Satinsky Clamp Research Articles

Laparoscopic Ice Slush Renal Hypothermia for Partial Nephrectomy: The Initial Experience

We describe a novel technique of laparoscopic renal hypothermia with intracorporeal ice slush during partial nephrectomy as well as clinical experience with the initial 12 patients. A total of 12 select patients with an infiltrating renal tumor who were candidates for nephron sparing surgery underwent transperitoneal laparoscopic partial nephrectomy with renal hypothermia. An Endocatch II (United States Surgical Corp., Norwalk, Connecticut) bag was placed around the mobilized kidney and its drawstring was cinched around the intact renal hilum. The renal artery and vein were occluded en bloc with a Satinsky clamp. The bottom of the engaged bag was retrieved through a 12 mm port site and opened, and ice slush was introduced within the bag to completely surround the kidney. After renal hypothermia was achieved laparoscopic partial nephrectomy was performed by duplicating open surgical techniques. Renal parenchymal temperature was measured using a thermocouple needle in 5 patients. Median tumor size was 3.2 cm (range 1.5 to 5.5), 6 tumors (50%) were central in location and an imperative indication for partial nephrectomy was present in 7 patients (58%). All procedures were successfully completed laparoscopically without open conversion. Median time to deploy the bag around the kidney was 7 minutes (range 5 to 20), the median volume of ice slush introduced was 600 cc (range 300 to 750) and the time needed to insert the ice slush was 4 minutes (range 3 to 10). Median blood loss was 200 cc, total ischemia time was 43.5 minutes (range 25 to 55) and total operative time was 4.3 hours (range 3 to 5.5). Nadir renal parenchymal temperature was 5C to 19C and the mean decrease in systemic temperature was 0.6C. Histopathology confirmed renal cell carcinoma in 11 patients (92%), of whom all had negative surgical margins. Intraoperative complications occurred in 2 initial patients, including partial bag slippage in 1 and Satinsky clamp malfunction in 1. Postoperatively renal scan confirmed a functioning ipsilateral kidney in all cases. To our knowledge we present the initial clinical report of laparoscopic renal hypothermia for partial nephrectomy. By replicating standard open surgical practice our intracorporeal ice slush technique has the potential to extend the scope of laparoscopic partial nephrectomy to more complicated renal tumors.

Local hemostasis during laparoscopic partial nephrectomy using biodegradable hydrogels: initial porcine results.

Despite the advance of laparoscopic partial nephrectomy, significant technical limitations remain with regard to control of bleeding and closure of the collecting system. An attractive approach on the horizon for local hemostatic and wound control is the use of local tissue sealants. To date, sealants remain largely derived from natural biologic products and are difficult to apply laparoscopically with precise local control. In this study, we examined the novel strategy of forming occlusive tissue-adherent hydrogels utilizing a synthetic biodegradable polyethylene glycol-lactide copolymer (PEG-lactide) as an in situ occlusive barrier for hemostasis and wound control. Specifically, the objects of this study were to determine if PEG-lactide hydrogels could be formed intraperitoneally on renal tissue, to test the adhesiveness of the hydrogels to injured renal parenchyma, and to evaluate the ability of adherent hydrogel barriers to limit renal parenchymal bleeding and collecting system leakage following renal pole amputation or wedge excision. Five kidneys from three female pigs were used in a nonsurvival study. A standardized model for laparoscopic partial nephrectomy was created by performing wedge excision or polar amputation under vascular control using a laparoscopic Satinsky clamp. Bleeding briskness following injury was assessed utilizing a scoring system and free blood quantitated comparing a conventional "clamp and wait" strategy with an adherent hydrogel strategy. For the hydrogel group, PEG-lactide hydrogel primer and macromer were applied through laparoscopic ports. The hydrogel was polymerized using a xenon light source, and the pedicle clamp was released to observe for bleeding. A subsequent opposite polar injury was created to confirm renal perfusion and the sites were compared. The kidneys were removed, and the adhesion of the hydrogel to the renal parenchyma was examined. The PEG-lactide macromer was effectively applied to five kidneys following partial nephrectomy. In all cases, successful intraperitoneal in situ polymerization was achieved, with resultant hydrogel formation. Polymeric hydrogel adhesion to the cut renal parenchyma was assessed semiquantitatively following vigorous cyclic washing. In all cases, polymer gels remained adherent without any evidence of peeling, delamination, or separation from the underlying tissue surface. In the control group, the mean bleeding score was 2.63 +/- 0.48 v 0.00 +/- 0.00 in the gel-treated group (P < 0.001). Blood loss in the control group was 56 +/- 5 ml v 0.00 +/- 0.00 in the gel-treated group (P < 0.001). In an ex vivo retrograde ureteral perfusion, no leakage was observed at pressure as high as 100 mm Hg. In this feasibility study, a biodegradable PEG-lactide polymer system photopolymerized rapidly in situ on exposed renal parenchymal surfaces, forming adherent hydrogel barriers. When applied during vascular clamping, an adequate physical bond and patch-like cap was created to prevent bleeding at physiologic renal perfusion pressures. Use of locally applied occlusive hydrogels holds promise for hemostasis and local wound control during laparoscopic urologic procedures.

Hand Assisted Laparoscopic Radical Nephrectomy for Renal Cell Carcinoma With Inferior Vena Caval Thrombus

To our knowledge we present the initial clinical report of hand assisted laparoscopic radical nephrectomy for renal cell carcinoma with tumor thrombus extending into the inferior vena cava. A 76-year-old man was referred to our medical center with a 12.5 x 10 cm. stage T3b right renal tumor extending into the inferior vena cava. The caval thrombus was limited and completely below the level of the hepatic veins. After preoperative renal embolization via the hand assisted transperitoneal approach the right kidney was completely dissected with the renal hilum. Proximal and distal control of the inferior vena cava was obtained with vessel loops and a single lumbar vein was divided between clips. An endoscopic Satinsky vascular clamp was placed on the inferior vena cava just beyond its juncture with the right renal vein, thereby, encompassing the caval thrombus. The inferior vena cava was opened above the Satinsky clamp and a cuff of the inferior vena cava was removed contiguous with the renal vein. The inferior vena cava was repaired with continuous 4-zero vascular polypropylene suture and the Satinsky clamp was then removed. A literature search failed to reveal any similar reports of laparoscopic radical nephrectomy for stage T3b renal cell cancer. Surgery was completed without complication with an estimated 500 cc blood loss. Pathological testing confirmed stage T3b grade 3 renal adenocarcinoma with negative inferior vena caval and soft tissue margins. The introduction of vascular laparoscopic instrumentation and the hand assisted approach enabled us to extend the indications for laparoscopic radical nephrectomy to patients with minimal inferior venal caval involvement.

Successful repair of blunt cardiac rupture involving both ventricles

Blunt cardiac rupture occurs infrequently and is usually lethal. Successful repairs of isolated atrial or ventricular ruptures have been reported when the diagnosis is made early. Our patient sustained blunt cardiac rupture of both ventricles in a motor vehicle accident. The diagnosis was made during emergency exploratory laparotomy when her vital signs deteriorated without obvious cause. A large Satinsky clamp was placed across the apices of the right and left ventricle to control hemorrhage while the repair was done without cardiopulmonary bypass. She survived and was discharged to home with a normal echocardiogram

Successful Repair of Blunt Cardiac Rupture Involving Both Ventricles

Blunt cardiac rupture occurs infrequently and is usually lethal. Successful repairs of isolated atrial or ventricular ruptures have been reported when the diagnosis is made early. Our patient sustained blunt cardiac rupture of both ventricles in a motor vehicle accident. The diagnosis was made during emergency exploratory laparotomy when her vital signs deteriorated without obvious cause. A large Satinsky clamp was placed across the apices of the right and left ventricle to control hemorrhage while the repair was done without cardiopulmonary bypass. She survived and was discharged to home with a normal echocardiogram

The Hilar Snare, an Improved Technique for Securing Rapid Vascular Control of the Pulmonary Hilum

Massive hemorrhage from pulmonary injuries is often refractory to hilar crossclamping. We report a simple technique, the hilar snare, to control such injuries and compare it to the standard technique of hilar occlusion with a vascular clamp. Standardized lacerations were made in the lung in each of six adult dogs. Blood loss from the injured lung was measured before and after placement of the hilar snare and compared to that following hilar occlusion with a Satinsky clamp (occlusive surface, 5.5 cm). The rate of blood loss before control was not significantly different between the two groups. Blood loss from the lacerated lung was significantly less (p less than 0.05) in the Hilar Snare group (9 +/- 4 ml/min) when compared to the Satinsky group (46 +/- 14 ml/min). The snare's flexible nature ensures complete occlusion of the hilar vessels and is a useful adjunctive technique to present methods of controlling severe pulmonary hemorrhage.

THE MARTIN TITAN LINE ARTERIAL CLAMP A NEW LIGHTWEIGHT ALTERNATIVE

When haemostatic clamps are applied, evidence of injury at the site of clamp application may be seen when the clamp is removed. Rarely, the intima may be disrupted. When a new arterial clamp became available, a study was designed to compare the Martin Titanline arterial clamp (13-143-35, curved arterial clamp) with several other arterial clamps already in use. The Martin clamp is a modified pivot-point, preset-tension, spring-controlled arterial clamp. The closing pressures of several clamps were measured objectively. The injury produced when the clamps were applied to occlude the blood flow on the carotid artery of a dog was assessed by histological study of the excised segments of the arterial wall. Histological cross-sections were prepared from canine carotid artery which had been perfused for 1 h after the clamp had been applied for 1 h. Histological evidence of injury was limited to disruption of the intimal layer and compression of the medial layer. No significant difference between the amount of damage caused by the DeBakey, Satinsky or Martin clamp was identified. When compared to the other varieties of clamp listed above, the Martin clamp had a significantly lower closing pressure (304 g) compared with 580g (Bulldog), 580 g (Satinsky), and 686 g (DeBakey). The Martin clamp was easier to apply, did not obstruct the operative field as readily and had good clamp-retention characteristics throughout the procedure.

Comparative Evaluation of Vascular Clamps on the Arteriosclerotic Aortic Walls

Seven different vascular clamps selected from among those in routine use in vascular surgery (Satinsky clamp, Satinsky rubber clamp, Fogarty clamp, Bull dog clamp, Bulldog rubber clamp, Potts clamp, and Potts rubber clamp) were applied to arteriosclerotic rabbit abdominal aortae to evaluate both grossly and histologically the relative degree of injury thus caused to the vessel wall at dif ferent levels of clamping pressure. Of the vascular clamps examined, the Satin sky clamp and the Fogarty clamp, followed by the Bulldog rubber clamp, proved to cause the least damage to the vessel wall. The Satinsky clamp and Fogarty clamp, in particular, appeared to be the most suitable for arterioscle rotic vessels. The Potts clamp, the Potts rubber clamp, and the Bulldog clamp, which were highly traumatic, should probably not be applied to peripheral or other small-sized blood vessels.

Efficacy of Intralesional Alcohol Injection as Preoperative Treatment of Upper Lip Arteriovenous Malformation

Management of vascular malformation remains a major challenge because treatment carries a substantial risk of morbidity and recurrence of the fundamental problem. Intra-lesional 96% alcohol injection as a combination with other treatment modalities has good-to-excellent results. Six-year old female with a 5-year history of arteriovenous malformation on her upper lip underwent intralesional alcohol injection under general anesthesia. Afterward we performed excision of the lesion. During the surgery we used Satinsky intestinal clamp to control the bleeding by compressing the artery. The follow up period was 9 months; there were no complications and no signs of relapse. Aesthetically, the result perceived as acceptable to the parents and other viewers. In cases of arteriovenous malformation involving the lip the technique of injecting alcohol 96% intralesional in conjuct with reducing blood loss by using Satinsky intestinal clamps had an acceptable result aesthetically.

Primary Pulmonary Leiomyosarcoma

J. R., a 19-year-old white male farmer, was first seen on June 7, 1954, for complaints including weakness, anorexia, and loss of 35 lbs. weight since March, 1954. Although a recent posterioanterior chest film had been reported as normal, chest x-ray film was repeated, revealing a large round tumor mass with small nodular extensions (Fig. 1), all of which had been previously hidden by the cardiac shadow. A left lateral x-ray film of the chest localized this mass in the left lower lobe behind the heart. The patient suddenly became dyspneic and developed signs and symptoms of severe internal hemorrhage. X-ray films now showed the left hemithorax to be opaquely blurred with some shift of the mediastinum to the right (Fig. 2). Closed (water-sealed) drainage through catheters introduced intercostally resulted in escape of considerable bloody fluid. X-ray film showed opacity of the lower two-thirds of the left lung field with some improvement in the position of the mediastinum, but dyspnea, requiring the administration of oxygen through an intranasal catheter continued. He was given whole blood transfusions and his blood pressure maintained at 120/80. He was started on penicillin, and his oral temperature of 104#{176} fell over a period of a few days to 101#{176}. His pulse rate fell from 150 to 120 per minute. He was unable to void voluntarily (necessitating an indwelling Foley catheter), sweated profusely and complained of dyspnea, weakness and chest and back pain. Bronchoscopy and studies of the bronchial secretions for malignancy were negative. On June 29, 1954, operation was performed through a standard left thoracotomy incision. The pleural space was filled with an extensive blood clot and some free bloody fluid. Almost as soon as removal of this blood clot was undertaken, the anesthetist reported that free bloody fluid was filling and escaping out of the endotracheal tube. The operator (A.M.T.) introduced his hand blindly through the extensive blood clot to the upper hilar region and compressed the left main stem bronchus there, later applying a Satinsky clamp to this region. The anesthetist was then able to clear the tracheobronchial tree and maintain a satisfactory anesthetic for the remainder of the operation.