Skill and talent
Simplified renorrhaphy using self-retaining barbed suture during laparoscopic partial nephrectomy
Renorrafia simplificada empleando sutura barbada durante la nefrectomía parcial laparoscópica
A. García-Segui
, E. Bercowsky, M. Gascón-Mir
Corresponding author
Servicio de Urología, Hospital General Mateu Orfila, Mahón, Spain
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García-Segui, E. Bercowsky, M. Gascón-Mir" "autores" => array:3 [ 0 => array:4 [ "nombre" => "A." "apellidos" => "García-Segui" "email" => array:1 [ 0 => "agarciasegui@gmail.com" ] "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">¿</span>" "identificador" => "cor0005" ] ] ] 1 => array:2 [ "nombre" => "E." "apellidos" => "Bercowsky" ] 2 => array:2 [ "nombre" => "M." "apellidos" => "Gascón-Mir" ] ] "afiliaciones" => array:1 [ 0 => array:1 [ "entidad" => "Servicio de Urología, Hospital General Mateu Orfila, Mahón, Spain" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Renorrafia simplificada empleando sutura barbada durante la nefrectomía parcial laparoscópica" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0015" "etiqueta" => "Figure 3" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr3.jpeg" "Alto" => 1105 "Ancho" => 1401 "Tamanyo" => 218657 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">‘Sliding clip’ technique for adjustment of the suture line using a Hem-o-lok<span class="elsevierStyleSup">®</span> clip without knotting. (A) The surgeon tightens the thread and centers it between the jaws of the stapler of the Hem-o-lok<span class="elsevierStyleSup">®</span>. (B) Placement of the clip on the suture. (C) The laparoscopic clamp pushes down the clip by sliding it on the thread toward the renal capsule. (D) The adjustment of the clip is made up to achieving an adequate apposition with the renal parenchyma.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">The development of laparoscopic and robotic surgery has allowed for the minimally invasive surgical procedures to obtain oncologic outcomes comparable to those of partial nephrectomy in renal masses smaller than 7<span class="elsevierStyleHsp" style=""></span>cm.<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1,2</span></a> Laparoscopic partial nephrectomy (LPN) is a technically challenging procedure, which requires the acquisition of skills in advanced laparoscopic suture to perform renal reconstruction quickly under the pressure of the ischemia time. This makes this technique involve a long learning curve and a limited application to centers of excellence in laparoscopy.<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2–5</span></a> Multiple refinements of the technique have been proposed to facilitate the preparation of the renorrhaphy during the LPN and decrease the ischemia times.<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1,6–8</span></a> Together, new suture materials have been developed, such as the so-called self-retaining barbed suture (SRBS), which has allowed for reconstructive procedures in a more simple and safe way.<a class="elsevierStyleCrossRefs" href="#bib0035"><span class="elsevierStyleSup">7,9–11</span></a> In order to facilitate renal reconstruction during LPN, we present a simplified renorrhaphy technique using the SRBS.</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Patients and methods</span><p id="par0010" class="elsevierStylePara elsevierViewall">Two patients with renal mass <4<span class="elsevierStyleHsp" style=""></span>cm were included, suitable for treatment by partial nephrectomy. The first case was a 47-year-old male patient with an incidental renal mass of 3.4<span class="elsevierStyleHsp" style=""></span>cm in the union of the upper and middle third of the left kidney. The second case was a 52-year-old female patient with a history of non-Hodgkin's lymphoma, with a neoproliferative injury of 1.5<span class="elsevierStyleHsp" style=""></span>cm in the upper pole of the left kidney.</p><p id="par0015" class="elsevierStylePara elsevierViewall">Both patients underwent LNP with the simplified renorrhaphy technique using SRBS by transperitoneal approach with 4 trocars.</p><p id="par0020" class="elsevierStylePara elsevierViewall">The SRBS (V-Loc<span class="elsevierStyleSup">®</span> 90 Absorbable Wound Closure Device-Covidien) is a copolymer of absorbable polygluconate with small projections, in the form of barbs or pins, which are deployed helically along the thread axis.<a class="elsevierStyleCrossRefs" href="#bib0035"><span class="elsevierStyleSup">7,11</span></a> This suture has been used effectively in urological reconstructive procedures, such as the urethrovesical anastomosis during the robotic radical prostatectomy.<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">12</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">Using the principle described by Van Velthoven et al.<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">13</span></a> for the urethrovesical anastomosis with a single knot, two suture wires were intertwined by their end to obtain 2 needles on a single thread with bidirectional barbs.<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a></p><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Surgical technique</span><p id="par0030" class="elsevierStylePara elsevierViewall">The procedure starts with the dissection and exposure of the renal hilum, followed by the release of renal fat to clear tumor exposure. Using monopolar cautery, the resection line is demarcated from the ring of normal renal parenchyma surrounding the tumor. The barbed suture is introduced into the cavity, and a first suture is placed on the outer edge of the incision, leaving the securing knot of the 2 sutures on the outside of the renal capsule (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>A and B). We proceed to selective clamping of the renal artery with ‘Bulldog’ vascular clamp. Using cold cut, the tumor is resected maintaining suction with the cannula for clear exposition of the resection bed. Renorrhaphy starts with two continuous suture planes, one deep and one shallow without any knots. Using the needle that was previously passed, renal reconstruction began starting with the deep level, including repair of the collecting system defects when these occurred (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>A–C). The last suture on this plane passes through the thickness of the renal cortex to externalize the thread, and it is secured with a Hem-o-lok<span class="elsevierStyleSup">®</span> clip using the technique of the ‘sliding clip’ described by Benway et al.<a class="elsevierStyleCrossRefs" href="#bib0025"><span class="elsevierStyleSup">5,8</span></a> (<a class="elsevierStyleCrossRef" href="#fig0015">Fig. 3</a>A). In this maneuver, the surgeon tightens the wire and centers it in the jaws of the stapler, so as to place the staple on the suture; then, the clip is pushed perpendicular to the renal capsule, in order to slide it on the suture toward the kidney up to a suitable renal parenchymal apposition. With this it is possible to adjust and readjust the tension without the need to knot<a class="elsevierStyleCrossRefs" href="#bib0025"><span class="elsevierStyleSup">5,8</span></a> (<a class="elsevierStyleCrossRef" href="#fig0015">Fig. 3</a>B–D). Next, a second plane of renorrhaphy on a surface level for the closure of the renal capsule is performed, using the other needle and the remaining thread. The needle is passed through the parenchyma and the renal capsule, on both sides of the defect, again performing continuous suture. Unlike the previous plane, each point is fixed by placing Hem-o-lok<span class="elsevierStyleSup">®</span> clips applied according to the same technique of the ‘sliding clip’ (<a class="elsevierStyleCrossRef" href="#fig0020">Fig. 4</a>A and B). The clamp of the renal artery is released and the hemostasis is checked. Two Hem-o-lok<span class="elsevierStyleSup">®</span> clips are placed at the level of the last suture for safety. A Jackson-Pratt drainage is introduced and the clamp is removed by an endobag. Additionally, the suture line is covered with a loose sheet of Surgicel.</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia><elsevierMultimedia ident="fig0015"></elsevierMultimedia><elsevierMultimedia ident="fig0020"></elsevierMultimedia></span></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Results</span><p id="par0035" class="elsevierStylePara elsevierViewall">The operative time was 156 and 163<span class="elsevierStyleHsp" style=""></span>min, the intraoperative bleeding was 50<span class="elsevierStyleHsp" style=""></span>ml and 850<span class="elsevierStyleHsp" style=""></span>ml, the warm ischemia time was 14.3 and 23<span class="elsevierStyleHsp" style=""></span>min, and the follow-up time was 7 and 3 months in the first and second case, respectively. In both patients, the hospital stay was 5 days and there were no postoperative complications. In the second case, there was inadvertent slippage of the Bulldog vascular clamp during the renorrhaphy, therefore, an intraoperative bleeding occurred, requiring blood transfusion.</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Discussion</span><p id="par0040" class="elsevierStylePara elsevierViewall">The LPN is a complex surgical technique with a long learning curve,<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> and with significant complication rates, even in expert hands, intra-and postoperative bleeding, urinary fistulas, transfusion requirements, and positive surgical margins<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">14</span></a> can often occur. That is why its application has been limited to centers with high experience in laparoscopy.<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1,2,14</span></a> However, contemporary innovations, in particular the advent of robotic surgery and the refinements of renorrhaphy, have simplified the procedure, shortening the learning curve, and reducing ischemic times, expanding its applicability as a real alternative to open surgery.<a class="elsevierStyleCrossRefs" href="#bib0020"><span class="elsevierStyleSup">4,6,15</span></a> These innovative renorrhaphy techniques can make the LPN more accessible to many laparoscopic urologists outside the academic centers of excellence.<a class="elsevierStyleCrossRefs" href="#bib0040"><span class="elsevierStyleSup">8,15</span></a></p><p id="par0045" class="elsevierStylePara elsevierViewall">Barbed sutures have recently been introduced, which are useful in complex reconstructive procedures, as they present retainers (by way of barbs or pins) that enable to evenly distribute the tension along the suture line and maintain optimal apposition of the tissues to obtain a better closure. Its application in renal reconstruction during the LPN has been described; however, there are few publications so far. Shikanov et al.<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a> conducted the first study on swine using barbed suture for closure of the collecting system and the renal parenchyma. Sammon et al.<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a> and Olweny et al.<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> demonstrated, in two comparative studies in humans, the effectiveness of the SRBS during the robot-assisted and LPN, which showed the favorable effects of this suture in reducing the ischemic times. Sukurman and Rogers<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">11</span></a> described the surgical technique used for the robot-assisted partial nephrectomy, and presented the modification of their technique with the advent of the barbed suture. Seideman et al.<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a> describe that they adopted the SRBS in their standard practice for conducting the LPN, due to the advantages of shortening the learning curve and reducing the ischemic times.</p><p id="par0050" class="elsevierStylePara elsevierViewall">To our knowledge, this is the first article in the Spanish medical literature to use the barbed suture in the LPN. As evidenced in the above-mentioned series, we believe that because the SRBS pins are anchored to the tissues, in addition to ensuring a good apposition, it enables to achieve a hemostatic closure of the renal parenchyma.<a class="elsevierStyleCrossRefs" href="#bib0035"><span class="elsevierStyleSup">7,10</span></a> These characteristics also prevent the suture line from loosening, avoiding the need to maintain a constant traction on the thread with the non-dominant hand of the surgeon, allowing them to have both hands free. This facilitates renorrhaphy and it could be favorably reflected in the ischemic time.<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">11</span></a></p><p id="par0055" class="elsevierStylePara elsevierViewall">The most demanding surgical step during the LPN is the suture of the renal defect,<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> which is why the refinements during the evolution of the technique focus on simplifying the renorrhaphy. In a review article recently published by Ghani and Anderson,<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a> the three major innovations that have simplified renal reconstruction<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a> are shown. The first is the implementation of renorrhaphy by means of continuous suture, allowing for a quicker closure and providing a better initial hemostasis.<a class="elsevierStyleCrossRefs" href="#bib0030"><span class="elsevierStyleSup">6,15</span></a> Similarly, Cáceres et al.<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> recently reported a series of 60 patients undergoing LPN applying the closure by means of continuous suture with good results. The second relevant refinement corresponds to the concept of the knotless suture facilitating the procedure by eliminating the need to knot, fixing the thread with staples (Lapra-Ty<span class="elsevierStyleSup">®</span> or Hem-o-lok<span class="elsevierStyleSup">®</span>). However, during robotic surgery, this maneuver had a limitation, since this technique requires the assistant to place the clip, the responsibility of the adjustment of the suture line of the renorrhaphy<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a> lies with them. This motivated Benway et al.,<a class="elsevierStyleCrossRefs" href="#bib0025"><span class="elsevierStyleSup">5,8</span></a> to devise the third refinement, called ‘sliding clip’ renorrhaphy, using a Hem-o-lok<span class="elsevierStyleSup">®</span> to allow the surgeon a precise control over the tension of the suture line and to reset it.<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a> Currently, this maneuver is considered the method of choice<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> to adjust the knotless thread, because it provides a closing pressure higher than other techniques, without tearing the renal parenchyma.<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2,5,7,8</span></a> Finally, we consider that the placement of the bolster of various materials within the defect of the renal parenchyma should fall into disuse, as its routine practice has been questioned and its application could rather complicate the raffia and prolong the ischemic time. Tsivian et al.,<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> and Weight et al.<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">15</span></a> concluded that the use of these hemostatic elements must be reserved for those patients with large renal defects. There are no studies showing benefits of the conventional use of the bolster beyond the surgeon's sense of ‘feeling safe’.<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> Based on these refinements, we decided to apply them to our center with a technique that simplifies the renorrhaphy of the LPN to the maximum, jointly using the SRBS to add the benefits of this material in facilitating the raffia and reducing the ischemic times.<a class="elsevierStyleCrossRefs" href="#bib0035"><span class="elsevierStyleSup">7,11</span></a> In the simplified renorrhaphy, we made two continuous sutures without knots, fixing the threads with clips and adjusting to the technique of the ‘sliding clip’, and without the use of bolsters.</p><p id="par0060" class="elsevierStylePara elsevierViewall">The effectiveness of the renorrhaphy in two suture planes has been widely described.<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1–7</span></a> Most authors agree on making a deep plane by means of a continuous suture line that may include the pyelo-calyceal systems. The closure of the second plane, however, is made with an interrupted suture line for safety by many.<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2,3,9,10,12</span></a> In our cases, we make the two planes of the renorrhaphy with continuous suture, for being the fastest and easiest technique, but also considering the qualities of apposition and hemostasis of the barbed suture, together with fixation of the thread with Hem-o-lok<span class="elsevierStyleSup">®</span> clips between each suture, readjusted with the technique of the ‘sliding clip’, we can say that we obtained a safety equal to or higher than that of a conventional interrupted plane.</p><p id="par0065" class="elsevierStylePara elsevierViewall">Our second patient had intraoperative bleeding due to accidental and inadvertent displacement of the Bulldog clamp, thus requiring transfusion. Some authors<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1,2</span></a> have reported this complication of poor control of the renal pedicle. Nevertheless, we believe that in our case the SRBS facilitated the raffia and enabled to perform it more quickly and effectively to control the hemostasis.</p><p id="par0070" class="elsevierStylePara elsevierViewall">Thus, we conclude that simplified renorrhaphy using SRBS is a relatively simple technique, which significantly facilitates renal reconstruction, is effective to ensure an adequate hemostasis, and could decrease the ischemia times. However, in order to obtain satisfactory results, it should be reserved for renal tumors of up to 4<span class="elsevierStyleHsp" style=""></span>cm, of peripheral anatomic location, to ensure full accessibility of the tumor defect and to allow for an appropriate placement of the suture. More studies are needed to determine the definitive role of the SRBS and of the simplified renorrhaphy during the LPN.</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Conflict of interest</span><p id="par0075" class="elsevierStylePara elsevierViewall">The authors declare that they have no conflict of interest.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:10 [ 0 => array:2 [ "identificador" => "xres101985" "titulo" => array:5 [ 0 => "Abstract" 1 => "Introduction and objectives" 2 => "Patients and methods" 3 => "Results" 4 => "Conclusions" ] ] 1 => array:2 [ "identificador" => "xpalclavsec89151" "titulo" => "Keywords" ] 2 => array:2 [ "identificador" => "xres101984" "titulo" => array:5 [ 0 => "Resumen" 1 => "Introducción y objetivos" 2 => "Pacientes y métodos" 3 => "Resultados" 4 => "Conclusiones" ] ] 3 => array:2 [ "identificador" => "xpalclavsec89150" "titulo" => "Palabras clave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 5 => array:3 [ "identificador" => "sec0010" "titulo" => "Patients and methods" "secciones" => array:1 [ 0 => array:2 [ "identificador" => "sec0015" "titulo" => "Surgical technique" ] ] ] 6 => array:2 [ "identificador" => "sec0020" "titulo" => "Results" ] 7 => array:2 [ "identificador" => "sec0025" "titulo" => "Discussion" ] 8 => array:2 [ "identificador" => "sec0030" "titulo" => "Conflict of interest" ] 9 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2012-03-27" "fechaAceptado" => "2012-04-05" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec89151" "palabras" => array:3 [ 0 => "Laparoscopic partial nephrectomy" 1 => "Renorrhaphy" 2 => "Sutures" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec89150" "palabras" => array:3 [ 0 => "Nefrectomía parcial laparoscópica" 1 => "Renorrafia" 2 => "Suturas" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:2 [ "titulo" => "Abstract" "resumen" => "<span class="elsevierStyleSectionTitle">Introduction and objectives</span><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Laparoscopic partial nephrectomy (LPN) is a challenging procedure that requires quick and effective intracorporeal suturing that could limit widespread adoption. Refinements of surgery have improved warm ischemia times and facilitated renal reconstruction. We present a technique that makes renorrhaphy easier using self-retaining barbed suture (SRBS) weaving two threads.</p> <span class="elsevierStyleSectionTitle">Patients and methods</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Two patients with carcinoma of the kidney, 3.4 and 1.5<span class="elsevierStyleHsp" style=""></span>cm, respectively, were subjected to the LPN. The SRBS is an absorbable polygluconate with small projections along its axis which are anchored in the tissue, distributing the tension of the suture line and eliminating the need for knots. Renorrhaphy was performed using the SRBS by two continuous suture lines without knots, setting the sutures with clips of Hem-o-lok<span class="elsevierStyleSup">®</span> and adjusting it with the technique of “sliding clip”, without placing “bolsters” inside the renal parenchymal defect.</p> <span class="elsevierStyleSectionTitle">Results</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Operative time was 156<span class="elsevierStyleHsp" style=""></span>min and 163<span class="elsevierStyleHsp" style=""></span>min, intraoperative bleeding was 50<span class="elsevierStyleHsp" style=""></span>ml and 850<span class="elsevierStyleHsp" style=""></span>ml, the warm ischemia time was 14.3<span class="elsevierStyleHsp" style=""></span>min and 23<span class="elsevierStyleHsp" style=""></span>min and follow-up time was 7 months and 3 months in the first and second cases, respectively. The hospital stay was 5 days and there were no postoperative complications.</p> <span class="elsevierStyleSectionTitle">Conclusions</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Simplified renorrhaphy using SRBS is effective, hemostatic, facilitates the renal reconstruction, and can help reduce the warn ischemia time.</p>" ] "es" => array:2 [ "titulo" => "Resumen" "resumen" => "<span class="elsevierStyleSectionTitle">Introducción y objetivos</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">La nefrectomía parcial laparoscópica (NPL) es una intervención desafiante que requiere sutura intracorpórea rápida y efectiva, lo que limita su aplicación de forma extendida. Refinamientos de la cirugía han mejorado los tiempos de isquemia y facilitado la reconstrucción renal. Se presenta una técnica que simplifica al máximo la renorrafia empleando sutura barbada de auto-retención (SBAR) entrelazando dos hilos.</p> <span class="elsevierStyleSectionTitle">Pacientes y métodos</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">A dos pacientes con carcinoma de riñón, de 3,4 y 1,5<span class="elsevierStyleHsp" style=""></span>cm respectivamente, se les realizó la NPL. La SBAR es un poligliconato absorbible con pequeños salientes a lo largo de su eje que se anclan en los tejidos, distribuyendo la tensión de la línea de sutura y eliminando la necesidad de nudos. La renorrafia se realizó con la SBAR mediante dos líneas de sutura continuas sin nudos, fijando los hilos con clips de Hem-o-lok<span class="elsevierStyleSup">®</span> y ajustándolos con la técnica del «clip deslizante», sin colocación de <span class="elsevierStyleItalic">bolsters</span> dentro del defecto del parénquima renal.</p> <span class="elsevierStyleSectionTitle">Resultados</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">El tiempo operatorio fue de 156 y 163 minutos, el sangrado intraoperatorio fue de 50 y 850<span class="elsevierStyleHsp" style=""></span>ml, el tiempo de isquemia caliente fue de 14,3 y 23 minutos y el tiempo de seguimiento fue de 7 y 3 meses, en el primer y segundo caso respectivamente. La estancia hospitalaria fue de 5 días y no hubo complicaciones postoperatorias.</p> <span class="elsevierStyleSectionTitle">Conclusiones</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">La renorrafia simplificada empleando SBAR es efectiva, hemostática, facilita significativamente la reconstrucción renal y puede ayudar a disminuir los tiempos de isquemia.</p>" ] ] "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara">Please cite this article as: García-Segui A, et al. Renorrafia simplificada empleando sutura barbada durante la nefrectomía parcial laparoscópica. Actas Urol Esp. 2012;36:497–502.</p>" ] ] "multimedia" => array:4 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1385 "Ancho" => 890 "Tamanyo" => 277319 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">After the demarcation of the resection line surrounding the tumor, a first suture is placed on the outer edge of the incision, leaving the securing knot of the two sutures outside the renal capsule. (A) Schematic view. (B) Laparoscopic view.</p>" ] ] 1 => array:7 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 1062 "Ancho" => 1301 "Tamanyo" => 284354 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">Following the tumor resection, the raffia of the deep plane is started, by means of a continuous suture line, which includes the repair of defects of the collecting system. (A and B) Schematic view. (C) Laparoscopic view.</p>" ] ] 2 => array:7 [ "identificador" => "fig0015" "etiqueta" => "Figure 3" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr3.jpeg" "Alto" => 1105 "Ancho" => 1401 "Tamanyo" => 218657 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">‘Sliding clip’ technique for adjustment of the suture line using a Hem-o-lok<span class="elsevierStyleSup">®</span> clip without knotting. (A) The surgeon tightens the thread and centers it between the jaws of the stapler of the Hem-o-lok<span class="elsevierStyleSup">®</span>. (B) Placement of the clip on the suture. (C) The laparoscopic clamp pushes down the clip by sliding it on the thread toward the renal capsule. (D) The adjustment of the clip is made up to achieving an adequate apposition with the renal parenchyma.</p>" ] ] 3 => array:7 [ "identificador" => "fig0020" "etiqueta" => "Figure 4" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr4.jpeg" "Alto" => 1264 "Ancho" => 1000 "Tamanyo" => 249941 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0060" class="elsevierStyleSimplePara elsevierViewall">Raffia of the surface plane for the closure of the renal capsule by means of a second line of continuous suture. (A) Schematic view. The needle passes through the parenchyma and the renal capsule, on both sides of the defect, and each suture is fixed by placing Hem-o-lok<span class="elsevierStyleSup">®</span> clips applied according to the technique of the ‘sliding clip’. (B) Laparoscopic vision of the culminated renorrhaphy, where the apposition of the tissues at the level of the line of the defect and the presence of the fixation and tension adjustment clips.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:15 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Laparoscopic partial nephrectomy" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:6 [ 0 => "F. Cáceres" 1 => "C. Núñez-Mora" 2 => "P.M. Cabrera" 3 => "J.M. García-Mediero" 4 => "A. García-Tello" 5 => "J.C. 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| Year/Month | Html | Total | |
|---|---|---|---|
| 2018 February | 15 | 3 | 18 |
| 2018 January | 16 | 1 | 17 |
| 2017 December | 20 | 1 | 21 |
| 2017 November | 19 | 1 | 20 |
| 2017 October | 22 | 1 | 23 |
| 2017 September | 23 | 2 | 25 |
| 2017 August | 23 | 3 | 26 |
| 2017 July | 19 | 4 | 23 |
| 2017 June | 36 | 12 | 48 |
| 2017 May | 33 | 16 | 49 |
| 2017 April | 35 | 10 | 45 |
| 2017 March | 16 | 15 | 31 |
| 2017 February | 24 | 4 | 28 |
| 2017 January | 30 | 5 | 35 |
| 2016 December | 44 | 2 | 46 |
| 2016 November | 28 | 2 | 30 |
| 2016 October | 39 | 11 | 50 |
| 2016 September | 30 | 5 | 35 |
| 2016 August | 32 | 3 | 35 |
| 2016 July | 17 | 2 | 19 |
| 2016 June | 20 | 3 | 23 |
| 2016 May | 25 | 14 | 39 |
| 2016 April | 29 | 9 | 38 |
| 2016 March | 25 | 10 | 35 |
| 2016 February | 49 | 15 | 64 |
| 2016 January | 31 | 18 | 49 |
| 2015 December | 22 | 9 | 31 |
| 2015 November | 25 | 9 | 34 |
| 2015 October | 28 | 4 | 32 |
| 2015 September | 24 | 5 | 29 |
| 2015 August | 54 | 6 | 60 |
| 2015 July | 45 | 4 | 49 |
| 2015 June | 17 | 1 | 18 |
| 2015 May | 13 | 6 | 19 |
| 2015 April | 25 | 6 | 31 |
| 2015 March | 18 | 4 | 22 |
| 2015 February | 21 | 3 | 24 |
| 2015 January | 27 | 3 | 30 |
| 2014 December | 34 | 7 | 41 |
| 2014 November | 26 | 1 | 27 |
| 2014 October | 57 | 10 | 67 |
| 2014 September | 47 | 8 | 55 |
| 2014 July | 2 | 0 | 2 |
| 2014 June | 1 | 0 | 1 |
| 2014 May | 4 | 2 | 6 |
| 2014 January | 7 | 1 | 8 |
| 2013 December | 11 | 1 | 12 |
| 2013 November | 15 | 1 | 16 |
| 2013 October | 22 | 7 | 29 |
| 2013 September | 8 | 1 | 9 |
Show all
