Moinzadeh Alireza, Hasan Waleed, Spaliviero Massimiliano, Finelli Antonio, Kilciler Mete, Magi-Galluzzi Cristina, El Gabry Ehab, Desai Mihir, Kaouk Jihad, Gill Inderbir S
Section of Laparoscopic and Robotic Surgery, Glickman Urological Institute and Department of Anatomic Pathology, Cleveland Clinic Foundation, Cleveland, Ohio, USA.
J Urol. 2005 Jul;174(1):317-21. doi: 10.1097/01.ju.0000161587.95033.c9.
Hemostasis represents a primary challenge during laparoscopic partial nephrectomy (LPN). We typically clamp the renal artery/vein en bloc and perform LPN expeditiously under warm ischemia conditions. We evaluated Helix Hydro-jet assisted LPN without renal hilar vascular control in the survival calf model.
Staged bilateral LPN using the Hydro-jet was performed without renal hilar vessel control in 10 survival calves (20 kidneys). Parenchymal hydrodissection was performed with a high velocity, ultracoherent saline stream at 450 psi through a small nozzle with integrated suction at the tip. The denuded intrarenal parenchymal blood vessels were precisely coagulated with a BIClamp bipolar instrument and transected. Followup involved biochemical, radiological and histopathological evaluation at designated sacrifice intervals of 1 and 2 weeks, and 1, 2 and 3 months, respectively.
All LPNs were completed successfully without open conversion. Of 20 LPNs 18 (90%) were performed without hilar clamping. Pelvicaliceal suture repair was necessary in 5 of 10 chronic kidneys (50%). Mean Hydro-jet(R) partial nephrectomy time was 63 minutes (range 13 to 150), mean estimated blood loss was 174 cc (range 20 to 750) and mean volume of normal saline used for hydro-dissection was 260 cc (mean 50 to 1,250). No animal had a urinary leak. Histological sections from the acute specimen revealed a thin (1 mm) layer of adherent coagulum at the amputation site with minimal thermal artifact. At 2 weeks a layer of adherent fibro-inflammatory pseudomembrane with giant cell reaction was seen.
In this more stringent and robust survival calf model Hydro-jet assisted LPN can be performed without hilar vessel control, thus, completely avoiding warm ischemia. This approach has the potential to decrease the level of technical difficulty inherent in LPN.
止血是腹腔镜部分肾切除术（LPN）中的主要挑战。我们通常会整块夹住肾动脉/静脉，并在热缺血条件下迅速进行LPN。我们在存活小牛模型中评估了无肾门血管控制的螺旋水刀辅助LPN。
在10头存活小牛（20个肾脏）中，在不控制肾门血管的情况下，使用水刀分阶段进行双侧LPN。通过一个尖端带有集成吸力的小喷嘴，以450磅力/平方英寸的高速、超相干盐水流进行实质水分离。用BIClamp双极器械精确凝固并横断裸露的肾实质内血管。随访分别在指定的1周和2周以及1、2和3个月的处死间隔进行生化、放射学和组织病理学评估。
所有LPN均成功完成，无需转为开放手术。在20例LPN中，18例（90%）在不夹闭肾门的情况下完成。10个慢性肾脏中有5个（50%）需要进行肾盂输尿管缝合修复。平均螺旋水刀部分肾切除时间为63分钟（范围13至150分钟），平均估计失血量为174毫升（范围20至750毫升），用于水分离的生理盐水平均用量为260毫升（范围50至1250毫升）。没有动物出现尿漏。急性标本的组织学切片显示截肢部位有一层薄（1毫米）的附着凝血块，热损伤最小。在2周时，可见一层有巨细胞反应的附着纤维炎性假膜。
在这个更严格且可靠的存活小牛模型中，螺旋水刀辅助LPN可以在不控制肾门血管的情况下进行，从而完全避免热缺血。这种方法有可能降低LPN固有的技术难度水平。
