HEMOSTASIS IN PARTIAL NEPHRECTOMY
315
of the difficulty of controlling hemorrhage. Few studies have
been published in either humans or animals describing various
CONCLUSION
1
–7
Nephron-sparing surgery can be performed in the pig using
a purely laparoscopic vascular pedical clamping technique or
hand-assisteddigitalcompressionwithout significantdifficulty.
In trained hands, the purely laparoscopic technique produces
similar resection times with less blood loss, easier suturing, a
smaller abdominal incision, and no noticeable difference on
pathologic examination. This study would need to be extended
to survival procedures and specifically address the collecting
system and internal urine diversion. These techniques can be
applied to partial nephrectomies in the human.
techniques of laparoscopic partial nephrectomy.
and colleagues performed the first laparoscopic partial
Winfield
1
nephrectomyfor benign disease in 1992. They used a technique
developed by McDougall and coworkers in a porcine model.3
In these animal studies, successful partial nephrectomies were
performed using a plastic cable as a renal tourniquet and elec-
trosurgical scissors for renal transaction. Hemostasis was
achieved with argon beam coagulation. Wolf and associates8
compared open and laparoscopic hand-assisted nephron-spar-
ing surgery and showed an advantage using a minimally inva-
4
sive technique. Winfield and colleagues had a similar result,
with a reduction of operative morbidity and duration of conva-
lescence compared with open surgery. Other studies have
shown the feasibility of laparoscopic partial nephrectomy in
both humans and animal models.2–5
REFERENCES
1
. Winfield HN, Donovan JF, Godet AS, et al. Human laparoscopic
partial nephrectomy: Case report. J Min Inv Ther 1992;1(suppl):66.
Numerous technologies have been studied for laparoscopic
partial nephrectomy because of the suboptimal clinical results
and technical difficulty of the procedure. Hand-assisted lapa-
roscopic techniques are becoming more widespread because of
the shorter learning curve and alleged ease of kidney manipu-
lation and perhaps suturing.9–12 To our knowledge, no group
2. McDougall EM, Clayman RV, Anderson K. Laparoscopic wedge
resection of a renal tumor: Initial experience. J Laparoendosc Surg
1993;3:577.
3. McDougall EM, Clayman RV, Chandhoke PS, et al. Laparoscopic
partial nephrectomy in the pig model. J Urol 1993;149:1633.
4. Winfield HN, Donovan JF, Godet AS, et al. Laparoscopic partial
nephrectomy: Initial case report for benign disease. J Endourol
has compared hand-assisted digital compression of the kidney
with laparoscopic clamping of the vascular pedicle in terms of
feasibility, EBL, or tissue damage. The pig was chosen as the
animal model for this experiment because, as demonstrated by
1
993;7:521.
5
. Winfield HN, Donovan JF, Lund GO, Kreder KJ, Stanley KE,
Brown BP, Loening SA, Clayman RV. Laparoscopic partial
nephrectomy: initial experience and comparison to the open surgi-
cal approach. J Urol 1995;153:1409.
1
3
Sampaio and colleagues, the morphometric and anatomic
characteristicsof its kidneys are similar to those of human kid-
neys. The technique classically described in open surgery with
bidigital compression of the parenchyma can be transposed di-
rectly to HAL. In contrast, clamping of the vascular pedicle is
more effective in controlling hemorrhage but carries a risk of
warm ischemia time with associated kidney damage and tubu-
6. Gill IS, Delworth MG, Munch LC. Laparoscopic retroperitoneal
partial nephrectomy. J Urol 1994;152:1539.
7
. Elashry OM, Wolf JS Jr, Rayala HJ, et al. Recent advances in lap-
aroscopic partial nephrectomy: Comparative study of electro sur-
gical snare electrode and ultrasound dissection. J Endourol
1
997;11:15.
8
9
. Wolf JS, Seifman BD, Monyie JE. Nephron sparing surgery for
suspected malignancy: Open surgery compared to laparoscopy with
selective use of hand assistance. J Urol 2000;163:1659.
. Nakada SY. Hand-assisted laparoscopic nephrectomy. J Endourol
1999;13:9.
3
lar necrosis as well as vascular trauma. Moreover, digital com-
pression may produce some warm ischemia of the affected re-
gion and may produce total ischemia with kinking of the
vascular pedicle during hand manipulation. Our study showed
no difference in kidney damage in the two groups, as judged 10. Wolf JS Jr, Tchetgen MB, Merion RM. Hand-assisted laparoscopic
by macroscopic and microscopic evaluation.
live donor nephrectomy. Urology 1998;52:885.
1. Stifelman M, Sosa RE, Shichman S. Hand-assisted laparoscopy
1
1
In our study, the blood loss was significantly lower in an-
imals having vascular pedicle clamping. This is attributed to
the total occlusion of the blood supply to the kidney, pro-
ducing warm ischemia. Digital compression resulted in much
greater blood loss, poorer field visibility, and more difficult
control of the bleeding parenchyma and suture placement.
Nevertheless, both groups had good outcomes, and no com-
plication or death occurred in either group. This result would
favor a purely laparoscopic approach with good technique
and suturing. Moreover, we experienced more difficulty with
knot tying and suture placement in HAL because of the lim-
ited working space and less expeditious suture manipulation.
Further survival studies will need to be done to show further
advantages of a purely laparoscopic technique with increased
experience.
(HAL). Curr Surg Tech Urol 1999;12:1.
2. Wolf JS Jr, Moon TD, Nakada SY. Hand assisted laparoscopic
nephrectomy: Comparison to standard laparoscopic nephrectomy.
J Urol 1998;160:22.
3. Sampaio FJB, Pereira-Sampaio MA, Favorito LA. The pig kidney
as an endourologic model: Anatomic contribution. J Endourol
1
1
998;12:45.
Address reprint requests to:
Thomas M.T. Turk, M.D.
Dept. of Urology
Loyola University Medical Center
Maywood, IL 60153