Page 42 - World Association of Laparoscopic Surgeons - Journal

Santhosh Narayana Kurukkal

common titanium clip failures resulted from scissoring or 2009, a polyglactin-0 tie was placed on the renal artery in
malformation (52%), jamming (19%) and dislodgement addition to the two usual Hem-o-lok clips in LLDN at our
(14%). Clip dislodgement was most common with the institution (n = 10) using a pretied loop suture (Endoloop
locking clip, either postoperatively in seven (58%) or ligature, Ethicon) placed on the artery stump, proximally
intraoperatively in three (25%). Intraoperative conversions to the aorta, after kidney removal. This artifice increased
were required for 21 (36%), one (5%) and two (17%) for operating time of 65 seconds (range, 35 to 85 seconds)
staplers, titanium clips and locking clips respectively. The with no modification of warm ischemia time and led to
estimated overall failure rate was 3.0% for staplers, 4.9% visually decreased aortic pulsation transmitted to the clips.
for titanium clips and 1.7% for locking clips. They Without evidence of increased safety, they assume
concluded that donor surgeons must be familiar with and that this use may protect surgeons from prosecution in
anticipate the potential failures seen with each of the cases of clip displacement. It certainly decreases the risk
techniques used to secure the renal hilum. Knowledge of of clip slippage and should be considered as a cheap, easy
potential device failures, combined with prompt and
artifice to reduce the already low-risk of hemorrhage in
appropriate corrective action, may limit donor morbidity
LLDN.
when malfunction occurs. Finally, it is the responsibility of 17
Liu et al had concerns about the stapler malfunction
surgeons to act as donor advocate and continue to petition
and satisfied clips. They had no vascular complications and
device manufacturers to improve the safety of existing
no device failure during vascular control using polymer
devices. In a previous study by the same author of
locking clips. They believe that polymer locking clips are
complications with hemostatic devices during laparoscopic
safe, yielding greater vessel length during laparoscopic
nephrectomy, they observed a greater proportion of locking
donor nephrectomy.
clip failures occurring during donor procedures compared 18
Geron et al from South America described their
with stapler and titanium clip failures (67 vs 24 and 19% experience with the use of nonabsorbable polymer ligaclip
respectively). 21 (NPL) to control the renal artery, vein, and ureter in hand-
Nasser Simforoosh et al 14 reported the use of a new
assisted laparoscopic donor nephrectomy (HALDN). They
modification of the technique for controlling the renal
performed 85 procedures and reported the NPL was safe
pedicle during laparoscopic donor nephrectomy (LDN) with
and cost-effective, not increasing morbidity of the
Hem-o-lok clips. They did LDN in 241 candidates. At the
procedure.
end of procedure for renal-artery closure, one 10 mm 19
Edmund et al reported a retrospective review of Mayo
Hem-o-lok clip was applied a few millimeters distal to the
Clinic experience with 400 LDN from 1999 to 2007. The
root from the aorta, and a medium-large titanium clip was
endovascular gastrointestinal anastomosis (GIA) stapler has
applied distal to the Hem-o-lok clip using a nonautomatic
been used for renal vascular control for their donors since
firing applier to exert sufficient closing pressure to the
the inception of their LDN program. Forty-one were on the
titanium clip to ensure adequate tightness. Then the renal
right. There were no statistically significant differences
vein was doubly ligated with one 12 mm and one 10 mm
between the donor groups or their respective recipients.
Hem-o-lok clips. They reported that there were no
There were four (1%) stapler malfunctions, all occurring
intraoperative or perioperative bleeding complications, clip
on the left side; two of these procedures were converted to
dislodgments or slippages. The conversion rate was zero,
open to obtain hemostasis. There were nearly equal rates of
and the mean warm ischemia time was 7.50 ± 0.71 minutes
(range, 3-17 minutes). Graft function was excellent, with a vascular complications, 4.9 and 4.7%, in the right and left
mean serum creatinine concentration of 1.42 ± 0.46 mg/dl groups respectively. The overall immediate graft failure rate
after 12 months of follow-up and no renal-artery or vein was 2.3%. Right and left recipient creatinine levels up to
thrombosis in any of the grafts. They concluded that with 24 months demonstrated no statistically significant
these techniques, there is more security on the arterial differences. They proposed that the endovascular GIA
closure, and sufficient pedicle length can be obtained for stapler for left and right laparoscopic donor nephrectomy
anastomosis. The warm-ischemia time is within an is safe for the donor. It standardizes the process, minimizes
acceptable range. Also, this approach is less expensive than the need for additional maneuvers in securing the renal
the use of endovascular staplers. hilum, and produces similar outcomes for the recipient. The
16
Tmsit et al reported the feasibility of a simple surgical transplant team also plays an equally large role in favorable
artifice that aims to preserve the advantages of lockable graft outcomes.
clips with increased safety while respecting the In contrast to vessel wall occlusion with metal clips, the
manufacturer’s legal recommendations. Since January Endo-TA stapler transfixes the vessel with three rows of

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