of the urinary tract defect. Then ureter is removed outside through laparoscopic port and ureter is sputted along anterior medial surface 1 cm long. Pre-prepared buccal graft of required size is fixed along whole length of proximal edge of ureter by continuous suture with monocryl 4/0. An internal drainage stent N7 Ch is inserted, and the buccal graft is closed above the stent with a continuous external monocryl suture 4/0, not reaching 1 cm to its distal edge. On free edge of buccal graft monocryl thread 4/0 is laid and knot is fastened, after which buccal ureter transplant is immersed through laparoscopic port into abdominal cavity. In the bladder wall an intermuscular tunnel is formed in a distal direction, the mucous membrane is exposed and pulled up by the suture, buccal transplant is delivered through a tunnel; its edges are anchored to the edges of the bladder mucosa by single interrupted sutures of vicryl 4/0. Bladder wall defect is closed transversally to the incision with continuous monocryl 4/0 suture. Then, the omentum flap is cut out on feeding pedicle 3 cm wide and the omentum flap is placed without tension over the entire surface of the buccal graft and the implantation site in the bladder, thereafter, the omentum flap is fixed with single monocrysular sutures 4/0 to a buccal transplant and a bladder wall, a drainage is placed in the abdominal cavity. Trocars are removed under video endoscopic control, carbon dioxide is desufflated, sutures and aseptic dressings are applied on the skin.

EFFECT: method enables replacing the entire affected lower 1/3 of the ureter in the patients with prolonged postradiation strictures and ureter obliteraions, avoiding traumatic mobilization of adjacent organs from postradiation conglomerates and recovering the injured part of the ureter, reducing the extent of the surgical intervention, its length and intraoperative blood loss.

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Description

The invention relates to medicine, in particular to urology, and can be applied in the laparoscopic treatment of extended strictures and obliterations of the lower third of the ureter in patients with post-radiation damage.

Surgical treatment of urinary tract obstruction (MP) remains a difficult problem in urology (Onopko V.F., 2011; Loran O.B., 2012; Zuban O.N. et al. 2014; Yarovoy S.Yu., 2016 ). Although strictures and obliterations of the ureters often show the same symptoms, they have different localization and different origins, therefore, for each part of the ureter, when it is damaged, different types of surgical interventions have been developed.

Ureteral obstruction, which occurs as a long-term complication of radiation therapy to the pelvic organs, is considered one of the most difficult pathologies for surgical treatment in patients with this disease. The bulk of these patients are persons who have undergone irradiation for cancer of the bladder, cervix or uterine body (Elliott S. P., Bahaa S., 2011). The very use of radiation energy impairs the vascularization of the exposed tissues and their ability to regenerate, which makes conservative treatment of this disease unpromising.

Currently, there are no standard methods of surgical treatment for post-radiation ureteral obstruction (Polyakov N.V., 2016).

It is known that surgical treatment of extended obliterations of the lower third of the ureter with the use of own MP is the most preferable option for restoring its patency. However, the possibilities of such operations are significantly limited due to the lack of MP tissue (Nishimura Y. et al, 2017; Srivastava D. et al., 2017). So, the imposition of the ureterocystoanastomosis is available for strictures / obliterations of short length (up to 5 cm); psoas-hitch surgery, which involves the mobilization of the bladder and its fixation to the psoas muscle, makes it possible to replace up to 10 cm of the MP defect, but requires isolation of the muscle and almost the entire lateral wall of the bladder, and also has a number of complications. Boari's operation makes it possible to restore the length of the ureter to 15 cm, however, the operation technique itself implies a significant decrease in the volume of the bladder, and also has a high rate of complications (Manassero F.F. Et al., 2012).

The use of various intestinal segments as autografts for ureteral replacement is a fairly effective method, but it has a significant number of early and late postoperative complications, including electrolyte complications, which is unacceptable for patients with chronic kidney disease; has significant intraoperative trauma and requires high surgical technique (Zuban O.N. et al., 2012; Komyakov B.K. et al., 2015, 2018; Schott F. et al., 2017). Also, the presence of post-radiation enteritis (Fallon B., Gaynor-Drupnick D. Μ., 2004) is a contraindication to this operation.

The graft of choice in such cases may be the use of the buccal mucosa. Buccal graft ureteroplasty is well suited for the reconstruction of the ureter, as it provides minimal disruption of the blood supply to this organ and allows anastomosis without tension. The method is effective in patients with extensive ureteral strictures (Lee Ζ. Et al. 2018).

Currently, minimally invasive laparoscopic surgical access is widely used in urology. The technique of laparoscopy ensures the minimization of the surgical access, however, it creates objective difficulties in applying the ureteral-vesical anastomosis in this area, especially during repeated operations. In this case, the best option is to perform part of the operation outside the abdominal cavity.

For the first time in the world, extracorporeal treatment of the ureter during laparoscopic plasty of the pelvic-ureteric segment (LMS) was described in 2009 by Nadu A. et al (Nadu., Mog., Ramon J. Direct extracorporeal ureteric stenting during laparoscopic pyeloplasty: a novel technique. BJU Int 2009; 103 (6): 844-847). The method of surgical treatment developed by them consisted in the fact that after laparoscopic dissection of the ureter from the pelvis, the latter was extracted extracorporeally through the port in the iliac region, then the stenotic portion of the ureter was removed, followed by spatulation of its lateral surface and antegrade insertion of a catheter-stent into it. Subsequently, the ureter was laparoscopically immersed in the abdominal cavity for pyeloureteral anastomosis.

However, this technique was not used by the authors for strictures and obliterations of the lower third of the ureter and was used only with the minimum length of its narrowing.

Also known is the method of laparoscopic LMS plasty (Kocherov S. et al. Extracorporeal Ureteric Stenting for Pediatric Laparoscopic Pyeloplasty. European Journal of Pediatric Surgery, 2014), which includes extracorporeal excision of scar tissue of the ureter, spatulation of its lateral catheter, antegrade and the imposition of a provisional suture on the lower corner of the anastomosis.

The disadvantages of this method is that it was used in pediatric practice and only for strictures of the LMS in patients without previous operations on the ureter.

A known method for the treatment of extended strictures of the pelvic ureter using an autograft from the buccal mucosa (RF Patent 2712863 dated 01/31/2020), including a longitudinal dissection of its stenotic part with an extension of the incision to healthy tissues by at least 0.5 cm in each direction, that the resulting defect in the pelvic ureter is replaced with an autograft sutured to the side wall of the bladder from the buccal mucosa.

The disadvantages of this method are the impossibility of its use in case of complete obstruction of the ureter - its obliteration, since in this method simply suturing of a buccal graft was used by the method of forming a patch. Also, with this method, the minimally invasive laparoscopic method was not used.

There is a known method of extracorporeal treatment of the ureter in laparoscopic reconstructions of the upper urinary tract, associated with the stricture of the lower third of the ureter in patients with ureterohydronephrosis (RF Patent No. 2695570, dated 07.24.2019), characterized in that the surgical field is treated with a solution of iodopyrone below the umbilicus, created in the midline carboxyperitoneum, optical port No. 10 is carried out, manipulation ports are installed medial to the iliac spine on the right and left and in the umbilical region, 5 cm of the middle third of the ureter and the lower third of the ureter are mobilized to the level of its confluence into the bladder, a provisional retainer suture is applied to the anterior surface of the ureter followed by cutting off the ureter, then additional mobilization of the posterior and lateral walls of the bladder from the side of the operation is carried out, the ureter is removed outward by the suture-holder through the zone of the port installation medial to the iliac spine from the side of the operation, the port is previously removed, spatulation of the ureter is performed along the anterior surface, a hydrophilic guidewire is inserted into the ureter, an 8 Ch stent catheter is inserted into the upper urinary tract, a proximal stent curl is formed in the spatulation zone, a provisional suture vicryl 4-0 is applied to the lower point of the planned anastomosis, the ureter immersed in the abdominal cavity, restore the remote port and carboxyperitoneum, form the lower point of the anastomosis between the bladder and the ureter by means of the provisional suture vicryl 4-0, immerse the distal curl of the stent into the bladder, form the ureterocystoanastomosis with single sutures vicryl 5-0, check the tightness of the anastomosis drainage into the small pelvis through the port in the iliac region from the side of the operation, the port is removed under video endoscopic control, the carboxyperitoneum is resolved, skin sutures and aseptic stickers are applied. The method according to claim 1, characterized in that when performing spatulation of the ureter along the anterior surface, the scar tissue is additionally excised.

We have adopted this method as a prototype.

The disadvantages of the prototype method are:

1. Impossibility of its application for extended strictures / obliterations.

2. Complete excretion of the ureter is impractical when it is obliterated.

3. Traumatic mobilization of the posterior and lateral walls of the bladder.

4. The lack of a method for the formation of a new mouth, which increases the risk of developing vesicoureteral reflux and progressive kidney death.

The problem to be solved by the claimed invention is to develop a more effective method of extracorporeal treatment of the ureter in laparoscopic reconstructions of the lower third of the ureter in patients with extended postradiation strictures and obliterations of the ureter.

This problem is solved by the fact that laparoscopically the ureter is isolated and cut off along the border of the stricture or obliteration within the healthy tissue, the ureter is mobilized proximally by 7-10 cm, depending on the thickness of the muscle layer and adipose tissue, an incision is made in the bladder wall to form an anastomosis without tension, pulling the ureteral catheter from the bladder, measure the length of the urinary tract defect, then remove the ureter outside through the laparoscopic port and perform spatulation of the ureter along the anteromedial surface with a length of 1 cm; a pre-prepared buccal graft of the required size is fixed along the entire proximal edge of the ureter with a continuous 4/0 monocril suture, an internal drainage stent No. 7 Ch is installed and the buccal graft is sutured over the stent with a continuous external monocril suture 4/0, not reaching 1 cm to its distal edge; a 4/0 monocryl thread is applied to the free edge of the buccal graft and a knot is tied, after which the buccal graft with the ureter is immersed through the laparoscopic port into the abdominal cavity, an intermuscular tunnel is formed in the bladder wall in the distal direction, the mucosa is opened and, pulling the thread, the buccal graft pass through the tunnel, suture its edges to the edges of the bladder mucosa with single interrupted sutures with vicryl 4/0, the defect in the bladder wall is sutured transversely to the incision with a continuous monocryl 4/0 suture, then an omentum flap is cut out on the feeding leg 3 cm wide and an omentum flap without tension over the entire surface of the buccal graft and the place of its implantation into the bladder, after which the omentum flap is fixed with several single monocryl sutures 4/0 to the buccal graft and the bladder wall, drainage is installed into the abdominal cavity, trocars are removed under video endoscopic control, desufflation of carbon dioxide, sutures and aseptic dressings are applied to the skin.

The technical result provided by the above set of features is a decrease in the invasiveness of the intervention and a decrease in the number of postoperative relapses in patients with extended post-radiation strictures and ureteral obliterations.

This result is achieved due to minimal isolation of the bladder wall, exclusion of traumatic mobilization of adjacent organs from post-radiation conglomerates, and restoration of the affected part of the ureter using a transplant from the oral mucosa.

The use of the buccal mucosa as a replacement graft allows avoiding excessive mobilization of the ureter, kidney and bladder and, thus, reducing the volume of surgery, its duration and intraoperative blood loss.

It was possible to restore the length of the entire lower third of the ureter due to the complete replacement of the ureteral defect using a buccal graft. Additional vascularization of the buccal graft is carried out by fixing an omentum strand to it and to the wall of the bladder. Installation of the stent of internal drainage No. 7 and suturing of the buccal graft (tubularization) over the stent with a continuous external monocryl suture 4/0, ensures complete tightness of the anastomosis. The formation of a new orifice reduces the risk of vesicoureteral reflux and renal dysfunction.

Detailed description of the method and examples of its clinical implementation

The operation is performed under endotracheal anesthesia. Cystoscopy and retrograde ureteropyelography are performed, a ureteral catheter and a Foley balloon catheter are inserted under sterile conditions. The patient is transferred to the supine position, the affected side is raised at an angle of 45 degrees. Create carboxyperitoneum. Ports location: 5 mm optical port is installed in the umbilical region, manipulation ports are installed: the first (5 mm in size) - along the midclavicular line on the affected side, the second (5 mm) and third (10 mm) - in the opposite iliac region lateral to the rectus abdominis muscle ... Intraperitoneally, the ureter is isolated, starting from its middle third, it is separated from the surrounding tissues in a blunt and sharp way, cut off at the border of obliteration, the ureter is additionally mobilized to its free length of 7-10 cm. The urinary bladder is inflated with saline to 200 ml, it is minimally isolated from the upper - the side wall on the affected side, a transverse incision of the bladder wall is performed, which is necessary for the formation of an anastomosis without tension, 3 cm long, the ureteral catheter is passed from the bladder to the free end of the ureter, thus determining the length of the ureteral defect.

The second team of surgeons, according to generally accepted rules, takes a buccal graft of the appropriate size and at least 2 cm wide.

Desufflation is performed, the ureter is pulled out through the laparoscopic port, the ureter is spatulated along its anteromedial surface with a length of 1 cm.

Then the buccal graft is fixed throughout the proximal edge of the ureter with a continuous 4/0 monocril suture, an internal drainage stent # 7 Ch is placed in the ureter, the buccal graft is sutured over the stent to its distal curl with a continuous external monocryl suture 4/0, not reaching 1 cm to its distal edge.

A 4/0 monocril thread is applied to the free edge of the buccal graft, a knot is tied, carbon dioxide insufflation is performed, the buccal graft with the ureter is immersed through the laparoscopic port into the abdominal cavity. In the wall of the bladder, endoscissors form an intermuscular tunnel in the distal direction, open the mucous membrane in order to create a new mouth. The buccal graft, pulling by the thread, is passed through the tunnel, the edges of the buccal graft are sutured to the edges of the bladder mucosa with interrupted 4/0 Vicryl sutures starting from the provisional suture.

Then the defect of the bladder wall is sutured transversely to the incision line with a continuous monocryl 4/0 suture. The neoureter from the buccal graft is additionally fixed from the outside to the bladder wall with additional vicryl 4/0 sutures. A 3 cm wide omentum flap is cut out on the feeding leg, which is placed without tension over the entire surface of the buccal graft and the place of its implantation into the bladder. The omentum flap is secured with multiple single 4/0 monocryl sutures to the buccal graft and bladder wall. Drainage is installed into the abdominal cavity, trocars are removed under video endoscopic control, carbon dioxide desufflation is performed, sutures and aseptic dressings are applied to the skin.

The efficiency of the proposed method is confirmed by the following clinical examples.

Example 1.

Patient N-ko, 36 years old, was operated on on July 30, 2019.

Diagnosis: Extended post-radiation obliteration of the lower third of the right ureter.

In 2017, for malignant neoplasm of the cervix with appendages and the upper third of the vagina, an extended extirpation of the uterus with appendages was performed, followed by radiation therapy courses in 2017 and 2018. In May 2018, she began to notice pain in the lower back on the right, which later became permanent. In October 2018, an ultrasound examination revealed hydronephrosis on the right. There was no treatment. On March 22, 2019, a computed tomography of the kidneys was performed, a diagnosis was made of stricture of the lower third of the right ureter, ureterohydronephrosis on the right. Upon further examination, a diagnosis of obliteration of the lower third of the right ureter was established, and puncture nephrostomy on the right.

06/18/19 the patient underwent surgery by the claimed method.

Cystoscopy was performed under endotracheal anesthesia. The orifice of the right ureter is visualized. When trying to catheterize, it was revealed that the orifice is reduced in diameter, the ureter is obstructed for the catheter and contrast agent 2 cm above the mouth. Installed a urethral catheter. The patient was transferred to the supine position, the right half of the body was fixed at an angle of 45 degrees, and a carboxyperitoneum was created. 4 ports are installed in the abdominal cavity. On examination, a cicatricial conglomerate was visualized along the right side of the abdominal cavity, including the lower third of the right ureter, bowel loops, iliac vessels, and the bladder wall. The cicatricial-adhesive process in the area of the laparotomic incision after the previous operation is also determined. Excretion of the ureter started distally from its middle third, it was separated from the loop of the intestine, the iliac artery, then cut off along the border of obliteration within its healthy tissue, the ureter was additionally mobilized proximally by 5 cm.The bladder was inflated with saline to 200 ml, at its apex it was made a 3 cm incision required to form an anastomosis without tension, the ureteral catheter was pulled from the bladder to the edge of the ureter, the length of the defect was measured, which was 6 cm.

Desufflation was performed, the ureter was pulled out through the laparoscopic port and spatulated along its anteromedial surface by 1 cm.

The second team of surgeons, according to generally accepted rules, performed a 65 × 22 mm buccal graft collection.

Then the buccal graft along the entire length of the proximal edge of the ureter was fixed to it with a continuous 4/0 monocril suture, an internal drainage stent # 7 Ch was installed, the buccal graft was sutured over the stent with a continuous external monocryl suture 4/0, not reaching 1 cm to its distal edge, leaving distal curl of the stent.

A 4/0 monocril thread was applied to the free edge of the graft, a knot was tied, carbon dioxide insufflation was performed, the buccal graft with the ureter was immersed through the laparoscopic port into the abdominal cavity. In the wall of the urinary bladder, endoscissors formed an intermuscular tunnel in the distal direction, the mucous membrane was opened in order to create a new mouth. Pulling the suture, the buccal graft is passed through the tunnel, the edges of the buccal graft are sutured to the edges of the bladder mucosa with interrupted 4/0 Vicryl sutures starting from the provisional suture.

Revealed a slight tension in the ureter. In order to eliminate it, the incision of the bladder was continued by an additional 1 cm. Then the defect in the bladder wall was sutured transversely to the incision line with a continuous monocrylic 4/0 suture. Additional 4/0 vicryl sutures were placed outside the bladder, fixing it to the buccal graft. An omentum flap was cut out on the feeding leg 3 cm wide, positioned without tension over the entire surface of the buccal graft and the place of its implantation into the bladder, the omentum flap was fixed with several single monocryl sutures 4/0 to the graft and the bladder wall.

A tubular drainage was installed into the abdominal cavity through port No. 3, trocars were removed under video endoscopic control, carbon dioxide desufflation was performed, sutures and aseptic dressings were applied to the skin.

Control CT of the kidneys with contrast was performed 6 months after surgery - the right ureter was passable throughout. There were no postoperative complications.

The patient is under dynamic outpatient supervision.

Example 2.

Patient A-va, 42 years old, was operated on on November 16, 2018.

Diagnosis: Extended postradiation stricture of the lower third of the left ureter.

In 2015, she underwent extended extirpation of the uterus with appendages due to a malignant neoplasm. In 2016, 4 courses of radiation therapy were performed in the pelvic area. In April 2017, lower back pain appeared on the left, and hydronephrosis on the left was revealed. In July 2017, for acute obstructive pyelonephritis on the left, a puncture nephrostomy was installed.

During follow-up examination, a diagnosis of extended stricture of the lower third of the left ureter was established; on September 19, 2018, the operation was performed using the claimed method.

Cystoscopy was performed under endotracheal anesthesia. The orifice of the left ureter was visualized, which was obstructed by the ureteral catheter. Installed a urethral catheter.

The patient was transferred to the supine position, the left half of the body was fixed at an angle of 45 degrees, and a carboxyperitoneum was created. 4 ports are installed in the abdominal cavity. On examination, a cicatricial conglomerate was visualized in the pelvic area. Isolation of the left ureter started from its middle third in the distal direction, it was cut off along the border of the stricture within its healthy tissue, additionally mobilized proximally by 4 cm - the total length of the free end was 8 cm.The bladder was swollen with saline to 200 ml, at its apex a 3 cm incision was made, which was necessary to form an anastomosis without tension, the ureteral catheter was pulled from the bladder to the edge of the ureter, the length of the defect was measured, which was 7 cm.

Desufflation was performed, the ureter was pulled out through the laparoscopic port, spatulated along the anteromedial surface by 1 cm.

The second team of surgeons, according to generally accepted rules, performed a 75 × 22 mm buccal graft collection.

Then the buccal graft along the entire length of the proximal edge of the ureter was fixed to it with a continuous 4/0 monocril suture, an internal drainage stent # 7 Ch was installed, the buccal graft was sutured over the stent with a continuous external monocryl suture 4/0, not reaching 1 cm to its distal edge, leaving distal curl of the stent.

A 4/0 monocril thread was applied to the free edge of the graft, a knot was tied, carbon dioxide desufflation was performed, the buccal graft with the ureter was immersed through the laparoscopic port into the abdominal cavity. In the wall of the urinary bladder, endoscissors formed an intermuscular tunnel in the distal direction, the mucous membrane was opened in order to create a new mouth. Pulling the suture, the buccal graft is passed through the tunnel, the edges of the buccal graft are sutured to the edges of the bladder mucosa with interrupted 4/0 Vicryl sutures starting from the provisional suture.

Then the defect of the bladder wall is sutured longitudinally with a continuous monocryl 4/0 suture. Additional 4/0 vicryl sutures were placed outside the bladder, fixing it to the buccal graft. An omentum flap was cut out on the feeding leg 3 cm wide, positioned without tension over the entire surface of the buccal graft and the place of its implantation into the bladder, the omentum flap was fixed with several single monocryl sutures 4/0 to the graft and the bladder wall.

A tubular drainage was installed into the abdominal cavity through port No. 3, trocars were removed under video endoscopic control, carbon dioxide desufflation was performed, sutures and aseptic dressings were applied to the skin.

Control SCT of the kidneys with contrast was performed 6 months and 12 months after surgery - the left ureter was passable throughout. There were no postoperative complications.

The patient is under dynamic outpatient supervision.

Thus, the claimed method for laparoscopic treatment of extended postradiation strictures and obliterations of the lower third of the ureter is an alternative to intestinal plasty of extended strictures and obliterations of the ureter, as well as operations associated with extensive mobilization of the kidney and bladder, since it is less traumatic and provides a decrease in the number of postoperative relapses.

The claimed method operated on 6 patients. Relapses of the disease and postoperative complications were not observed over a follow-up period of 6-12 months. The proposed method is reproducible in a hospital environment and when using it, the specified technical result is achieved.

The use of the proposed method provides a unique opportunity to replace the entire affected lower third of the ureter in patients with extended post-radiation strictures and MP obliterations, reduces the possibility of recurrence of the disease due to complete removal of the affected tissue, tubularization of the flap and improvement of its vascularization. The operation, in comparison with intestinal urine diversion, is less traumatic, does not have significant postoperative immediate and long-term complications. Performing part of the operation extraperitoneally provides a decrease in the time of surgery, a decrease in its trauma.

The claimed method has been tested on sufficient clinical material, has shown its effectiveness and applicability and can be recommended for use in specialized hospitals.

Claims (1)

A method of laparoscopic treatment of extended post-radiation strictures and obliterations of the lower third of the ureter, including extracorporeal treatment of the ureter in laparoscopic reconstructions of the urinary tract, characterized in that the ureter is isolated laparoscopically and it is cut off along the border of the stricture or obliteration within the healthy tissue, mobilization of the ureter is performed on the 7 10 cm, depending on the thickness of the muscle layer and adipose tissue, an incision in the bladder wall is performed to form an anastomosis without tension, pulling the ureteral catheter out of the bladder, the length of the urinary tract defect is measured, then the ureter is removed through the laparoscopic port and the ureter is spatulated along the anteromedial surface 1 cm long, a pre-prepared buccal graft of the required size is fixed along the entire length of the proximal edge of the ureter with a continuous 4/0 monocryl suture, installed with internal drainage tent # 7 Ch and the buccal graft are sutured over the stent with a continuous external monocryl suture 4/0, not reaching 1 cm to its distal edge, a 4/0 monocryl thread is applied to the free edge of the buccal graft and a knot is tied, after which the buccal graft with the ureter immersed through the laparoscopic port into the abdominal cavity, an intermuscular tunnel is formed in the distal direction in the wall of the bladder, the mucosa is opened and, by pulling the thread, the buccal graft is passed through the tunnel, its edges are sutured to the edges of the bladder mucosa with single interrupted sutures with vicryl 4/0, defect the walls of the bladder are sutured transversely to the incision with a continuous monocrylic 4/0 suture, then a 3 cm wide omentum flap is cut out on the feeding leg and the omentum flap is placed without tension over the entire surface of the buccal graft and the place of its implantation into the bladder, after which the omentum flap is fixed with single monocryl seams 4/0 to b drainage is installed into the abdominal cavity, trocars are removed under video endoscopic control, carbon dioxide desufflation is performed, sutures and aseptic dressings are applied to the skin.