Page 41 - World Association of Laparoscopic Surgeons - Journal

WJOLS

Techniques to Secure Renal Hilum in Laparoscopic Donor Nephrectomy

using parametric tests (α = 0.05). They found no significant metal clips. Hem-o-lok was successful in all 46 cases without
difference between groups with respect to preoperative any slipping of clips or uncontrolled bleeding.
factors, OT and EBL; however, WIT was shorter in group Controlled ligation and division of renal vessels is a
2 (3.6 ± 0.2 vs 2.6 ± 0.3, p = 0.048). Within-group critical step during any nephrectomy procedure. It has
comparisons revealed longer WIT for patients with generally been presumed that titanium clip ligation of renal
supernumerary renal artery compared with those with a vessels is risky and insecure. In a report from Sir JJ Hospital
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single artery (group 1, p = 0.044; group 2, p = 0.042). and Grant Medical College, Mumbai, India, they analyzed
Moreover, no major between-group variations were seen their experiences over 5 years with ligaclips 10 mm titanium
in postoperative donor outcomes. Left renal artery ligation clips for secure ligation of renal hilum during laparoscopic
during HALDN using a three-row vascular stapler is safe nephrectomy. Titanium clips of 10 mm were used to secure
and yields donor outcomes comparable with dual polymer renal vessels in 86 patients. They managed to get across the
clips. In addition, left renal artery stapling may decrease entire width of renal vein with a 10 mm titanium clip by
WIT compared with dual clipping. crimpling the vein with the help of the clip applicator before
7
Casale P et al reported their personal experience in 31 firing the clips. In all except two cases, ligaclips alone were
laparoscpic nephrectomies in which both the renal artery enough to ensure secure occlusion of renal hilum. There
and the renal vein were secured using only NPL clips. No was no incidence of slippage or dislodgement of clips
renal vessel injuries, cases of clip dislodgement or slippage, applied on renal vessels. On cost analysis, it was found that
or bleeding were recorded. They also achieved meaningful the Hem-o-lok clip and gastrointestinal anastomosis stapling
reduction in the cost of procedure. device were approximately 6-fold and 12-fold costlier than
8
Lee Ponsky et al reported a multiinstitutional review ligaclips.
from nine institutions with laparoscopic trained urologists Another report from Sanjay Gandhi Postgraduate
performed 1695 laparoscopic nephrectomies (radical Institute of Medical Sciences, Lucknow, India, (Kapoor R
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nephrectomy, N = 899; simple nephrectomy, N = 112; et al) included 246 laparoscopic ablative nephrectomies
nephroureterectomy, N = 198; donor nephrectomy, (178 simple; 68 radical) were performed for benign and
N = 486). Follow-up was a minimum of 6 months from the malignant conditions, underwent either standard
time of surgery. For each case, we used Hem-o-lock clips transperitoneal (N = 204) or retroperitoneal (N = 42)
to control the renal artery. The renal vein was controlled nephrectomy. Venous and arterial control was obtained
with Hem-o-lok clips in 68 cases (radical nephrectomy, using Hem-o-lock clips. In cases where the clips could not
N = 54; simple nephrectomy, N = 3; nephroureterectomy, be applied directly on the renal vein, various maneuvers
N = 5; donor nephrectomy, N = 6). Number of clips placed were employed to secure the occlusion. The features
on the patient side of the renal artery was most often 2, compared were the number of clips used, safety, cost and
occasionally 3. Number of clips placed on the patient side requirement for blood transfusion. Conversion to an open
of the renal vein was most often 2 and rarely 3. All cases procedure was required in 36 patients (28 in the
used the large (L-purple) clip on the artery, and most cases transperitoneal group and 8 in the retroperitoneal group).
of renal vein used the extra-large (XL- gold) clip on the In all cases, arterial and venous control was achieved by
vein. No cases of clip failure such as intraoperative or application of two Hem-o-lok clips on the patient side. Blood
postoperative clip dislodgement necessitating reoperation transfusion was required by 7.2% of the patients (right-side
was recorded. nephrectomy 4.6%; left-side nephrectomy 2.6%), but none
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Izaki et al reported 40 laparoscopic nephrectomies in was attributable to clip-related complication.
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which renal pedicle ligation was accomplished using Ryan SA Hsi et al reported a review to characterize
extralarge (XL) Hem-o-lok clips on both the renal arteries the mechanisms of failure and patient outcomes during
and veins by placing two clips on the patient side and one complications with the use of endoscopic stapling devices,
clip on the specimen side. Vascular control using XL Hem- nonlocking titanium clips, and locking polymer clips during
o-lok clips was successful in all 40 cases, without any laparoscopic donor nephrectomy. They identified 92 cases
slipping of clips or uncontrolled bleeding. of complications due to device malfunctions. In the 92
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Yip SK et al reported 46 nephrectomies (40 HALDN, complications identified, 59 (64%), 21 (23%), and 12 (13%)
6 lap). Venous control was achieved solely by the failures of endoscopic staplers, titanium clips and locking
Hem-o-lok clips where at least two clips were applied on clips had occurred respectively. The most common
the patient side. Arterial control was obtained by the mechanisms of stapler failure were missing/malformed
Hem-o-lok clips either alone or in combination with the staple lines (51%) and failure to release (25%). The most

World Journal of Laparoscopic Surgery, January-April 2012;5(1):21-26 23