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Laparoscopic urologic surgery in malignancies - part 8

Sau khi chảy máu đã được dừng lại với kỹ thuật này, bác sĩ phẫu thuật không cần phải hành động vội vàng, nhưng có rất nhiều thời gian để thực hiện các bước cần thiết. Hơn nữa, nghiên cứu động vật của các tác giả và kinh nghiệm lâm sàng đã chỉ ra rằng chảy máu tĩnh mạch, | 7 Laparoscopic Retroperitoneal Lymph Node Dissection for Testicular Tumors 207 Fig. 8. Left RPLND residual mass after chemotherapy Fig. 9. Left RPLND operative field after excision of mass Once the bleeding has been stopped with this technique the surgeon need not act in a hurry but has plenty of time to undertake the necessary steps. Furthermore the authors animal studies and clinical experience have shown that most venous bleedings including those resulting from small leaks in the vena cava can be stopped with the help of fibrin glue Bax-ter-Immuno Deerfield IL USA . A special laparoscopic applicator is available from the manufacturer with two separate channels for the two components of fibrin glue. The edges of larger defects are approximated with a grasper or clips and then sealed with fibrin glue. In addition a strip of oxidized regenerated cellulose or other hemostatic agents can be used to enhance the tightness of the repair. Owing to these hemostatic techniques only three out of 162 laparoscopic RPLNDs had to be converted to open surgery. No late bleeding was observed. Results Between August 1992 and June 2004 162 consecutive patients underwent laparoscopic RPLND. No patients were excluded because of body habitus or previous operations see Tables 1 and 2 . Stage I RPLND was performed for 103 patients with clinical stage I testicular tumor. The mean age was 29.9 years 16-51 . In 64 patients the tumor was located on the right side and in 39 on the left side. Patient selection was not based on assessment of risk factors or histologic findings. and the harmonic scalpel Ethicon . Because the authors have been using these tools dissection has become easier safer and faster. A small clamp for bipolar coagulation Johnson Johnson New Brunswick NJ USA allows for meticulous dissection of delicate structures whereas broader bipolar forceps provide highly efficient hemostasis. In the authors hands these tools have proved very efficient. In open surgery acute bleeding .