Haemostasis in Radical Prostatectomy 9 Evangelos N. Liatsikos ∙ Paraskevi Katsakiori ∙ Jens-Uwe Stolzenburg Contents 9.1 Introduction . 136 9.2 Mechanical Means. 136 9.3 Electrosurgical Tools. 136 9.3.1 Monopolar Electrocautery. 137 9.3.2 Bipolar Electrocautery. 137 9.3.3 The LigaSure Sealing System. 137 9.4 Ultrasonic Energy Device. 137 9.5 Lasers for Haemostasis . 138 9.6 Tissue Sealants. 138 9.6.1 Fibrin Glues. 138 9.6.2 Haemostatic Gelatine Matrix. 139 9.6.3 Human Fibrinogen and Thrombin Fleece. 140 9.6.4 Experimental Tissue Sealants in Radical Prostatectomy . 141 9.6.5 Possible Adverse Events of Tissue Sealants. 141 References. 141 136 Chapter 9 E. N. Liatsikos ∙ P. Katsakiori ∙ J.-U. Stolzenburg 9.1 Introduction mostasis. Local compression by itself may sometimes be sufficient. If not, the application of tissue sealants Adequate haemostasis is essential in every surgical in combination with local mechanical compression procedure. Uncontrolled bleeding hinders the sur- may adequately seal large vessels, even the vena cava. geon‘s work and potentially threatens the patient‘s Suturing techniques in laparoscopic radical pros- life. Particularly, during laparoscopic radical prosta- tatectomy differ from those in open surgery and re- tectomy, even small amounts of blood may critically quire advanced laparoscopic skills. Freehand intra- impair the view at a site where vision is already re- corporeal suturing is preferable to external knotting stricted a priori. For this reason, haemostasis in lapa- because it avoids excessive traction during suturing. roscopic procedures focuses mainly on primary pre- The use of endo-loops may be of great help, particu- vention of bleeding. larly for surgeons inexperienced in endoscopic sutur- There are various methods of securing surgical ing. During the application of endo-loops, however, a haemostasis, including mechanical means (sutures, significant amount of healthy tissue is sacrificed. ligatures or staples), vessel coagulation (electrocau- Moreover, the loops may slip off due to tissue isch- tery or ultrasonic energy) and tissue sealing. Fre- aemia, and loops that remain in place may loosen. quently, more than one type of procedure is needed to Laparoscopic vascular clips are the preferred tool achieve satisfactory haemostasis. The application of for sealing blood vessels. Small amounts of bleeding mechanical devices is time consuming, requires good may still occur, however, either due to malposition of access to the vessels and leaves a foreign material in- clips or because the enclosed bundles of tissue are too side the patient, which may lead to complications. small. Titanium clips tend to slip off during further Haemostatic clips are utilised for the mechanical liga- dissection. For this reason, at least two to five clips are 9 tion of vessels with a diameter of 3–7 mm. Stapling needed for safe control of vessels with a diameter of devices are costly for multiple single-vessel applica- 3 mm. tions [1]. Electrocoagulation systems are quickly ap- Vascular endo-staplers with 2.0- to 2.5-mm jaw plied and do not introduce foreign materials. They width and various lengths have been used to achieve are capable of sealing vessels with a diameter up to safe occlusion of major vessels and vascular pedicles. 2–3 mm. However, possible lateral thermal damage The modern endo-staplers are bulky instruments that and potential tissue necrosis impede their applica- require 12-mm access ports, utilise three lines of sta- tion. In addition, they are unreliable for vessels with a ples for safe vascular control and provide the cutting diameter >2 mm [2]. Tissue sealants can be applied simultaneously. These devices are costly, single-use with or without clips or staples and are capable of pro- instruments and require training before use. The lap- viding satisfactory haemostasis alone or in conjunc- aroscopic surgeon must always use the appropriate tion with other haemostatic methods. vascular jaw width (not the tissue width) and must This chapter provides an overview of the various ensure that the entire vessel is within the stapler line methods of haemostasis. before firing. 9.2 Mechanical Means 9.3 Electrosurgical Tools Mechanical means of haemostasis include mechani- Electrosurgery has been widely used in open surgery cal compression, sutures, clips and staples [3]. The for obtaining adequate haemostasis. Monopolar elec- same principles are used in both open and laparo- trocautery was the first tool to be adapted for laparo- scopic radical prostatectomy. Proper tissue dissection scopic procedures. However, owing to the high risk of and early identification of the supplying blood ves- thermal injury in the surrounding tissues during the sels, preferably before bleeding occurs, are necessary. application of electrocautery, new energy sources have Dissection with a laparoscopic styptic stick helps to been employed. Ultrasonic coagulation systems have control bleeding from the adjacent vessels. been used in radical prostatectomy with better hae- Local compression with a sponge in the case of un- mostatic effect, less thermal damage and better func- controllable venous bleeding provides the surgeon tional results. with time to elaborate further strategies for final hae- Haemostasis in Radical Prostatectomy Chapter 9 137 9.3.1 Monopolar Electrocautery compared to the standard approach. Urogenital func- tion at 14 months after operation was comparable to Although monopolar electrocautery provides ade- that with the standard method, assuming that the quate haemostasis, its use is restricted by potential parasympathetic nerves and the ventral urethral wall complications. By limiting the time of application and did not suffer any negative thermal effect. the maximum current force, the complications can be minimised. Electrical bypass may occur at sites of low impedance or damaged insulation. This is the reason 9.3.3 The LigaSure Sealing System why we do not use any monopolar energy during EE- RPE. The safety of monopolar electrocautery may be The LigaSure vessel-sealing system was developed in secured by active electrode monitoring. In the case of 1995. It works by coagulating the walls of the target any break in the integrity of the insulation, the in- vessel by means of bipolar energy. The feedback-con- strument is immediately shut off and the monitoring trol mechanism ensures that the adjacent tissues are device does not allow activation if the foot pedal is not charred by overcoagulation. This instrument is depressed. Another potential drawback is that re-us- effective in sealing vessels with a diameter of 1–7 mm able scissors may lose their sharpness after extensive and results in a high burst strength and permanent use of monopolar current during dissection. This seal while limiting the lateral thermal damage [7]. problem can be solved by using single-use scissors The LigaSure system has already been used in open blades for re-usable instruments. Modern re-usable radical prostatectomy for sealing the pelvic lymphatic instruments are thought to be safer. tissues and for ligating the lateral pedicles (from the A haemostatic monopolar cautery device that has base to the apex of the prostate), the puboprostatic been utilised in handling capillary bleeding is the ar- ligaments and the dorsal vein complex. Total opera- gon beam coagulator [3]. This device is a monopolar tion time and the need for blood transfusion were sig- cautery instrument that uses an argon jet to propel nificantly reduced with the use of LigaSure, compared blood away from the surgical field. Although it has to conventional ligation [7, 8]. proved efficacious in control of minor capillary bleed- The safety of blood vessel control with the LigaS- ing, argon beam coagulation alone cannot be success- ure system has also been demonstrated in a porcine fully used for tissue dissection. Additionally, it is not experimental study. The seals created by LigaSure, suitable for managing significant bleeding or haem- were stronger than those accomplished with other en- orrhage from larger vessels. ergy-based ligation methods (ultrasonic coagulation and standard bipolar coagulation). The seals obtained by the application of LigaSure were able to withstand 9.3.2 Bipolar Electrocautery a minimum of three times the normal systolic pres- sure [9]. Bipolar electrocautery has been proposed instead of monopolar and bulk clipping in order to obtain ade- quate haemostasis and safer dissection and to mini- 9.4 Ultrasonic Energy Device mise possible thermal injury of adjacent tissues [4, 5]. Bipolar coagulating forceps have already been used The piezoelectric ultrasonic energy device (UED – during radical retropubic prostatectomy for coagula- SonoSurg, Olympus; AutoSonix, Tyco; UltraCision, tion of the vascular plexus [6]. Radical prostatectomy Ethicon) simultaneously excises and coagulates tissue always involves a considerable risk of thermal and with the application of high-frequency ultrasound. electrical injury of the neurovascular bundles and the Dissection and cavitation are achieved using frequen- branches of the pelvic plexus. Significant reductions cies of 23.5 and 55.5 kHz. The UED minimises col- in intraoperative blood loss and in the need for trans- lateral damage, avoids tissue carbonisation and re- fusion during or after the operation were described. duces potential thermal injury compared to Furthermore, the visibility was improved, allowing monopolar energy sources. Use of the UED is limited maximal preservation of the urethral length, com-