Introduction

The use of bioadhesive technology in laparoscopic urologic surgery dates back to the mid-1990s (1); however, Bergel first used dry plasma to establish hemostasis in 1909 (2).

Fibrin patches to establish hemostasis during cerebral surgery (3) and to manage bleeding from battlefield parenchymal organ injuries were introduced subsequently. The adhesive properties of fibrin sealant were first recognized experimentally and then clinically in 1942, when investigators performed microsurgical peripheral nerve anastomoses (4). The quality of fibrin sealant during this time was poor because of low in vivo concentrations of fibrinogen and fibrin. A significant advance was made in 1944, when researchers attempted to accelerate the formation of fibrin clot by mixing fibrinogen with bovine thrombin (5). However, the adhesive properties remained inadequate because the fractionation techniques required to prepare concentrated fibrinogen were still not perfected. The use of fibrin sealant was therefore limited to applying dry fibrin to bleeding surfaces. In the 1970s, purification and fractionation techniques grew more sophisticated and high concentrations of freeze-dried fibrinogen became available. Gradually, high concentrations of fibrinogen and other components such as thrombin and factor VIII became commercially available. Europe saw the first commercial, multidonor fibrin-sealant products in the late 1970s, yet the United States was more reluctant to embrace a product that had the potential of viral contamination (6). In fact, licenses for the clinical use of fibrinogen substrates were revoked in the United States in 1978, and further purification and viral detection methods had to be developed before commercially available fibrin-sealant products could be employed clinically (7). Because of the potential benefits of fibrin sealant, American surgeons turned to fibrin preparations, either autologous or obtained from single-donor cryoprecipitates. Although the risk of disease transmission was theoretically prevented, the preparation of such products was time consuming and the fibrinogen concentration, critical to the sealant's tensile strength, was variable and unreliable. Despite the availability of several commercial

Today's fibrin sealants have excellent rheological properties that make them excellent additions to standard methods of tissue approximation and help secure hemostasis.

fibrin-sealant preparations in Europe, Canada, and Japan, the U.S. Food and Drug Administration did not approve Tisseelâ„¢a until 1998.

Today's fibrin sealants have excellent rheological properties (elasticity, tensile strength, and adhesiveness) that make them excellent additions to standard methods of tissue approximation and help secure hemostasis.

Fibrin sealant is the only agent truly considered a "bioadhesive." However, gelatin matrix, thrombin, collagen, and cellulose products are available for enhancing hemostasis. All can be applied laparoscopically by either directly passing the agent through a laparoscopic port or using long applicator devices.

The hemostatic process depends upon the integrated activity of vascular, platelet, and plasma factors in combination with the regulatory mechanisms of anticoagulation, which are necessary to stabilize the fibrin clot and prevent accumulation of platelets and fibrin in areas of noninjury.

Regional vasoconstriction and extrinsic compression of damaged blood vessels by extravasated blood contribute to hemostasis on a purely mechanical level. Temporary arterial occlusion during laparoscopic partial nephrectomy can help achieve the same goal by intentionally decreasing the blood flow to the cut surface of the renal parenchyma.

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