Haemostasis in Laparoscopy

european urology 50 (2006) 948–957
available at www.sciencedirect.com
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ESUT Special Paper
Haemostasis in Laparoscopy
Christoph H. Klingler a,*, Mesut Remzi a, Michael Marberger a, Gunter Janetschek b
a
b
Department of Urology, Medical University of Vienna, Austria
Department of Urology, Krankenhaus Elisabethinen Linz, Austria
Article info
Abstract
Article history:
Accepted January 31, 2006
Published online ahead of
print on February 24, 2006
Objective: Adequate haemostasis is essential for advanced laparoscopic
procedures since uncontrolled bleeding may cause significant complications and even required converting to laparotomy to obtain sufficient
haemostasis. The aim of this review is to give insight into the most
important tools and strategies to achieve sufficient haemostasis during
advanced urologic laparoscopy.
Methods and results: Lowering the risk of haemorrhage may be achieved
primarily by proper case selection, resulting in adequate laparoscopic
preparation and dissection technique or the use of local compression by
sponge stick to control local bleeding. For early bleeding control, laparoscopic clip appliers, staplers and suturing techniques may be utilised.
Various energy sources such as monopolar and bipolar electrocautery,
argon beam coagulators, laser or ultrasonic dissectors and topical
sealing agents can be used to augment natural haemostasis.
Conclusions: A wide armamentarium for achieving haemostasis
during laparoscopy is available. Consequently, laparoscopic surgeons
must have detailed knowledge of the physical concepts of each surgical
instrument or energy source and of proper use of tissue sealants
for obtaining sufficient haemostasis. This knowledge will improve
postoperative outcome, increase patient safety and guide laparoscopic
techniques to further perspectives.
Keywords:
Complications
Laparoscopy
Haemostasis
# 2006 Published by Elsevier B.V. on behalf of European Association of Urology.
* Corresponding author. FEBU, Department of Urology, Medical University of Vienna,
Währinger Gürtel 18–20, A-1090 Vienna, Austria. Tel. +43 1 40 400 2616; Fax: +43 1 408 99 66.
E-mail address: [email protected] (C.H. Klingler).
1.
Introduction
As in open surgery, uncontrolled bleeding during
laparoscopy is one of the major surgical pitfalls.
Haemorrhage may occur by gaining laparoscopic
access, during surgical preparation or during ablative
and reconstructive surgery [1,2]. In addition, even
minor bleeding may jeopardize improved vision
during laparoscopy owing to significant light
absorption by dark blood staining of the adjacent
tissue within the magnified optical field during
laparoscopy. Not surprisingly, haemostasis during
0302-2838/$ – see back matter # 2006 Published by Elsevier B.V. on behalf of European Association of Urology.
doi:10.1016/j.eururo.2006.01.058
european urology 50 (2006) 948–957
949
laparoscopic surgery focuses on primary prevention
of bleeding [3]. A variety of techniques and instruments have been transferred from open surgery and
adapted to the specific needs of laparoscopy to gain
adequate haemostasis. In addition, a variety of tissue
sealants were adapted for laparoscopy, particularly
during major ablative and reconstructive surgery.
The use of tissue sealants also may reduce operative
times and can reduce morbidity significantly. This
paper gives an overview of haemostasis during
laparoscopic interventions [1–7] and may support
development of laparoscopic surgery that aims at
special education for the appropriate use of haemostatic agents during laparoscopic surgery [8].
2.
Methods and results
2.1.
Dissection, mechanical compression, sutures, clips
Fig. 3 – Fan-like applicator used for fibrin-coated collagen
fleece mounting.
Standard surgical principles, such as proper tissue dissection
and identification of supplying blood vessels, also are used in
laparoscopy, allowing early identification of anatomical structures and timely implementation of appropriate measures,
Fig. 4 – Compression of Santorini plexus by catheter
balloon retraction.
Fig. 1 – Oxidised methylcellulous bolster used for
compressive sealing of parenchymal defects.
Fig. 2 – Sponge stick for local compression of aortal leak,
thereby achieving haemostasis.
preferably before bleeding occurs (Fig. 1). Dissection either with
a sponge (Fig. 2) or a haemostyptic stick (oxidised regenerated
cellulous; SurgicelTM) helps to dissect tissue and to control blood
vessels locally. Local compression with a sponge is similar to
digital compression in open surgery (Fig. 2), particularly with
uncontrollable venous bleeding, and gives the surgeon time to
elaborate further strategies for final haemostasis, or local
compression alone may be sufficient for haemostasis. Alternatively, the application of tissue sealants such as a collagen
patch coated with fibrin (TachoSilTM) in conjunction with local
compression may seal even the vena cava (Fig. 3).
Control of Santorini plexus during laparoscopic radical
prostatectomy or cystectomy may pose a significant problem
when massive haemorrhage occurs. Simple local compression
by balloon catheter retraction for temporary occlusion has
proven to be an excellent emergency measure (Fig. 4). This
local compression for >15 min may be supported by tissue
sealants such as oxidised regenerated cellulous to achieve
sufficient control of local bleeding.
Suture techniques used in laparoscopy resemble open
techniques but have specific modifications for laparoscopy.
Free hand intracorporeal suturing (Fig. 5) is preferable over
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european urology 50 (2006) 948–957
Fig. 5 – Haemostastis achieved by intracorporeal suturing
for renal parenchymal sealing.
Fig. 7 – Polymer ligation clips with the hook-like locking
system.
external knotting since it avoids excessive traction during
suturing. Ready to use Endo-loops may be of help particularly
for surgeons unfamiliar with endoscopic suturing techniques.
Endo-loops or cable ties have even been used for vascular
control during laparoscopic lower pole hemi-nephrectomy [9].
The disadvantage of this technique, however, is that a
significant amount of healthy tissue needs to be sacrificed
and that loops may slip off owing to tissue ischemia with
secondary loosening of the fixed loops.
Since suturing will require advanced laparoscopic skills,
clip systems are the preferable method of sealing blood
vessels. A wide variety of 5- and 10-mm clip appliers with
various sized clips are available. Even re-usable clip appliers
and flexible instruments are available; however, the reloading
time of such instruments may be an important limitation in
emergency situations. In addition, titanium clips tend to slip
off during further dissection. Consequently, at least 2 to 5 clips
seem mandatory for safe control of vessels sized 3 mm.
The self-locking, polymer ligation clip system (Hem-olockTM clips; Weck, Research Triangle, NC, USA; Fig. 6) contains
a self-sealing mechanism when applied correctly. Therefore,
these clips seem to have fewer tendencies to slip off, compared
with titanium clips, and therefore may be regarded as safer
[2,6,10,11]. Even major vessels such as the renal vein or artery
can be controlled safely. For oversized vessels, an XL ligation
clip sized 15 mm is available, or the vessel can be grasped with a
non-traumatic clamp to reduce the size; thereafter it is easy to
apply even L ligation clips. It is strongly recommended that
dissection be meticulous since the ‘‘hook-like’’ sealing mechanism (Fig. 7) may perforate venous vessels easily when applied
incorrectly, causing massive bleeding by itself. Therefore, it is
mandatory to receive adequate instruction before using these
clips; in particular, appropriate placement of the ligation clip
must be controlled before and after sealing. The ligation clips
can be removed easily by the aid of a special removal dissector;
however, this system will not work properly with the XL clips. In
addition, for nephron-sparing surgery, clips rather than freehand knotting are used now to secure the sutures [10].
Vascular Endo-stapler (vascular Endo-GIA) with 2.0- to 2.5mm jaw width and various lengths have been used to achieve
safe occlusion of major vessels or vascular pedicles [12].
Modern Endo-staplers are bulky instruments, require 12-mm
access ports, utilise three lines of staples for safe vascular
control and provide the cutting simultaneously. These devices
will require some educational training before use since the
main reason for a ‘‘malfunction’’ is still inappropriate use of
the instrument. Utilising a roticulating or flexible system is
advisable when the working space is limited or excessive
angulation of the instrument is to be avoided. Endo-staplers
are costly, single-use instruments. When multiple fires are
anticipated, however, cost may be reduced by using reloadable staplers, which requires replacement only of the
stapler magazine. The major disadvantage of endo-staplers
may occur when major vessels are sealed insufficiently,
resulting in life-threatening bleeding. Consequently, the
laparoscopic surgeon first must use the appropriate vascular
jaw width (2.0–2.5 mm) and must check that the entire vessel
is within the stapler line before firing.
Fig. 6 – Vascular control of suprarenal vein by application of
polymer ligation clips.
2.2.
Electrosurgical tools
2.2.1.
Monopolar electrocautery
As in open surgery, a monopolar current is used widely for
haemostasis and was the first tool adapted for laparoscopic
european urology 50 (2006) 948–957
needs. Predominant instruments used for monopolar dissection or cutting are forceps, scissors or the J-hook electrocautery [5–7], attached to a monopolar generator. Monopolar
instruments however, have various disadvantages. Electrical
bypass may occur at sites of either low impedance (tissue
related) or at the site of damaged insulation. These effects
cannot be realised by simple visual control and the use of
disposable instruments solely has been suggested. However,
according to our personal experience modern re-usable
instruments may be utilised safely [7]. Likewise, it seems
advisable to limit time and maximum current force for
monoploar dissection since complications associated with
extensive use of monopolar current have been reported in the
literature [2–4,6]. Another safety feature to increase safety of
monopolar electrocautery is active electrode monitoring
(AEM; Encision, Boulder, CO). This system registers any break
in the integrity of the insulation that could allow leakage of the
electric current. The monitoring device will shut off the
instrument and not allow it to be activated when the foot pedal
is depressed. Unfortunately, re-usable scissors will lose their
sharpness earlier from extensive use of monopolar current
during dissection, but this problem may be solved by using
single-use scissors blades for re-usable instruments (Richard
Wolf, Knittlingen, Germany).
The first haemostatic device used for capillary bleeding
control in renal parenchyma was the argon beam coagulator.
This instrument is a monopolar electrocautery instrument
that uses an argon jet to blow off the surgical field and is
sufficient for minor capillary bleeding after dissection.
However, the argon beam coagulator by itself cannot be
used for tissue dissection and is unsuitable for control of
significant bleeding or larger vessels. In addition, significant
complications such as argon gas embolism or pneumothorax
have occurred [13,14] even when used correctly, particularly
when unfavourable anatomical situations were present. The
Tissue-linkTM device uses monopolar radio frequency energy
with low-volume saline irrigation for simultaneous blunt
dissection, haemostatic sealing and coagulation of the renal
parenchyma. Urena et al. [15] demonstrated in 10 patients
undergoing nephron-sparing renal surgery that excellent
haemostasis and tumour control was achieved without
clamping of the renal vessels, but no interfere with the
pathological assessment of the tumour margin status was
documented. This finding differs from our experience in
which significant carbonisation of the tissue occurred even
with the use of a regular current, which may impair visual
control for oncological safe dissection. Likewise, histopathological examination for negative resection margins proved to
be very difficult for our pathologists at frozen section. In
addition, the Tissue-linkTM device will destroy locally a
significant margin of healthy tissue. This effect could be of
importance in patients with impaired renal function. Likewise, the collecting system could be damaged inadvertently
during resection without being noticed at the time of
surgery.
2.2.2.
Bipolar electrocautery
Introduction of bipolar instruments in laparoscopy improved
safe dissection and haemostasis simultaneously, thus allowing early vascular and bleeding control while avoiding
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complications [1,3,7]. Current flow is present between the
forceps jaws only, which minimises the risk of damage of
adjacent tissue and allows selection of the overall depths of
tissue damage specifically by using different sized forceps. For
micro-dissection, small single-use instruments are recommended to guarantee perfect insulation. Larger instruments
have been adapted for achieving vascular control of even
major vessels.
The most advanced systems consist of a bipolar radio
frequency generator and a 5-mm laparoscopic Marylandstyle forceps (LigaSureTM; Valleylab, Boulder, CO, USA;
PlamaKinteticTM; Gyrus Medical, Maple Grove, MN, USA)
[16,17]. Constant et al. investigated the use of the so-called
LigaSureTM device in 124 consecutive patients undergoing
laparoscopic living-donor nephrectomy [16]. They found the
device to be extremely effective for obtaining haemostasis
even for major renal vessels. It has to be noted, however,
that the LigaSureTM device is recommended by the manufacturer for vessels sized 6 mm only. The use for larger
vessels (renal pedicle) is still purely experimental. Carbonell
et al. investigated several laparoscopic bipolar-sealing
devices in controlling small-, medium- and large-sized
arteries [17]. The extent of thermal injury was measured
in a domestic pig model, and determined by coagulation
necrosis and burst pressures. They concluded that the
LigaSureTM produces supra-physiologic seals with significantly higher bursting pressures than that of PlasmaKineticTM devices (Table 1). Thermal spread increases with vessel
size, but the degree of lateral thermal injury from the two
instruments does not differ. The same results were obtained
by Santa-Cruz et al.; they concluded that bipolar-cutting
forceps are a safe, cost-effective and time-saving device
with numerous applications during laparoscopy [18]. As
with any laparoscopic instrument, however, the anatomic
geometry of the operative field may limit the use on the basis
of port placement, thus limiting the use of these systems for
surgical interventions in the pelvic region, such as in radical
prostatectomy.
2.2.3. Ultrasonic or harmonic scalpel (UltracisionTM,
Harmonic ACETM [7,19–23])
The Piezoelectric harmonic scalpel is a tool that simultaneously excises and coagulates tissue with high-frequency
ultrasound. A frequency of 25 kHz results in dissection and
cavitation; at >55 kHz thermal effects and coagulation take
place. The harmonic scalpel is known to cause less collateral
damage, avoids carbonisation of the tissue and reduces local
thermal damage. It has been used widely in laparoscopy for
tissue dissection and control of local blood vessels.
Janetschek et al. found the harmonic scalpel very helpful in
achieving adequate haemostasis for retroperitoneal lymph
node dissection [20]. However, the use of the harmonic
scalpel is limited to vessels <4 mm, and dissection of renal
parenchyma may still require local ischemia. Tomita et al.
demonstrated in their study that, for dissection of renal
parenchyma, the harmonic scalpel may be of some help but
that haemostasis of larger vessels was not obtained, even
when the harmonic scalpel was used at maximal coagulation
power [21]. They concluded that complete haemostasis of
larger vessels cannot be achieved. The same problem may
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european urology 50 (2006) 948–957
Table 1 – Comparison of the bursting pressure of various haemostatic devices and agents
Bursting
pressure/arterial
size (mm Hg)/[mm]
Sutures [47]
Titanium clip [11,47]
Polymer clip [11]
Vascular endostapler [12]
Electrocautery [11]
Harmonic scalpel [11]
Bipolar vessels
sealer [11,47]
Fibrin glue [33–35]
Polyethylene glycol
Fibrin-coated
collagen fleece [40]
Oxidised methylcellulose
Gelatine matrix [36–39]
900 [3–7 mm]
593 [4 mm]
854 [4 mm]
>310 [17 mm]
230
205 [4 mm]
601 [4 mm]
378 [parenchyma]
>490 [1 mm]
>290 (suture 900)
NA (suture 900)
NA
Collecting
system
sealing (mm Hg)
Parenchymal sealing
87
166
Solid clot
Dense fleece;
sutured bolster
Sutured bolster
No clot formation
22 hPa (17 mm Hg)
80 hPa (61 mm Hg)
59 hPa (46 mm Hg)
Sutured polster
Special instruments
Clip appliers; single use
Clip applier; re-usable
Stapler arm + jaws; multiple loads
Single/re-usable
Special generator + single-use forceps
Standard generator;
single/re-usable instruments
Two components; application needle
Single component; application needle
Dry fleece; Endo-Doc carrierTM
Cellulous fleece; no special applicator
Two components; application needle
NA = not available.
occur at the Santorini plexus or vascular pedicles. Since the
immediate vascular control of all supplying vessels during
dissection cannot be achieved, the use of the harmonic
scalpel alone is not advisable. A promising development is the
introduction of a new harmonic generator (Harmonic ACETM,
Ethicon, USA). Owing to a higher velocity of transaction, the
device is more rapid in tissue dissection, and vessels 5 mm
can be sealed with decreased smoke formation or less lateral
thermal damage to surrounding tissue [23]. However, data
from larger series are not yet available.
2.3.
Lasers for haemostasis
2.3.1.
Holmium laser
The Holmium laser has been used for parenchymal tissue
resection such as prostatectomy because of the significantly
reduced blood loss, even in high-risk patients. Not surprisingly
there have been several attempts to use the Holmium laser for
renal partial resection. Lotan et al. presented results obtained
with the Holmium:yttrium aluminum garnet (YAG) laser for
laparoscopic partial nephrectomy in a porcine model [24]. A 550to 1000-micron end-fire holmium laser fibre set at 0.2 J and 60 Hz
was used to transect the lower pole of the kidney; the
parenchymal surface was then sealed with fibrin glue. They
concluded that this laser provides an efficacious modality for
transecting the kidney in a porcine model. In another study, the
Holmium laser was used in kidney, bladder, prostate, ureteral
and vassal tissues [25]. When used through the laparoscope, the
Holmium:YAG laser provided precise cutting and—combined
with electrocautery—allowed the dissection to proceed quickly
and smoothly. Haemostatic control was adequate in all surgical
procedures. Clinical data, however, are very limited. In a small
clinical setting, three patients (complex cyst, non-functioning
lower pole, renal mass) underwent nephron-sparing procedures with the Holmium laser setting of 0.2 J/pulse at 60 Hz and
0.8 J/pulse at 40 Hz [26]. Tissue sealants also were used to
reinforce the lesion although haemostasis seemed sufficient.
No complications were documented, and good haemostasis
without the need for hilar occlusion resulted. This technique
promises to facilitate the laparoscopic management of renal
tumours. It has to be noted, however, that laser application
causes significant tissue vaporisation and spreading of liquid
during manipulation. These effects may result in significant
tumour cell spillage within the abdominal cavity; for the same
reason, the harmonic scalpel is regarded as unsafe in
oncological interventions.
2.3.2.
Experimental lasers
With the use of an 810-nm, pulsed diode laser (20 W), a 50%
liquid albumin-indocyanine green solder was welded to the
cut edge of the renal parenchyma to seal the collecting system
and achieve haemostasis in an animal model [27]. No evidence
of urinoma or haemorrhage occurred. Histopathologic analysis showed preservation of the renal parenchyma immediately
beneath the solder. Laser tissue welding provided reliable
haemostasis and closure of the collecting system while
protecting the underlying parenchyma from the deleterious
effect of the laser.
Likewise, a 980-nm diode laser (23 W) without hilar occlusion was used in a laparoscopic, transperitoneal, lower-pole
partial nephrectomy in five pigs [28]. In three cases, laser
haemostasis was insufficient, and adjunctive haemostatic
clips were necessary to stop bleeding; therefore, it seems
questionable that this particular laser type will survive further
clinical trials or its indication may be limited to very small and
exophytic tumours. Promising results for laparoscopic partial
nephrectomy were obtained with a potassium-titanyl-phosphate (KTP) laser without vascular hilar clamping in the
survival calf model [29]. KTP laser is not absorbed by water, but
the selective uptake of KTP laser energy by haemoglobin
leads to haemostasis. In all 12 procedures, renal parenchymal
resection and haemostasis were achieved with the laser
only, without any adjunctive haemostatic sutures or bioadhesives. At 1-month follow-up there was no evidence of
urinary leakage or arterio-venous fistula. This initial study of
laparoscopic, KTP laser, partial nephrectomy without hilar
clamping confirms its technical feasibility with good shortterm outcomes.
european urology 50 (2006) 948–957
Fig. 8 – Fibrin-coated collagen fleece (yellow) and fibrin glue
applied on cut defect.
2.4.
Tissue sealants
2.4.1. Fibrin glues (CrossealTM, TisseelTM, TissuecolTM,
VivostatTM [30–35])
Fibrin glues are a mixture of human thrombin and fibrinogen;
these terminal products of the clotting cascade form a solid
fibrin matrix. They are the most common tissue sealants used
in laparoscopy. They have been used extensively in open
surgery, and owing to their liquid nature they are ready for use
in laparoscopy. The only tool required is a long applicator
needle (Fig. 8) with a dual-lumen adapter. Human-derived
fibrin glue (CrossealTM) showed a trend toward a shorter
operative time but was associated with a higher complication
rate [30], and TisseelTM alone did not seem effective enough in
dealing with a major vascular or collecting system injury [31].
However, the combination of other measurements (suturing)
or tissue sealants is more effective in dealing with both
vascular and collecting system injury [31-33]. Likewise, the
success of sealants can vary with the depth of the resection
and blood pressure. Most thrombin- or fibrinogen-based
products work well for resections superficial to the collecting
system. Fibrin glue used in conjunction with a gelatine sponge
(hydrogel tissue sealant = TisseelTM/gelfoam) was utilised for
this purpose. Gelfoam/TisseelTM was found to be the only nonsutured method that worked on resections up to or barely into
the collecting system [33]. VivostatTM (Vivolution A/S, Birkeroed, DK) is an autologous, platelet-enriched, fibrin sealant
applicator system, which utilises 120 ml of patient blood that
is processed overnight. This tissue sealant seems to outperform other fibrin glues with respect to haemostasis and
adhesion to tissue [34]. However, knowledge of its use in
laparoscopic urologic surgery is very limited.
Various tissue sealants will behave differently when they
are in contact with urine [34]. Fibrin glue (TisseelTM) and
oxidized regenerated cellulose (SurgicelTM) maintain a solid
form when initially placed in direct contact with urine and
then assume a semisolid gelatinous state, which is still
present at 5 days. Polyethylene glycol (CoSealTM) forms a solid
clot initially and does not change after 5 days. Only a
haemostatic gelatine matrix (FloSealTM) remained as a fine
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Fig. 9 – Oxidised methylcellulose fleece covered with fibrin
glue at renal cut surface.
particulate suspension in both normal and sanguineous urine.
However, the clinical implications of these findings with
regard to sealing the renal parenchyma are still unclear.
2.4.2. Oxidised regenerated methylcellulose (SurgicelTM,
TapoTampTM)
This tissue fleece is utilised commonly for resections that
widely enter the collecting system and the renal parenchyma
[36]. These ‘‘sutured bolsters’’ (Fig. 1) are sutured into a cavity,
achieving approximation and local compression at the
resected site. In addition, capillary bleeding is prevented by
supporting local haemostasis of the cellulose tissue. Superficial defects can even be treated safely by a methylcellulose
cover with fibrin glue (Fig. 9).
2.4.3.
Haemostatic gelatine matrix (GMHS or FlosealTM)
The two-component FloSealTM matrix is a combination of a
bovine gelatine–based matrix with a bovine-derived thrombin
component [37–39]. The gelatine base is composed of bovine
collagen cross-linked with glutaraldehyde. The matrix can be
prepared easily without any special preparation. Once prepared, the matrix is ready for use up to 2 h. GMHS has been
used to obtain haemostasis in laparoscopic partial nephrectomy with hilar clamping [37,38]. The sealant was applied after
resection of the tumour to the moist resection site under
controlled compression for 1 to 2 min. After renal re-perfusion, haemostasis was immediate and durable in all cases. In
highly selected patients with exophytic renal tumours, use of
this agent may reduce warm ischemia time by circumventing
the need to perform laparoscopic suturing. It has to be noted,
however, that this tissue sealant will not work properly at
bloodless fields. Therefore, FloSealTM followed by the application of a cap of TisseelTM seemed to be more effective in
achieving adequate haemostasis in renal defects [39].
2.4.4. Human fibrinogen and thrombin fleece (TachoSilTM,
TachocombTM)
This unique, dry, equine fibrin-adhesive–coated collagen
fleece is applied with a special fan-like Endo-doc carrier
(Fig. 8) to allow controlled application of the dry fleece [40].
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While under constant compression and moisturizing with
normal saline, the fleece forms a dens tissue-like sealant at the
surface of the parenchymal lesion within 3 to 5 min and will be
replaced by vital tissue. Therefore, the dry sponge may be used
even when no bleeding is present and in patients with
bleeding disorders. With the aid of TachoSilTM, any parenchymal defect at the liver, spleen or kidney can be sealed. After
proper application, the sealed surface is ready to use even for
further bipolar coagulation, or sutures may be applied when
needed, without jeopardising the sealant effect. In addition,
owing to its nature, this sealant separates tissue; therefore, it
is an anti-adhesive to other structures situated around the
resection site. However, its use for sealing of the collecting
system is not yet answered.
2.5.
More experimental tissue sealants
2.5.1.
Polyethylene glycol hydrogel (CoSealTM [41,42]
Bernie et al. evaluated a porcine, laparoscopic, partial
nephrectomy model and three haemostatic techniques
(suturing, TisseelTM, CoSealTM) [41]. All animals in the
CoSealTM group had small urinary leaks, but none of the pigs
in the fibrin glue cohort had leaks. Consequently the authors
concluded that CoSealTM was not as effective as suturing or
fibrin glue in adhering to the cut renal surface and sealing of
the collecting system.
2.5.2.
Bovine serum albumin + glutaraldehyde (BioglueTM)
In clinical settings, this non-fibrin–derived tissue sealant was
use for renal parenchyma, vessels and collecting system
sealing in addition to other measures [43]. Its use in collecting
system repair alone, compared with the traditional method,
significantly decreased the procedural time for partial
nephrectomy. Whether this technique alone is safe enough
for dealing with large parenchymal defects remains unclear.
2.5.3.
Haemostatic fibrin sealant powder
Haemostatic fibrin sealant powder (HFSP) may be delivered
laparoscopically as a dry powder spray and was investigated in
an animal model for achieving haemostasis and sealing of the
collecting system during laparoscopic hemi-nephrectomy [44].
No haematoma but urinary extravasation was detected in 8 of
10 (80%) animals in the HFSP group and 1 of 11 (9%) in the
conventional group at 48 h postoperatively ( p < 0.008). At the
6-week computed tomography evaluation, none of the
animals showed evidence of urinoma or haematoma formation, and the cut surface in both groups had been replaced by
dense scar tissue at the cortex with a sharp line of
demarcation between the scar and normal kidney. HFSP,
therefore, may facilitate laparoscopic hemi-nephrectomy
greatly by providing rapid and lasting haemostasis without
suturing.
2.5.4.
Thrombin and collagen granules (CostasisTM)
CostasisTM consists of bovine collagen, bovine thrombin and
autologous plasma granules. This sealant has been investigated in animal and clinical models [45]. CoStasisTM–treated
sites demonstrated significantly shorter time to haemostasis,
compared with fibrin sealant or collagen sponge. In anticoagulated animals, CoStasisTM and fibrin sealant had
comparable mean times to haemostasis; therefore, it was
concluded that, under conditions of compromised coagulation,
Table 2 – Pertinent characteristics of various haemostatic devices and agents
Haemostatic
background
Sutures, loops [2,6,9,32,47]
Titanium clips [6,10,11,47]
Polymer clips [6,7,10,11]
Vascular endostapler [7,12]
Electrocautery
Monopolar [5–7]
Bipolar [6,7,10,20,47]
Argon beam
coagulator [13,14]
Harmonic scalpel [19–23]
Bipolar vessels sealer
[15–18,47]
Lasers [24–29]
Fibrin glues [2–4,30–35]
Oxidised Methylcellulose
[4,6,10,20,36]
Fibrin-coated collagen
fleece [40]
Gelatine matrix [36–39]
Polyethylene glycol [42]
Mechanical
Mechanical
Mechanical
Mechanical
Thermal coagulation
and cutting
Thermal coagulation
Tissue vaporization and
ultrasonic coagulation
Thermal coagulation
and sealing
Tissue vaporization and
thermal coagulation
Clotting cascade
Clotting cascade and
haemostyptic polster
Clotting cascade and
surface covering
Clotting cascade
Artificial sealants
Ease
of use
Collecting
system sealing
Major disadvantage
+++
++
+
Yes
No
No
No
Difficult to learn
May slip off
Hook-like tip
Bulky to use; costs
+++
No
Current leakage;
bipolar—no cutting
++
+
No
No
++
No
No dissection;
capillary bleeding only
Vessels <4 mm
++
No
Very slow; vessels 6 mm
++
No
Expensive; cell spillage
++
Yes
Yes (bolster !)
Dry surface needed
Suturing skills required
+
Yes
Tricky to apply
++
++
Unknown (No)
Yes
Bloody surface needed
Experimental
Ease of use: [+++] = very simple/easy to use; [ ] = very difficult/elaborate.
european urology 50 (2006) 948–957
treatment with CoStasisTM demonstrates a reduction in
average blood loss.
[8]
2.5.5.
2-Octyl-cyanoacrylate (DermabondTM)
Cyanoacrylate has been used extensively in clinical practice
for skin closure and laparoscopic hernia repair. It was found
that cyanoacrylate is a useful tissue sealant in laparoscopic
partial nephrectomy [46]. It may be used as an additive to
secure haemostasis in laparoscopic surgery as an additional
tool, but it is not designed to be a primary haemostatic agent or
tool (see Table 2).
[9]
[10]
[11]
3.
Conclusion
Successful haemostasis in laparoscopy has opened
the surgical field of laparoscopic indications since the
limitation attributable to insufficient haemostasis or
conversion to open surgery related to uncontrollable
bleeding during laparoscopy has become rare in
centres experienced in modern haemostasis. A
number of techniques and sealant products have
augmented the armamentarium of surgical techniques, instruments and tissue sealants used as an
adjunct or principal haemostatic agent, even for
major surgical procedures. Advances in haemostasis
increased the applicability of the laparoscopic procedures and bring them within the grasp of every
urologist. However, the haemostatic performance
and reliability of all tissue sealants used so far are not
high enough for surgeons to rely solely on tissue
sealants, and there is no ideal sealant on the horizon.
Laparoscopic surgeons must have detailed knowledge of the biophysics of their tools, their spectrum of
effectiveness and their methods of application that
may improve our ability to perform surgery in a safe
manner. Still there is an urgent need for further
development of tools to make even complex laparoscopic interventions feasible and safe.
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Editorial Comment
H.R.H. Patel, Institute of Urology,
University College Hospital, London
[email protected]
As we advance through the ever increasing
complexities of laparoscopic urology, it was
refreshing to read this excellent educational
review. Clearly, anyone embarking on a career in
laparoscopy in any field would be wise to read this
review. The subject is complex, but these eminent
authors have done well to distil the data into
salient and simple areas. As the development of
haemostatic devices and sealants has expanded,
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surgeons have become more daring in there use:
the harmonic scalpel (Ethicon-EndosurgeryTM) for
renal vasculature ligation instead of clips or
stapling; or the tissue glues (floseal/Tisseel –
BaxterTM) instead of suturing for partial nephrectomy.
Novel uses appear in the field of prostatectomy
where glue has been used over the lateral pedicle to
avoid thermal injury to the nerve bundles [1] or for
splenic injuries during nephrectomy [2].
Overall, the message from this review is clear:
understand the principle of the haemostatic
armamentarium used and always have more than
one option during uncontrolled bleeding.
european urology 50 (2006) 948–957
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