Cadeddu J A, Corwin T S, Traxer O, Collick C, Saboorian H H, Pearle M S
Department of Urology, University of Texas Southwestern Medical Center at Dallas, Dallas, Texas 75390-9110, USA
Urology. 2001 Mar;57(3):562-6. doi: 10.1016/s0090-4295(00)01009-8.
Laparoscopic partial nephrectomy (LPN) has generally been reserved for small exophytic lesions because of the limited hemostatic capabilities when excising large segments of renal parenchyma. To overcome this problem, we investigated a technique of laparoscopic reversible, regional hypoperfusion using a cable-tie to minimize blood loss and optimize exposure.
Ten domestic pigs underwent LPN after securing a cable-tie around one pole of the kidney and tightening it until the distal parenchymal surface blanched completely. Eight large amputations involving the collecting system and eight smaller amputations excluding the collecting system were performed using laparoscopic scissors. Fibrin glue was applied to seal the cut surface prior to cable-tie removal. Four pigs (4 large and 4 small amputations) were killed immediately and methylene blue was injected retrograde into the ureter to identify collecting system leaks. The remaining 6 pigs (4 large and 4 small amputations) were killed 4 weeks later and retrograde urograms were performed to assess collecting system integrity.
Median cable-tie ischemia time was 15 minutes (range 7 to 48) and median blood loss was 30 mL (range 10 to 300). In each case, hemostasis was attained with fibrin glue. In the survival group, all 4 small amputations healed with a fibrotic scar. In the large amputation group, 1 animal died from urinary extravasation on postoperative day 4. The collecting systems of the remaining 3 pigs sealed completely.
In the porcine model, cable-tie-assisted LPN provides an almost bloodless surgical field that facilitates rapid resection of large renal segments and hemostasis during a short ischemic period. We anticipate that this technique will broaden the clinical application of LPN.
由于在切除大片肾实质时止血能力有限，腹腔镜部分肾切除术（LPN）一般仅用于较小的外生性病变。为克服这一问题，我们研究了一种使用束带进行腹腔镜可逆性区域低灌注的技术，以尽量减少失血并优化视野暴露。
对10头家猪进行LPN，先在肾脏的一极周围系上束带并收紧，直到远端实质表面完全变白。使用腹腔镜剪刀进行8例涉及集合系统的大切除和8例不涉及集合系统的小切除。在移除束带之前，应用纤维蛋白胶封闭切割面。立即处死4头猪（4例大切除和4例小切除），并向输尿管逆行注射亚甲蓝以识别集合系统漏口。其余6头猪（4例大切除和4例小切除）在4周后处死，并进行逆行尿路造影以评估集合系统的完整性。
束带缺血时间中位数为15分钟（范围7至48分钟），失血量中位数为30毫升（范围10至300毫升）。在每种情况下，纤维蛋白胶均可实现止血。在存活组中，所有4例小切除均通过纤维化瘢痕愈合。在大切除组中，1只动物在术后第4天死于尿外渗。其余3头猪的集合系统完全封闭。
在猪模型中，束带辅助的LPN提供了一个几乎无血的手术视野，便于在短时间缺血期内快速切除大的肾段并实现止血。我们预计该技术将扩大LPN的临床应用。
