UTILITY OF THE HARMONIC SCALPEL FOR LAPAROSCOPIC PARTIAL NEPHRECTOMY

Laparoscopic partial nephrectomy (LPN) remains a technically challengi ng procedure largely because of the lack of methods for obtaining cons istent parenchymal hemostasis. The objective of this study was to dete rmine if the extent of resection influences the ability of the harmoni c scalpel to achieve hemostasis and to define the cases in which the h armonic scalpel is appropriate for LPN, Thirty LPNs were performed in a 25-kg domestic pig model. The blunt blade of the laparoscopic harmon ic scalpel (LaparoSonic Coagulating Shears; Ethicon Endo-Surgery, Cinc innati, OH) at power level 5 was used to divide the parenchyma, Contro l of the renal hilar vessels was not obtained. Three standardized type s of resections were performed: I = peripheral wedge biopsy; II = uppe r- or lower-pole nephrectomy; and III = heminephrectomy, Bleeding was graded on a scale from 0 to 4: 0 = no hemostasis; 1 = steady bleeding; 2 = moderate bleeding; 3 = parenchymal oozing; and 4 = dry. Hemostasi s grades of 2 or less were clinically significant bleeding necessitati ng supplemental coagulation. The mean hemostasis scores showed a signi ficant (P < 0.02) trend toward inadequate hemostasis with increasing e xtent of resection: 3.3 for Type I, 3.0 for Type II, and 2.4 for Type III. The percent of kidneys with grade 2 bleeding or worse was 9% for Type I surgery, 25% for Type II, and 57% for Type III. Successful hemo stasis with the harmonic scalpel correlates with the extent of parench ymal resection in the porcine model. Most wedge excisions can be done with the harmonic scalpel alone, whereas larger resections necessitate supplemental coagulation. On the basis of this study, heminephrectomi es with the harmonic scalpel are not recommended because of the high i ncidence of significant hemorrhage.