Page 40 - World Association of Laparoscopic Surgeons - Journal

Santhosh Narayana Kurukkal

There were concerns about the safety of the The efficacy of nonabsorbable polymer ligating (NPL)
nonabsorbable polymer locking clips since 2004 to 2006 and titanium clips applied with and without a 1 mm vascular
and FDA had temporarily banned it in 2006. With cuff at physiologic and supraphysiologic pressures in vitro
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reintroduction late in 2006, transplant surgeons, urologists equine-vessel model was compared by Jellison FC et al in
and minimally invasive surgeons were using the polymer Loma Linda University Medical Center, CA. Ten millimeter
locking clips extensively for securing the renal artery in NPL and standard Ti clips were applied to veins (10 mm)
donor nephrectomies as it was clear that the reported clip and arteries (10, 6 and 5 mm) with and without a 1 mm cuff
malfunctions were not frequent. Even though it is infrequent, and tested until they held a pressure of 300 mm Hg (veins)
it is catastrophic and we should respect the privilege of or 760 mm Hg (arteries) for 2 minutes or leaked. The NPL
kidney donor. clip was noted statistically more secure on 10 mm veins
Intraopeartive clip malfunction is not infrequent. with and without a cuff, 10 mm arteries with and without a
Maartense S et al reported two cases of perioperative clip cuff and 6 mm arteries with a cuff than was the Ti clip.
dislocation during laparoscopic donor nephrectomy and the Leaving a 1 mm cuff resulted in a statistically higher leak
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techniques to tackle the situation. In the first case, during point in all vessels tested except the 6 mm arteries secured
left HLDN the clips placed on the renal artery dislodged, with the Ti clip. They concluded that the NPL clip was more
and the surgeon managed to control the bleeding by secure than the Ti clip on larger arteries and veins. A 1 mm
compressing the focus of the bleeding with his finger. vascular cuff enhances the security of both NPL and Ti clips
A balloon occlusion catheter was inserted through a groin in vessels of all sizes. The NPL clip is secure and reliable
incision in the aorta and advanced to the origin of the renal in securing both arteries and veins.
artery. Due to control of the hemorrhage, it was possible to Endolinear stapling devices with clips in hand-assisted
close the renal artery stump by laparoscopic suturing and a laparoscopic donor nephrectomy were compared by Baldwin
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conversion was averted. In the second case, during right DD et al. The stapling devices have a potential for misfire.
HLDN, the clips on the renal artery dislodged during Use of the NPL clip during laparoscopic donor nephrectomy
stapling of the renal vein. The bleeding was controlled by provides increased graft vessel length compared with the
finger compression and new clips were placed. The cuff of stapling device, and the NPL clip has a locking mechanism
the artery was long enough to be clipped again. The use of which may increase security compared with standard
a balloon occlusion catheter is an elegant way to avert titanium clips. The 50 consecutive HALDN patients in their
conversion. series were conducted with two parallel NPL clips used to
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Elliott SP et al from the University of California studied control both the renal artery and vein. They opined that the
the bursting strength with various methods of renal artery NPL clip was 100% safe and effective in controlling the
ligation and potential mechanisms of failure. One end of an renal artery and vein during HALDN, allowed for additional
adult porcine artery (3-7 mm diameter) was occluded with vessel length, and resulted in a disposable cost savings of
a titanium clip, self-locking polymer clip or laparoscopic US 362 dollars per patient.
linear cutting stapler. Comparisons were made with one or Another report comparing the outcomes in left renal
two clips and with different distal cuff lengths (i. e. flush or artery clipping vs stapling in HALDN by James et al 15
2 mm). The open end was secured to a pulsatile infusion at the Medical College of Georgia. A 55 HALDN procedures
pump. Leak/failure pressures were measured using a were performed by one laparoscopy-trained urologist from
digital barometer. The mean bursting pressures for the clips 2003 to 2007. During the first 30 months, 27 consecutive
were found above physiologic arterial pressures (1220- HALDN patients underwent renal artery occlusion with two
1500 mm Hg). However, the vessels closed with the stapler nonabsorbable polymer locking clips (group 1). The
leaked at a lower mean pressure (262 mm Hg). Failure of subsequent 18 months saw 28 consecutive HALDN patients
titanium or self-locking polymer clips was the result of receive three-row vascular stapling to occlude the renal
vessel retraction into and behind the clip, while staple-line artery (group 2). The preoperative patient factors were age,
leakage occurred between individual staples. Bursting sex, body mass index, serum creatinine (Cr) and presence
pressures with the titanium and self-locking polymer clips of supernumerary left renal artery. Intraoperative factors
were unaffected by the number of clips or length of vascular included estimated blood loss (EBL), operative time (OT)
cuff. He concluded that all tested methods of vascular and warm ischemia time (WIT). Postoperative data were
control performed well at physiologic pressures, suggesting 24 hours Cr and hemoglobin concentration, transfusion
that safety is not increased with traditional maneuvers such requirement, hospitalization time and complications. Data
as additional clips or longer cuff length. are presented as mean ± standard deviation and analyzed

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