Elashry O M, Wolf J S, Rayala H J, McDougall E M, Clayman R V
Department of Surgery/Division of Urologic Surgery, Washington University School of Medicine, St. Louis, MO, USA.
J Endourol. 1997 Feb;11(1):15-22. doi: 10.1089/end.1997.11.15.
Although technically feasible, laparoscopic partial nephrectomy (LPN) using conventional instrumentation presents the intraoperative challenge of hemostasis, creating a flush (i.e., precise guillotine) incision, and closure of the collecting system. In an effort to resolve these technical problems, we used a unique electrosurgical snare electrode (ESE) in combination with an ERBE electrosurgical generator and compared its effectiveness with that of two ultrasonic dissectors (Cavitron Ultrasonic Surgical Aspirator [CUSA] and harmonic scalpel [HS]) in performing LPN. Twelve female minipigs underwent right lower-pole LPN using one of the aforementioned modalities. Six weeks later, in the same animals, a left lower-pole LPN was performed using the same device, thereby providing an acute and chronic renal remnant to examine. The animals were harvested, and transverse and perpendicular histologic sections were prepared of the cut surface of each specimen. The weights of the LPN specimens and the remaining kidney were also recorded. The time required for partial nephrectomy, degree of hemostasis (i.e., blood loss), ease of excising the targeted tissue, changes in renal function, tissue reactivity, and depth of damage to the surface of the remaining renal parenchyma were measured for each device. All 12 procedures were successful using the ultrasonic dissection, and 11 procedures were successful using the ESE. The ESE was significantly faster than the two forms of ultrasonic dissection (p < 0.0001) and produced less intraoperative bleeding (P = 0.002). Both forms of ultrasonic energy produced significantly deeper parenchymal injury in the acute surgical specimen (P = 0.03) and more parenchymal fibrosis and chronic inflammation in the chronic surgical specimens (P = 0.007) than the ESE. None of the animals exhibited any extravasation from the incised collecting system when studied by retrograde pyelography 6 weeks postoperatively at the time of left LPN and harvest. The function of the renal remnant was consistent with the size of the partial nephrectomy specimen. No hypertension developed in any of the study animals. Our results using a unique electrosurgical snare probe show it to have potential advantages as a rapid, hemostatic method for performing a partial nephrectomy. We believe that this instrument may represent an important tool for performing nephron-sparing surgery via an open or laparoscopic approach. Clinical trials are in progress.
尽管从技术角度可行，但使用传统器械进行腹腔镜部分肾切除术（LPN）在术中面临止血、形成平整（即精确的断头台式）切口以及封闭集合系统等挑战。为解决这些技术问题，我们将一种独特的电外科圈套电极（ESE）与ERBE电外科发生器联合使用，并将其在进行LPN时的有效性与两种超声解剖器（Cavitron超声手术吸引器[CUSA]和谐波刀[HS]）进行比较。12只雌性小型猪使用上述其中一种方式接受了右肾下极LPN。六周后，在同一批动物身上，使用相同设备进行了左肾下极LPN，从而提供了急性和慢性肾残端以供检查。对动物进行处死后，对每个标本的切面制备横向和垂直组织学切片。还记录了LPN标本和剩余肾脏的重量。针对每种设备测量了部分肾切除术所需时间、止血程度（即失血量）、切除目标组织的难易程度、肾功能变化、组织反应性以及对剩余肾实质表面的损伤深度。使用超声解剖法的所有12例手术均成功，使用ESE的11例手术成功。ESE比两种超声解剖法明显更快（p < 0.0001），且术中出血更少（P = 0.002）。与ESE相比，两种超声能量形式在急性手术标本中造成的实质损伤明显更深（P = 0.03），在慢性手术标本中导致的实质纤维化和慢性炎症更多（P = 0.007）。在术后6周进行左LPN和处死时通过逆行肾盂造影研究，没有动物出现切开的集合系统渗漏。肾残端的功能与部分肾切除标本的大小一致。所有研究动物均未出现高血压。我们使用独特的电外科圈套探针的结果表明，它作为一种快速止血方法进行部分肾切除术具有潜在优势。我们认为该器械可能是通过开放或腹腔镜途径进行保肾手术的重要工具。临床试验正在进行中。
